Podcast 1020: Benign Paroxysmal Positional Vertigo (BPPV)

0:00This is the emergency medical minute sponsored by CarePoint and HCA Health One. Okay, so I'm going to talk about everyone's favorite cheek complaint, which is dizziness, but specifically I want to talk about BPPV. It's our benign positional vertigo, which is when we can diagnose it, it's really nice because we get to avoid all kinds of imaging and emissions. We had a patient yesterday who's 65 and she was having vertigo symptoms and it'd been going on for a couple of days and her symptoms did seem very positional. We were able to put the maneuver that shows the hey, she actually does have a posterior canal of BPPV and then we actually had our physical therapist do an epi maneuver on her and fix her and made her feel better and she was up walking around, didn't have any other neuro symptoms. So even though she was 65 and had a couple medical problems, she was able to go home without any imaging, no CT, no MRI and no admission, which I think we really are trying to do a lot more of that because if we can really be confident in differentiating between the types of vertigo, we do definitely save patients a lot of work up and a lot of extra emissions.

1:03So to talk about the different types of BPPV, there's a couple different types and what maneuver you do is a little bit different and there's kind of a lot to think about, but I can have a workflow that helps me memorize the things that I really need to memorize and then really offload the things I don't and just when they come up because they're less common, just go look them up essentially. So there's the three canals, there's the posterior canal, the horizontal and the anterior canal, the classic BPPV that we think about is posterior canal, so that's the one that we do with Dix Hall Pike maneuver if you've seen us do this sometimes and then the epi maneuver is a treatment one and but that's actually only about 70% of positional vertigo is that kind. 20% or so is horizontal canal and then 5% is anterior canal. To go through each of those for the posterior canal, the maneuver we do is we turn the head to the side and lay them back and then see if what you want to induce for a positive sign is you want to induce not just nistagmas and dizziness, you need to induce a rotational, like a torsional nistagmas that beats towards the affected eye. So it's pretty honestly a pretty weird looking nistagmas. Sometimes when we see, oh, they're

2:06like a little dizzy or it's a little bit of nistagmas that doesn't actually count as being positive and you can run into trouble there and then you want to do the other side and it should be nothing. So if you have one side where you get a torsional rotational nistagmas when you do the Dix Hall Pike maneuver, you say, hey, we've really diagnosed BPPB here and this is not a central positive vertigo and then the epi maneuver, it's not always going into the exact details of it, it's better to like watch a video or see, watch us do it, but you seem to do a couple rolling maneuvers trying to get the crystals that are dislodged in the inner ear to kind of navigate back to the right part of the canal. So we're just sort of rolling them in these certain ways and sit them up and then you can do it a couple of times if you need to, but that's how we actually try to treat the vertigo. So the first maneuver is to diagnose it and then the second part is to treat it. So for horizontal canal, that one, we don't do this, I think, near enough, but if you have somebody who really does seem positional and the Dix Hall Pike doesn't work, it's worth doing the next one, which is the supine roll test where you just lay them, it's actually simpler, you lay them back, you tilt their

3:06head up a little bit and you have their head resting looking straight up at the ceiling and then you turn them just to the left and then see if that induces misdiagnas and then turn them to the right, see if that induces misdiagnas. And this time you're not looking for rotational, you're looking for horizontal misdiagnas. This is the one where if you do on one side induce a horizontal misdiagnas, you've now have a positive horizontal canal and which maneuver you do is kind of complicated based on which one you find and it's not worth memorizing. So if you get down beating the sagmas, that's called geotropic BPPV and if you get up beating the sagmas, that's apogetropic. You can think like, you know, geo like the ground, like it's beating towards the ground, beating up. With the supine roll, if you get beating towards the ground, that's the effect of the air, if it's beating the opposite way like towards the ceiling, then it's the other is affected. But whether you have geotropic or apogetropic is actually a different new treatment maneuver you do. And so for geotropic, you do this barbecue roll and then for the apoget geotropic, you do a, it's like a goofony maneuver. They're both pretty simple maneuvers, but you are already you're probably like, I don't even remember what all that think all that is.

4:10So for me, my workflow with those two is I go in, if I really think it's positional, I do a Diggs Hallpike. If it's positive, I do an FLE because that one's so common, we do that a lot, we just kind of have that memorized, doing that with a maneuver. If that doesn't work and I, like, man, I really think this is a BPPV though, then I'll do the supine roll and if it's positive, I just note to myself, okay, is it being towards the ground, which year, or being up, which year? I write that down, give them a break, I go to my computer and sort out, okay, which year is it, which maneuver, which way, which side do you do each maneuver? So you really don't have the memorizers, other ones, it's just worth knowing they exist and just noting, okay, which misagments did I see? And then the last one is anterior BPPV. This one's much rare, you'll see why we really are probably not going to diagnose this one ourselves and be confident to send somebody home without any narrow involvement. So this one, the way you actually trigger and diagnose it is, you lay them flat back with their head tilting way back and you're trying to induce a downbeating to stagmas and the treatment is kind of this like where you tilt their head back up in a similar way, but with that one, one is much rare, two, because it's not sighted, like if you have somebody

5:13with disney as you're worried about a stroke and on one, you can induce a stagmas on one side and not the other side, you start to feel okay, that really seems peripheral because it's one of you, not the other year, but with this, you're going straight down the middle and inducing a stagmas. And so it's like, I don't feel that confident because it's this central thing that you're doing and so you don't have like a sightedness to it and so it's much riskier, I think saying, oh, that's what that is. And in the same way, let's say if you have somebody with a cerebellar stroke, if you do these maneuvers and they're only dizzy on one side, that doesn't sound very cerebellar, but if you take someone with a cerebellar stroke and you just lay them back, that's probably going to make them dizzy. So it doesn't feel that great and because you're inducing downbeating the stagmas, which is usually kind of a concerning type of a stagmas, I'm probably still getting neurology involved with those. So that's when we tend not to do the interior when that often, but the first thing I think, you know, we really do try to do do a lot and it'll help us definitely avoid a lot of MRIs that don't necessarily have to do. This has been the emergency medical minute. Thank you to our sponsor's care point and HCA Health One. Support from them and listeners like you helps us to

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