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Vertigo en Servicio de Urgencia

Publicado en: Educación, Salud y medicina
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  1. 1. Vértigo¿O mandé un ACV a la casa? Dr. Carlos Basaure V EmergenciólogoDepartamento Medicina de Urgencia Universidad de Chile
  2. 2. Vértigo• Sensación de desorientación en el espacio más sensación de movimiento• Mareos• Debilidad• Nauseas• Lipotimia
  3. 3. Desafío• ¿Es vértigo?• ¿Es central o periférico?
  4. 4. Equilibrio•Núcleo vestibular: • Integra todas las señales en el cerebelo
  5. 5. Sistema Vestibular
  6. 6. Nistagmo
  7. 7. Enfrentamiento• ¿Es Vértigo? • Sensación de movimiento • Nauseas, vómitos, diaforesis, palidez.
  8. 8. Enfrentamiento VértigoPeriférico Central SVA Hemorragia VPPB Tumor Meniere Isquemia
  9. 9. Enfrentamiento VértigoPeriférico Central SVA Hemorragia VPPB Tumor Meniere Isquemia
  10. 10. Enfrentamiento VértigoPeriférico Central SVA Hemorragia VPPB Tumor Meniere Isquemia
  11. 11. Enfrentamiento VértigoPeriférico Central SVA Hemorragia VPPB Tumor Meniere Isquemia Neuritis Vestibular ACV Vertebrobasilar Esclerosis Múltiple
  12. 12. Sindrome Vestibular Agudo• SVA: vértigo de inicio súbito, nauseas, vómitos, marcha inestable y imposibilidad de mover la cabeza y nistagmo que dura días a semanas• 25% de estos son ACV cerebeloso o de tronco• TC tiene sens. baja (16%) para fosa posterior• RNM no esta presente en todas partes• Menos de a mitad tiene disartria o dismetría
  13. 13. Enfrentamiento• ¿Periférico o central? • Periférico: episódico, intenso, cambios de posición, tinítus, hipoacusia • Central: ataxia, lateropulsión, edad avanzada, FA, HTA, DM, E Coronaria. • Asociación a trauma (cuello, craneo)
  14. 14. It has clearly been shown that isolated vertigo can be the The abnormal jerk nystagmus of inner ear disease consists , and only initial symptom of cerebellar and other posterior circula- of slow and quick components. The eyes slowly “drift” in theasion- tion bleeds, transient ischemic attacks (TIAs), and infarc- direction of the diseased, hypoactive ear, then quickly jerkediate Table 12-1 Characteristics of Peripheral and physicians often tion.11-13 One study showed that emergency back to the intended direction of gaze. Positional nystagmus, laby- did not make Vertigo diagnosis in patients with validated Central the correct induced by rapidly changing the position of the head, stronglyquires strokes or TIAs that presented with only vertigo.6 Risk factor suggests an organic vestibular disorder. The characteristics ofdenti- CHARACTERISTIC and symptom patterns can beCENTRAL helpful in assessment PERIPHERAL extremely nystagmus are one of the most valuable tools for distinguishing deciding which patients warrant imaging and admission. Older peripheral from central causes of vertigo (Table 12-2).e 12-1 Onset age, male sex, hypertension, coronary artery disease, diabetes Sudden Gradual or sudden Positional Testing. If nystagmus is not present at rest, positionall and mellitis, and atrial fibrillation put patients at higher risk. In Intensity Severe Mild testing can be helpful in determining its existence and char- addition, frequent episodes lastingor Duration Usually seconds only minutes weeks, Usually or prolonged acteristics. In the Hallpike maneuver, the patient is moved episodes of a day minutes; are more often associated with or more months quickly from an upright seated position to a supine position, 6,11,12 central processes. occasionally retrospective study showed A recent (continuous) but and the head is turned to one side and extended (to a head- emergency physicians often failed to chartcan be seconds hours, days triggers and dura- down posture) approximately 30° from the horizontal plane off tion of dizziness, information that could potentially lead to (intermittent) or minutes with the end of the stretcher. The eyes should be observed for increased likelihood of a more serious cause of symptoms.14 vascular causes nystagmus and the patient queried for the occurrence of symp- Past Medical History. Many medications have direct vestibulo- Direction of One direction Horizontal, rotary, orma- toxicity. The most commonly encounteredor verticalare the aminogly- Does nystagmus (usually cosides, anticonvulsants, alcohols, quinine, quinidine, and horizontorotary), (differente or a minocycline. In addition, caffeine and nicotine can have wide- never vertical directions in Distinguishing Characteristics of Nystagmus indi- ranging autonomic effects that may exacerbate vestibular Table 12-2 with Central and Peripheral Vertigo different r, and symptoms. The history of past and present illnesses should be positions) explored, with specific questioning about the existence of dia- ms of Effect of headdrug or alcohol use,by the risk factors mentioned Worsened and Little change, CHARACTERISTIC CENTRAL PERIPHERAL betes, ertigo position earlier. position, often associated with Direction Any direction Horizontal or effect single critical more than one horizontorotaryave an position position Laterality Unilateral or bilateral Bilateral Physical Examination Associated None Usually present on of Position testingy, dis- neurologic Vital Signs. In some cases, pulses and blood pressure should be effects: findings checked in both arms. Most patients with subclavian steal Latency Short Long entral Duration Sustained Transient Associated auditory syndrome, whichMay canpresent, also be cause vertebrobasilar artery insuffi- None Intensity Mild Mild to severe findings ciency, have pulseincluding or systolic blood pressure differences often between the two arms. tinnitus Fatigability Nonfatigable Fatigable have Effect of visual Not suppressed, may Suppressed Head and Neck. Carotid or vertebral artery bruits suggest ath- fixation be enhancedspells. erosclerosis. The neck is auscultated along the course of theble to evidence suggesting seizures, syncope, or imbalance unrelatede able to feelings of vertigo. iately The time of onset and the duration of vertigo are important addi- clues to the cause. Episodic vertigo that is severe, lasts several cover hours, and has symptom-free intervals between episodes sug-
  15. 15. Enfrentamiento• ¿SVA es Central o periférico? • HINTS HINTS to Diagnose Stroke in the Acute Vestibular Syndrome : Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh and David E. Newman-Toker Stroke. 2009;40:3504-3510; originally published online September 17, 2009; doi: 10.1161/STROKEAHA.109.551234 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2009 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628 The online version of this article, along with updated information and services, is located on the World Wide Web at:
  16. 16. Enfrentamiento• Head Impulse (HI) : • Evalúa el reflejo vestíbulo-ocular • Se fija la mirada en un punto y se gira la cabeza en 30º de manera aleatoria • Si esta presente, indica lesión vestibular
  17. 17. Head Impulse (HI)Prueba POSITIVAPeriféricoBueno
  18. 18. Head Impulse (HI)Prueba POSITIVAPeriféricoBueno
  19. 19. Enfrentamiento• Nistagmo (N) • Multidireccional, no agotable, alternante
  20. 20. Nistagmo “Horizontal” Horizontal Periférico Bueno
  21. 21. Nistagmo “Horizontal” Horizontal Periférico Bueno
  22. 22. Nistagmo “vertical” Vertical Central Malo
  23. 23. Nistagmo “vertical” Vertical Central Malo
  24. 24. Enfrentamiento• Test of Skew (TS) • Se cubre un ojo y se pide que fije la mirada en un punto comandos ojos. • Central si el ojo examinado esta desalineado de manera vertical
  25. 25. Test of Skew (TS) Desalineamiento Central
  26. 26. Test of Skew (TS) Desalineamiento Central
  27. 27. Enfrentamiento Sindrome Vestibular Agudo• Util: • Múltiples episodios → ACV • Cefalea o Cervicalgia → LR 3.2 • Sint Neurológicos: ataxia de tronco o lateropulsión • Head Impulse: Normal LR 18.4 para ACV • Nistagmo: alternante S30% E98% • Test Skew: anormal → ACV S38% E98% • RNM: S83% para ACV
  28. 28. EnfrentamientoInútil:• Diferenciar tipo de vértigo• Onset del vértigo• Provocación con movimiento• Proporcionalidad de síntomas (distinto → periférico)• Hipoacusia• Parton y vector del nistagmo• TC Cerebro sin cte. S16% para ACV
  29. 29. EnfrentamientoHINTS• INFARCT• Impulso Normal• Fast-Phase Alternating• Refixation on Cover Test• Si 1 de 3 anormal S100% E96% para CENTRAL
  30. 30. Vértigos Periféricos• VPPB: • Intenso, corta duración, sintomas asociados, nistagmo reproducible con cambios de posición• Meniere: • Horas de duración, tinítus, hipoacusia, periodos de ataques frecuentes y periodos largos asintomáticos, sin nistagmo posicional
  31. 31. Sindrome Vestibular AgudoHINTS• Head Impulse: anormal SVA Periférico• Nistagmo: horizontal, agotable, unidireccional Neuritis Vestibular• Test Skew: normal
  32. 32. FIN