Antivert

The phone rings at 9:15 Wednesday evening. It's my mother. She reports that she began to feel dizzy while reading in bed 30 minutes earlier.

"The room suddenly began to spin," she says. A few minutes later, walking to the bathroom was difficult. "I had to hold on to the wall." She thinks it may be her blood pressure and wants me to stop by tomorrow to check it for her.

The sudden onset of dizziness and gait difficulties for a 69-year-old can be very serious. Couple this with the fact that no history of blood pressure problems exists and the need for evaluation becomes immediate. "Not tomorrow," I tell her. "I'll be over in a few minutes."

Stroke?

I stop by the office to pick up a cuff and stethoscope. I am thinking about the differential diagnosis for senior patients with dizziness. Stroke is my first and most severe concern. Stroke is a leading cause of brain injury in adults and the third leading cause of death in United States. The dizziness and ataxia she described are common in the clinical presentation of a stroke. Aphasia (incoherent speech) and dysarthria (slurred speech) are also signs of stroke. Thankfully, neither was present during our phone conversation. She did not mention headache, facial weakness, visual loss, double vision, or weakness in the extremities. Then again, I did not ask about these symptoms.

Vestibular System?

Vestibular (inner ear) problems are my second thought. Mom had an upper-respiratory infection last week that could have spread to her middle ear. Describing the room as "spinning" certainly fits the dizzy sensation attributed most often to dysfunction of the vestibular system. This is apposed to the feelings of imbalance and lack of coordination that are usually attributed to cerebellar problems, or lightheadedness and fainting feelings that are usually due to vascular or psychogenic trouble. I wonder if vestibular problems typically have an onset as suddenly and severe as she described.

Hypertension?

Hypertension is my next concern. High blood pressure is often present for long periods of time prior to detection. When signs and symptoms do arise or high readings are recorded, significant damage may already have occurred. Hypertension sneaks up on you-thus, the name, "The Silent Killer." Mom's blood pressure had been evaluated routinely for months without signs of hypertension. As her primary diagnosis, it is low on my list of differentials. Orthostatic hypotension is also a differential. However, Mom reported that her symptoms began while lying still, and not after a change in posture. Medication Side Effects?

Side effects of medications are a stronger possibility than hypertension. Mom is taking a variety of prescription and non-prescription medications. Maybe two or more of the drugs have interacted in a negative way. I cannot rule this out until I know what she has been taking for the past few days.

Cervicogenic Dizziness?

Cervicogenic dizziness is a possibility, but not a probability. Mom has severe degenerative disc disease and spondylosis throughout the cervical spine. However, stiffness, headaches, and arm paresthesias are her most common symptoms. Her current symptoms are new and do not relate to physical activity.

I find Mom in the living room, sitting on the sofa. She is visibly upset. Her blood pressure is 170/100 mmHg. She still has no aphasia or dysarthria. "Does your head hurt?" "Is your vision blurred?" "Are you seeing double?" "Do your arms or legs feel funny?" She answers "No" to all of the above. "What medications are you taking?" "Prilosec for gastric reflux, an over-the-counter sinus medication, and Tylenol." "How long have you been taking this combination?" "Months." The concern over medications quickly moves down on the list.

Her face moves normally during conversation, but I ask her to smile and raise her eyebrows anyway Both are normal. With no facial weakness, stroke seems less and less likely.

I have her perform the dizziness test next in an attempt to identify or rule out vestibular trouble. First, her head is rotated to the right, then to the left, holding each position for 10 to 20 seconds. The dizziness increases in both directions. Shoulder rotation to the right and left with the head stationary follows. No change in symptoms. If symptoms had increased with head and shoulder rotation, a vertebral artery problem would be indicated. Increased symptoms, with head rotation only, indicate a vestibular problem. Cervicogenic problems move further down the list, and vestibular trouble becomes the primary diagnosis.

I tell Mom I think she has an inner ear infection. "I did have some right ear pain earlier today, but it doesn't hurt now," she says. I attribute her high blood pressure to excitement. She doesn't seem to believe me. Despite arriving at a likely diagnosis, Mom's dizziness and excitement continue to increase. We decide to seek help in the local emergency room.

At the ER, a triage nurse speaks in a way that makes it clear she believes Mom is confused and hard of hearing. Mom is neither. I make a mental note not to treat my senior patients that way. They take her into the emergency room while I stay in the waiting room.

Thirty minutes later, I'm at Mom's bedside. She is hooked up to EKG leads and has a heparin lock in her left hand. The monitor shows that her blood pressure is still up and her pulse is rapid. "What have they done for you so far?" "They asked more questions, took some blood, checked my blood pressure lying down, sitting up, and standing, and did an EKG. My blood pressure is still up. The lady doctor said the EKG was normal." "Did they give you anything?" "Valium." "What's next?" I don't know."

In another 30 minutes, her doctor says she has also decided to order a CT of Mom's head to rule out a cranial bleed. The lab work is still not back. She won't commit to a diagnosis.

The CT scan turns out normal. The ER doctor will keep her overnight for observation. Her blood pressure is down, but there is still no word on her labs.

I am back at the hospital by 9 the next morning. Mom is tired, but much less dizzy now. Her doctor has not been in to see her. Finally, her doctor's partner enters the room. Mom asks about her CT scan and lab. He cannot answer her. It doesn't appear that he has read her chart. He talks with Mom and me for a few minutes and agrees with my original diagnosis of inner ear trouble. He thinks the infection is probably viral, but prescribes an antibiotic just in case. He also prescribes Antivert for her dizziness. His plan is to give Mom the initial dose of each medication and have the nurses walk with her after the medications have had time to take effect. If she is stable walking, she can go home. A few minutes later, he tells us the CT and labs were negative. Later in the day, she returns home.

I am thankful a more catastrophic problem was not responsible for my mother's trouble. I am also thankful for a recent emergency procedure refresher course. Two months ago, I took a CPR course because one of the managed care organizations I am a provider for requires current CPR certification for doctors and support staff.

At the seminar, I learned that the American Heart Association was about to release a new book, Bwi Life Support (BLS) for Healthcare Providers. I received it two weeks ago. The new text had been expanded to include chapters on stroke and defibrillators. The stroke chapter intrigued me when I first reviewed the book. I read the chapter two days ago, just before Mom's sudden dizziness onset. The chapter detailed the use of the fibrinolytic therapy now available for acute stroke victims. If administered within three hours of onset, the therapy can have a dramatic effect on the degree of neurologic insult and the ultimate outcome for stroke patients. That's why "now" was better than "tomorrow," as my mother originally suggested. In years past, making sure vital signs were stable was all that could be done initially for stroke victims. Now, time is crucial.

Most of what we do in chiropractic is at a leisurely pace. We see patients who have hurt for days, weeks, or months. Even if they are in acute, painful spasm, we are reasonably sure our patients are not going to die. This is in sharp contrast to health care providers who are routinely faced with life-and-death matters that require fast thinking. I have a newfound appreciation for emergency medical technicians and emergency room doctors. I also have more respect for the doctors of chiropractic who work the sidelines in contact sports. They must think fast when they see a head injury that may result in a cranial bleed, abdominal trauma that may have ruptured the spleen, and other injuries that require immediate critical care.

I plan to continue improving my abilities to respond quickly to emergency situations. First, I'll finish the BLS text and take seriously the emergency procedures portion of the certified chiropractic sports physician (CCSP) program I just began. There is always room for improvement. I found that I should have alerted the emergency medical system immediately-as the BLS text recommends for possible stroke victims (also, I should have had my cuff and stethoscope with me). The BLS text cites several studies that indicate EMS personnel are consistently more reliable than friends and loved ones under these circumstances. I hope there isn't a next time, but if there is, I'll be ready. We just never know when well have to think on our feet -and fast.

BY K. JEFFREY MILLER, DC, DABCO

Copyright American Chiropractic Association Feb 2002
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