Greetings from Brazil colleague! Great and short video! Helped me a lot bc it makes me realise that it's not as simple as these tables state as i was suspecting

Another helpful video. Happy New Year Dr. Johns

Thank you for helping me understand vertigo and dizziness.

How do you treat central vertigo? Drugs or exercise?

Great video. Simplification sometimes leads to wrong conclusions.

@PeterJohns

2 жыл бұрын

Thanks Fabiano! These sorts of tables have been in emergency medicine textbooks for 40 years. And Rosen's (one of the top ones) still has one. Difficult to teach the things ED docs need to know about vertigo when their heads are filled with bad info to start with.

Great i am an emergency medicine resident in Pakistan. i was using these tables most of the times till I watched your video. Thanks alot sir

Thanks for the video! Came here after a UWorld question on cerebellar stroke. I'm surprised anyone would emphasize the insidious nature of central vertigo w/o emphasizing the important exception of the acute onset of stroke.

@PeterJohns

17 күн бұрын

When I was first taught vertigo 40 years ago, I got the impression that vestibular schwannomas were a frequency cause of vertigo. I never saw one!

Nice video Peter. I won’t expand on it except to say that this is not just a problem amongst ED docs

@PeterJohns

2 жыл бұрын

That is for sure. What percentage of ENTs actually like seeing vertigo patients do you think?

@CanHammer

2 жыл бұрын

@@PeterJohns im the only one

I'm so grateful I got here before watching the example videos 😢

❤❤❤Another helpful video. Dr. Johns❤❤❤

I have a problem with the vestibular neuritis diagnosis. It seems it's a bit like vestibular hypofunction I.E. a cop-out diagnosis basically meaning patient is dizzy - let them deal with it. If symptoms came on suddenly with no trauma, medication changes or viral infections but perhaps some unusual head movements then it would seem that an otoconia displacement would be likely even if nystagmus had ceased in the days since symptoms started.

@PeterJohns

Жыл бұрын

I don't follow what you're trying to say. Please rephrase it so I can understand your comment.

@mb-3faze

Жыл бұрын

@@PeterJohns Sorry to be vague: I've watched many of your useful videos and I know you are more at the emergency end of the diagnosis spectrum. My question is about non-emergency diagnosis. From other videos and some personal experience, it seems possible to have BPPV (displaced otoconia) conditions without nystagmus. A few weeks after a vertigo incident, some patients still have dizziness symptoms but have long ceased to have positional or spontaneous nystagmus. The DixHallpike tests do not show any outwardly visible nystagmus even if the patient feels dizzy being moved in to the positions. A HIT test could show a saccade and that might prompt a vestibular neuritis diagnosis. However, surely it is possible that the patient is actually a BPPV sufferer and with some careful VNG, VEMP and vHIT tests, be diagnosed as such and then potentially be successfully treated?

@PeterJohns

Жыл бұрын

@@mb-3faze OK, you're moving into an area that only specialists in vertigo would likely be able to assess. I am not a vertigo specialist. My role is to try and get emergency physicians and really any clinicians who assess the undifferentiated dizzy patient, to be able to recognize and be able to diagnose the most common and important causes of vertigo. So the answer to your question is not in my domain, and I will refrain from commenting on it further.

Always a pleasure doc

If patient fails road test, think central. I find it more helpful to examine other cranial nerves (skew, horners) or cerebellar to separate brain stem vs vestibular in the acute setting, rather than sorting out the nystagmus or HINTS.

@PeterJohns

Жыл бұрын

I agree inability to walk unaided (as well as other features not consistent with a peripheral cause) are important red flags. This is why my "Big 3" algorithm asked clinicians to look for these features before even considering HINTS or HINTS plus. See this video at this time stamp. kzread.info/dash/bejne/f6uW06yvfafVnrg.html. For the emergency physician, these central features are how most posterior circulations strokes will be picked up. Since vestibular neuritis is more common in most emergency departments than stroke as a cause of dizziness/vertigo and nystagmus, the real value of HINTS is to see the abnormal HIT, which should always be seen in patients with vestibular neuritis in the first several days. If a patients screens negative for central features, and has a clearly abnormal HIT, (as well as peripheral results in the rest of the HINTS plus exam) then vestibular neuritis is reliably diagnosed and the patient does not require diagnostic imaging. I'm not sure why you are suggesting that nystagmus doesn't need "sorting out". The characteristics of nystagmus in BPPV, vestibular neuritis and dizzy strokes are a very important finding in my opinion. Emergency physicians are expected to be able to appreciate subtle findings on ECG in the setting of chest pain. Due to exposure to ECG from medical student years through residency, most ED docs can interpret ischemia on an ECG fairly well. The reason why most physicians are not competent in evaluating vertigo is because of the faulty approaches such as "central vs peripheral" tables, as well as relying on "what do you mean by dizzy?" to generate a differential diagnosis. Add to that the lack of easily accessible videos of the abnormal nystagmus and other eye findings in educational materials available to learners, and you find ourselves in the current predicament where most doctors dislike seeing vertigo patients.

@KFire

7 ай бұрын

@@PeterJohns Thanks Peter for your very helpful videos. As an emergency physician, I have had a lot of patients present with vertigo in the ER without a clear HINTS exam pointing either way (e.g. negative HI, no nystagmus, no test of skew), also able to walk unaided but still having some mild-residual vertigo. Some of these patients obviously have risk factors, >50, HTN, Dysl, T2DM, and no other central features (Deadly Ds). I often find myself completing a CT/CTA, providing antiplatelet therapy, and then sending to stroke prevention clinic follow-up. Most of these in follow-up end up being diagnosed vestibular neuritis, I am not clear how they end up on this diagnosis as no MRI is completed for these patients. If you have an equivocal HINTs, without a clear exam pointing towards either central vs peripheral, do you think leaning towards stroke etiology and treating for that until follow-up can be arranged would be appropriate?

I think test writers need to catch up with reality, I was able to digest your perspective on this and it is solid, but test writers want to add uncommon symptoms into their clinical vignettes in order blurr the diagnosis and also to create more differentials to add to the answer options. Her perspective lines up with a new NBME question. The triad of Hypoacusia , tinnitis, vertigo is classic for Menier's Disease, but in the question they are able to use "slow progression" and additional CN manifestion as the diferentiating feature for Unilateral Acustic Neuroma. So in essence the answer was Unilateral Acustic Neuroma with the triad of tinnitis , hypoacusia and vertigo. Exams arent corelating with reality now a days.

@PeterJohns

Жыл бұрын

Completely agree. It's sad when clinicians have a difficult time diagnosing BPPV, which in it's typical presentation is so easy to diagnose. Yet the relatively rare causes such as Meniere's and vestibular schwannomas pop up in exam questions with frightening regularity. Can you send me the NBME question you refer to? I'm 33 years away from the last exam I wrote. For your interest, it was worse 36 years ago. The vertigo chapter in the first textbook in emergency medicine I bought in 1984 had a table with 10 ways to differentiate vertigo caused by vestibular seizures vs vestibulogenic seizures. You can't make this up!

Wait what about labyrthyntitis, isn't that constant vertigo besides vestibularneuritis?

@PeterJohns

2 жыл бұрын

Yes, but it’s fairly rare compared to vestibular neuritis. Also, hearing loss can be related to AICA stroke. See my video on HINT “plus” exam.

@lifeisgood628

2 жыл бұрын

@@PeterJohns thanks!

@nicky2591

Жыл бұрын

@@PeterJohns is this hearing Los only for a second,that switch from left to tight

@PeterJohns

Жыл бұрын

@@nicky2591 No.

Excellent video ❤

Dr Johns is doing on his channel what Peter Smith did for acute coronary syndrome in his blog. Contemporary heroes of emergency medicine

@PeterJohns

2 жыл бұрын

Thanks for the compliment. I am not aware of Peter Smith's blog and couldn't find it with a quick search. Mind sending me a link? Thanks!

Peter Johns is excellent. But many KZread vertigo/dizzy videos contain inaccurate information. KZread journal of vestibular research videos are great for neurologists.

@PeterJohns

2 жыл бұрын

Yes, there are many bad vertigo videos. The problem with videos made for neurologists is that ED docs have very little mental bandwidth that they are willing to devote to vertigo. And vertigo experts tend to make information that is aimed at other vertigo experts. I try and only teach what will help the average ED doc evaluate vertigo patients.

@kennethmoore3783

2 жыл бұрын

@@PeterJohns thanks so much. great videos too.

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thank u sir for ur clarification.

nice