“I feel dizzy” is a common complaint in the ER and triage nurses sometimes use the shorthand, IFD, when describing the patient’s complaint. Finding a diagnosis for this vague symptom can be challenging. One thing the nurse can do to speed up the process is to drill down to a more firm description than dizziness.
Dizziness is a complaint that can include four separate symptoms, sometimes overlapping. A careful history will reveal one or more of these: vertigo, disequilibrium, presyncope, or lightheadedness.
Vertigo is the feeling that the room is spinning. Often, there is a false sense of movement. Sometimes vertigo is accompanied by nausea, vomiting, sweating, and/or nystagmus. It gets worse when the patient’s head is moving. The question the nurse can ask to differentiate vertigo from other forms of dizziness is, “Do you feel like the room is spinning or moving around you?”
Vertigo has relatively few causes. Benign paroxysmal positional vertigo (BPPV), Meniere’s disease, and labyrinthitis are the most common. Less common are brain tumors, brain injury, stroke, MS, and migraines. You can see that they divide into central and peripheral causes; central causes involve the brain and peripheral causes come from the middle ear. Anything that causes inflammation in the structures surrounding the organs of balance can lead to vertigo. Often the patient will have a cold or sinus problems. Tinnitus, hearing loss, and feeling of fullness in the ear can accompany vertigo. There is a rapid compensatory process when things go wrong with the organs of balance. Usually the course is self-limiting and resolves within a few days.
BPPV is caused by loose granules of calcium carbonate moving in the semicircular canal. It can be diagnosed with the Dix-Hallpike test and can sometimes be effectively treated with repositioning movements called the Epley maneuver. BPPV does not present with hearing loss.
Meniere’s disease involves episodic vertigo along with hearing loss and a sensation of fullness, usually in one ear. There are few treatments and the disease is poorly understood. The course can last from 5-15 years before the episodes stop and the patient is left with mildly disturbed balance and decreased hearing.
Labyrinthitis is believed to be caused by a viral infection of the inner ear and can result in permanent symptoms of dizziness.
Disequilibrium exhibits itself in the patient’s gait. A stumbling or shuffling gait can be a sign of stroke, a life threatening emergency that calls for immediate activation of the emergency medical system. Other causes are Parkinson’s disease and peripheral neuropathy. Alcohol and drug intoxication frequently lead to disequilibrium. In older people, poor vision can accompany disturbances in gait, leading to falls. Benzodiazepines and tricyclic antidepressants can also lead to higher incidences of falls in the elderly.
Presyncope is a problem of circulation and is most commonly described as feeling like one is going to pass out without actually losing consciousness. It’s either a pump or a fluid problem and exhibits as orthostatic hypotension. When the patient stands up, he or she gets dizzy. It can be caused by dehydration (fluid problem), arrhythmias, myocardial infarction (pump problem), multiple medications, or debilitating illness. The nurse should ask the patient if he or she gets dizzy when standing up from a sitting position.
Lightheadedness is often associated with a psychiatric diagnosis and/or hyperventilation. Anxiety is the number one factor predisposing a person to lightheadedness. It is reproducible with voluntary hyperventilation.
Asking the patient a few extra questions and taking a careful history can assist the provider in making a diagnosis. Dizziness is not a very good descriptor of this problem, so drill down a little.