Approach To Giddiness

Approach To
Giddiness
By: Aizura Binti Abdul Aziz
Supervisor: Dr Maslina
Introduction
• Giddiness is one of the commonest symptoms encountered by
physicians on a day to day basis.
• Giddiness can be an innocent symptom of a simple disease or may be
of a serious condition.
• The challenge today for physicians is to make a diagnosis of such a
vague symptoms and to identify more dangerous disease.
Types of giddiness
• An illusion of motion, frequently rotary, maybe rocking, swaying, or a sense

Vertigo of linear propulsion. Can be of varying degree of intensity and persistence. It

is indicative of vestibular dysfunction, whether peripheral or central. Not all
patient able to describe vertigo in vivid terms.

• A sensation that fainting is about to occur, During episode, patient often

Presyncope senses his vision is growing dark or dim. There may be nausea, vomiting,
weakness, dyspnoea and anxiety. It is transient in nature

Non speciifc • Vague giddiness symptoms that do not fit into the above.

giddiness
 Giddiness

Non-
True vertigo vertiginous
giddiness

Central Peripheral
Characteristics Peripheral Vertigo Central Vertigo

Onset Abrupt Gradual

Intensity Moderate to intense Mild to moderate

Temporal pattern Brief, episodic, lasts<1 min, fatigues with Chronic, continuous, lasts >1 min, does not
repetition fatigues
Nystagmus Rotatory/unidirectional/horizontal Any kind/ multidirectional including
Suppressed by visual fixation bizarre/vertical
Not suppressed by visual fixation
Head motion Aggravation of symptoms Little aggravation of symptoms

CNS symptoms and signs Rare Common

Imbalance Mild to moderate, patient can usually Severe. Patient has great difficulty in
walk walking
Risk factor for vascular disease May be present or absent Commonly present

Tinnitus Characteristic Uncommon

Hearing Loss Characteristic. Uncommon

Nausea/vomiting Common Uncommon

Common Important Causes Of Non-vertiginous Giddiness
• Acute myocardial infarction or any condition that causes decreased cardiac output

Cardiac
• Dysrhtmias
• Valvular heart disease
• Congestive heart failure

Orthostatic • Blood loss eg GIT bleeding, ectopic pregnancy,

• Dehydration

hypotension
• Drug

• Hypoxia
• Hypoglycaemia

Metabolic • Drugs
• Uraemia
• Hepatic failure

Heamatological
• Anaemia
• Hyperviscosity syndrome
Medication associated with giddiness
• Alcohol
• Antibiotics eg aminoglycosides
• Antidysrhtmics
• Anticonvulsant eg phenytoin
• Antidepressants
• Antihistamine
• Antihypertensive
• Anti-inflammatory agents. eg salicylates
• Antiparkinsons agents
• Diuretics
• Hypoglycaemic agents
• Phenothiazines
• Sedative
Initial Management
• Patients with significant giddiness and unsteadiness should be triaged to
yellow zone.
• Vital sign
• Stat capillary glucose
• ECG – especially with cardiac risk factors
• Postural parameters
• - postural hypotension : decrease in SBP of > 20 mmHg on standing and
increase in pulse rate of > 20/min upon standing.
• - symptoms may occur occur up to 30 % elderly patients
• - Medication such as antihypertensive and antidepressant is an attributing
factor.
Vertigo Management
• Symptomatic treatment
• IV/IM prochlorperazine (stemetil) 12.5 mg or IV/IM promethazine
(Phenergan) 12.5-25 mg
• PO diazepam2 mg
• IV hydration if severe vomiting
• Distinguish between peripheral or central
Dix- Hallpike Test
Epley Manoeuvre
Head Impulse test
Vertigo Disposition : Discharge if
• Has true vertigo
• Has no neurological deficits
• Has no symptoms to suggest episode of vertebrobasilar insufficiency.
E.g diplopia/visual blurring, dysarthria, dysphagia, or focal
neurological deficits.
• Is well and self-ambulatory after observation.
• Has no significant medical history.
• Has good social support.
Non- specific giddiness

• Exclude obvious neurological problems such vertebrobasilar

insufficiency, multiple sclerosis, brainstem or cerebello-pontine
infaction/haemorrhage or trauma or Parkinsons’ disease.
• Recommend bed rest
• Symptomatic treatment if giddiness is severe:
• IM prochlorperazine
• Admit patient if shows no improvement
Disposition : Discharge if
• Cerebrovascular disease or vertebrobasilar insufficiency has been excluded.
• Following significant disease have been excluded:
• 1. Ishaemic heart disease
• 2. Dysrhytmias
• 3. Pneumonia/infection
• 4. Bleeding or dehydration
• The patient has no significant risk factors.
• 1. Ischamic heart disease
• 2. Hypertension
• 3. Diabetes mellitus
• The patient is well after observation:
• 1. alert and attentive
• 2. No significant giddiness
• 3. Able to retain orally
• Good home care available
• General discharge advice. DO NOT
• 1. Drive a motor vehicle
• 2. Climb heights
• 3. Operate heavy machines
• 4. Drink alcoholic beverages.
• 5. Swim
Important to rule out life threatening causes

• Ischaemic heart disease. e.g Acute coronary syndrome

• Cardiac failure
• Cardiac dysrhtmias
• Stroke/vertebrobasilar insufficiency (VBI)
• Sources of hypovolaemia. eg GIT bleeding
• Gynaecological problems. eg ectopic pregnancy/vaginal bleeding.
• Hypoglycaemia
Ischaemic Heart Disease
• Giddiness can be a presenting complaint in ACS, acute heart failure,
and dysthymias.
• Diagnosis is based on cardiac risk, symptomatology, and ECG changes.
• Patients should be managed as for ACS, with a view to early
myocardial salvage, eg thrombolysis or PCI
• Such patients should be admitted to coronary care unit (CCU) for
evaluation.
Cardiac failure
Chronic heart failure can be present with giddiness if cardiac output is insufficient
to meet the demands of daily activity.
Cardiac Dysrhythmias
• Either fast or slow heart rhythms can cause giddiness
• Detectable using cardiac monitor or 12-lead ECG
• The management depends on cause.
• Significant rhythms that should receive immediate management and subsequent
CCU placement:
• 1. Significant or unexplained bradycardias
• 2. Second- and third-degree heart blocks
• 3. Ventricular tachydsrthymias
• 4. Supraventricular tachycardiacs with haemodynamic instability
• 5. Atrial fibrillation with rapid ventricular response and haemodynamic instability
Stroke
• Giddiness, either non-specific giddiness or vertiginous forms, could be
a sign of transient ischemic attack ( TIA) or impending stroke.
• Patients tend to be middle-aged and above and many of them will
have hypertension.
• The patient should be examined for evidence of brainstem signs and
neurological deficits.
Hypovolaemia
• Any source of bleeding/fluid loss producing hypovolaemia can cause
symptoms of giddiness. In mild cases,persistent or recurrent non-
specific may be felt. In severe cases, there may be a sensation of
blacking out or frank syncope.
• All patients should be screened for common sources of bleeding. Eg
GIT bleeding or in female vaginal bleeding.
• Patients should be asked wheter severe vomiting or diarrhoea has
occurred.
• Take blood for FBC and electrolyte assessment.
Gynaecological conditions
• Women of childbearing age should be screened for evidence of
vaginal bleeding or lower abdominal pain that may suggest ectopic
pregnancy.

Hypoglycaemia
Hypoglycaemia may be an important cause of giddiness in both healthy
patients as well as diabetics.
Reference
• Guide To The Essentials In Emergency Medicine (2ND Edition) by
Shirley Ooi, Peter Manning
• Tintinalli's Emergency Medicine: A Comprehensive Study Guide
Thank you!