Benzo for Dizziness

[ERDoc]

Why would you withhold treatment until you make a diagnosis? What difference would that make? Do you withhold pain meds for undiagnosed abd pain?

[uglyEMT]

Here is one for you.

Benign Postional Vertigo also known as BPPV (I forget what the other P is, I think it is proximal)

Not unlike regular vertigo with the spinning sensation and such BUT it is transiant depending on head position. Usually when tilting the head up or quickly moving it to the side.

It can be a tough diagnosis to get in the field. It may present as unkown reason for vomiting, dizziness that comes and goes, confusion, and in severe cases dehydration. If the person has remained still and in a position of comfort the feeling usually subsides on its own (unlike "regular" vertigo that stays no matter the position).

Now would the remidies be the same? (I ask because I truely don't know) Or would transport with finding a position of comfort that prevents the symptoms be enough and forego the meds?

[croaker260]

Now would the remidies be the same? (I ask because I truely don't know) Or would transport with finding a position of comfort that prevents the symptoms be enough and forego the meds?

Uhmm..both?

If the patients s/s are easily remedied with a non invasive intervention ...with no adverse side effects (i.e. a position of comfort that relieves or markedly reduces the s/s to a well tolorated level) ......then further intervention is not warranted in the prehospital setting.

IF this is NOT effective or practical to even try (i.e. hyperemesis) then more invasive and more risky (by comparison only, its still pretty safe)interventions such as medications (anti-emetics with or without benzo's) are indicated.

Its not an either /or question. Its a basics before (and side by side with) ALS solution.

I hope that makes sense.

[DwayneEMTP]

Here is one for you.

Benign Postional Vertigo also known as BPPV (I forget what the other P is, I think it is proximal)

Not unlike regular vertigo with the spinning sensation and such BUT it is transiant depending on head position. Usually when tilting the head up or quickly moving it to the side.

It can be a tough diagnosis to get in the field. It may present as unkown reason for vomiting, dizziness that comes and goes, confusion, and in severe cases dehydration. If the person has remained still and in a position of comfort the feeling usually subsides on its own (unlike "regular" vertigo that stays no matter the position).

Now would the remidies be the same? (I ask because I truely don't know) Or would transport with finding a position of comfort that prevents the symptoms be enough and forego the meds?

Yeah, sometimes called Top Shelf Vertigo as looking up will trigger it. This was actually the first Vertigo patient that I had. They explained their symptoms, I thought, "Holy shit! I think I know what this is!!" I had them on the cot, they were speaking and talking comfortably in a sitting position, so, like the rocket scientist I often am I said, " I want you to look at the ceiling for me.."

What I expected was a response of, "Oh hell...that makes me really dizzy and kind of sick to my stomach...." What happened was, this full grown man immediately grabbed both sides of the cot with white knuckles, his head started swinging from side to side, he yelled, " Oh fuck man! Oh fuck man!" and ceased answering any more of my questions..Withing a few seconds he was vomiting across his legs, crying, begging for me to make it stop! I actually had the thought, "Oh shit..I hope he's sick enough to forget that I started this in the first place.."

At least I'd already had access before starting this mess, so I pushed 12.5 IVSP/diluted Phenergan and with about 3-5 minutes he calmed down (I think, time was pretty relative at that point) And before long he was asymptomatic at rest...though I wanted to, really, really badly, even I wasn't a big enough idiot to ask him to move again to see how complete the relief was. But at the ER during transfer to the bed he chose to stand and move himself and seemed, other than a little dopey from the Phenergan, to be symptom free.

And as said before, if I'd not messed with this guy I might not have needed to medicate him...but I wanted to! I was new and wanted to 'cure' stuff...But now of course I want to do what's right way more than what's new to me....

Good posts all!

Dwayne

[Lone Star]

I've never heard of BPPV or 'Top Shelf Vertigo'...definately something to tuck away for future reference!

My question is this....in the above referenced scenario, wouldn't the twists, turns and bumps of transport also initiate the response (without being medicated)?

Also, is this serious enough for a responding BLS crew to have to call for an ALS intercept (presuming that transport is more than 10 minutes)?

As an ALS provider, how pissed at the BLS crew would you be for getting 'toned out' to respond (either on scene or intercepting) for this type of call?

As far as 'messing with this guy', it could be 'justified' as trying to gather enough information to establish a differential diagnosis based on field impression. However, if your only motive was to see if you could 'cure this guy', then that's a whole different bal of wax...

[ERDoc]

As usual, emedicine is a great resource;

http://emedicine.medscape.com/article/1159385-overview

http://emedicine.medscape.com/article/791414-overview

http://emedicine.medscape.com/article/794789-overview

[Lone Star]

After reading a little bit on BPPV and it's suspected causes, should I presume that we can expect an increase in cases among the 'headbanging crowd'?

[DwayneEMTP]

As far as 'messing with this guy', it could be 'justified' as trying to gather enough information to establish a differential diagnosis based on field impression. However, if your only motive was to see if you could 'cure this guy', then that's a whole different bal of wax...

Yeah man, it wasn't my intention to make him sick so that I could treat him, but to try and verify what I believed needed treatment was actually happening so that I could justify treating it. Know what I mean?

When I was new I wanted to push every drug, provide every treatment, encounter every illness, so that I could add that experience to my mental toolbox. I didn't want to be a cowboy and use things just because I could, but, early on, I needed to prove to myself that I wasn't afraid to use my drug box either. Of course, long ago now I've most everything in there and have more faith that each will do what I expect of it, but early on I had no such faith.

And yeah, if a basic crew had such a case with more than a few minute transport time without toning me out, I would seriously question their competence for continuing on the ambulance. Vertigo would still be a diagnosis of exclusions.

Dwayne

[Lone Star]

Yeah man, it wasn't my intention to make him sick so that I could treat him, but to try and verify what I believed needed treatment was actually happening so that I could justify treating it. Know what I mean?

When I was new I wanted to push every drug, provide every treatment, encounter every illness, so that I could add that experience to my mental toolbox. I didn't want to be a cowboy and use things just because I could, but, early on, I needed to prove to myself that I wasn't afraid to use my drug box either. Of course, long ago now I've most everything in there and have more faith that each will do what I expect of it, but early on I had no such faith.

And yeah, if a basic crew had such a case with more than a few minute transport time without toning me out, I would seriously question their competence for continuing on the ambulance. Vertigo would still be a diagnosis of exclusions.

Dwayne

With all the head bashing we've done over the years, I never would have even entertained the notion that you were the type that would be classified as 'cowoby' or 'rogue' just so that you could dip into the drug box.

I can completely understand why you did what you did, and if I were in the same place; would probably do the same thing, just for confirmation of my suspicions. Until I'm certain the nature of the illness, I can't provide adequate treatment.

Would I feel bad for the patient in this case? Without a doubt, unfortunately sometimes we have to put them in a situation that momentarily exacerbates their condition, in order to get an understanding of the full scope of their illness. Even with a patient with an isolated femur fracture who is stoned off the planet on morphine is going to scream at the top of their lungs when you put a traction splint on them. We're not putting it on them to make them scream, but in order to prevent potential further injury. Even when we see edema and potential deformation because of a wrist fracture, we still have to palpate it...it's just the nature of the beast.

[croaker260]

Yeah, sometimes called Top Shelf Vertigo as looking up will trigger it. This was actually the first Vertigo patient that I had. They explained their symptoms, I thought, "Holy shit! I think I know what this is!!" I had them on the cot, they were speaking and talking comfortably in a sitting position, so, like the rocket scientist I often am I said, " I want you to look at the ceiling for me.."

What I expected was a response of, "Oh hell...that makes me really dizzy and kind of sick to my stomach...." What happened was, this full grown man immediately grabbed both sides of the cot with white knuckles, his head started swinging from side to side, he yelled, " Oh fuck man! Oh fuck man!" and ceased answering any more of my questions..Withing a few seconds he was vomiting across his legs, crying, begging for me to make it stop! I actually had the thought, "Oh shit..I hope he's sick enough to forget that I started this in the first place.."

At least I'd already had access before starting this mess, so I pushed 12.5 IVSP/diluted Phenergan and with about 3-5 minutes he calmed down (I think, time was pretty relative at that point) And before long he was asymptomatic at rest...though I wanted to, really, really badly, even I wasn't a big enough idiot to ask him to move again to see how complete the relief was. But at the ER during transfer to the bed he chose to stand and move himself and seemed, other than a little dopey from the Phenergan, to be symptom free.

And as said before, if I'd not messed with this guy I might not have needed to medicate him...but I wanted to! I was new and wanted to 'cure' stuff...But now of course I want to do what's right way more than what's new to me....

Good posts all!

Dwayne

Not to laugh at your "ooopppsss"....because we have all been there at one time or another...but laugh I did. Good story with a lot of good points in it.