Note to myself: The material in EMCrit 316 and the associated resources on the show notes is incredily important and should be reviewed frequently. Here is the intro to EMCrit 316:
Way back in episode 33, we discussed the diagnosis of subtle posterior stroke and differentiating emergent and safe causes of vertigo. Over the years, I still note confusion on these issues. Luckily, while surfing Youtube, I came across a doc who is obsessive about vertigo, Peter Johns…
Peter Johns, MD
Since completing his emergency medicine residency at the University of Toronto in 1989, Dr. Johns has worked at the Ottawa Hospital in Ottawa Canada. Over the past 20 years, he has become a passionate teacher of vertigo. His accomplishments include a YouTube channel about vertigo with over 5 million views, and co-authorship of the vertigo chapter in the most recent edition of Tintinelli’s textbook of Emergency Medicine. @peterjohns84
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In this post, I review and link to Dr. Scott Weinguart’s outstanding transcript of his podcast EMCrit 316 – Vertigo and Posterior Stroke with Peter Johns. [Link to the transcript] [*Link to the podcast].
*In order to access the podcast you must be a member of EMCrit. I’m a member and I strongly recommend all clinicians join. Here’s the Join EMCrit button.
Here are excerpts from the transcript.
EMCrit Jan 17 2022
So first, I’ll try and recap and re-emphasize the role of HINTS in the assessment of patients who might be having a stroke presenting with dizziness.
In a nutshell, HINTS is to be applied to patients with the AVS [Acute Vestibular Syndrome]. And that means that they have
constant dizziness, nausea, vomiting, their symptoms get worse with head movement, they have some difficulty walking, and very importantly, they have nystagmus at rest. Meaning, that
you can see nystagmus when they’re looking straight ahead, or off to either side 30 degrees.
And the basic differential in these patients who present to the ED with AVS is: is this VN? [Vestibular Neuronitis] (which is more common) or is this a PCS [Posterior Circulation Stroke], which is less common but obviously much more worrisome.
And as you pointed out in your comments, the first line of defense against missing a PCS that presents with constant dizziness and nystagmus is NOT the HINTS exam. It’s to look for central features that wouldn’t be expected to be seen in a patient with a peripheral cause, like vestibular neuritis.
And these central features can be found in the central part of my Big 3 of vertigo algorithm, which is in the current edition of Tintinalli, and also if you google CMAJ and my last name Johns,
you can find an article with it.*
*See also Dr. Peter Johns‘ YouTube video, Clinical diagnosis of vestibular neuritis using the HINTS plus exam, which was created to go along with the above article. 5:42, Premiered Feb 24, 2020.