Scenario Saturday: Dizziness and the Devil in the Details

The Setup

You’re dispatched to a private residence for a 75-year-old female experiencing vomiting and dizziness. It’s mid-morning, and the caller—her neighbor—states she’s “not acting right.” Upon arrival, you’re greeted by the patient, who is seated but pale and sweating. She tells you she feels dizzy and weak and has vomited once since waking up. Her speech is clear, but she seems slightly disoriented.

The Scene

The home is clean but sparse, with no visible signs of hoarding or unsafe conditions. A glance into the fridge reveals only a few items, and her stove has several unopened cans of soup sitting on it. The patient lives alone, and there’s no one else to provide additional history.

Initial Presentation

• Chief Complaint: Dizziness, weakness, and nausea since waking up. No reports of chest pain or shortness of breath.

• Skin: Pale and clammy.

• Mental Status: Alert but seems mildly confused, with delayed responses to questions.

• Speech: Clear but slightly slower than expected.

• Vitals:

  • BP: 182/110 mmHg.

  • HR: 88 bpm, regular.

  • RR: 16 breaths/min, unlabored.

  • SpO2: 96% on room air.

  • Blood Glucose: 115 mg/dL (via glucometer)

What Do You Do Next?

This presentation is a head scratcher, but you know the devil is in the details. What’s your approach?

Option A: Perform a stroke assessment using the Cincinnati Stroke Scale and consider calling ALS for a RACE score evaluation.

Option B: Assume this is dehydration-related dizziness. Administer oxygen and encourage oral fluids en route to the hospital.

Option C: Investigate her medications, environment, and recent history to identify contributing factors.

Option D: Transport promptly without further assessment, as this could be a stroke, cardiac event, or another life-threatening issue.

The Outcomes

If You Choose Option A (Stroke Focus):

You perform the Cincinnati Stroke Scale:

• Facial droop? None.

• Arm drift? Negative.

• Speech changes? Mild but not definitive.
  

Although the Cincinnati Stroke Scale is negative, you call ALS to perform a RACE score. ALS arrives and detects mild ataxia (unsteady gait) and slurred speech. Based on the high BP and neurological findings, ALS alerts the stroke team at the hospital. Imaging confirms a posterior circulation stroke, which was causing dizziness and nausea.

If You Choose Option B (Dehydration Assumption):

Assuming dehydration, you provide oxygen and encourage fluids. The patient becomes more disoriented during transport, and by the time you arrive at the hospital, she is unable to follow commands. Imaging later confirms a posterior stroke—the delay in activating a stroke alert results in a worse outcome, as the treatment window for tPA or thrombectomy narrows.

If You Choose Option C (Investigate Further):

You ask about her medications and learn that she hasn’t taken her antihypertensive medication in several days because she’s “run out.” This explains the elevated BP but not necessarily the dizziness. As you question further, she mentions recent blurry vision and trouble balancing when walking. You call ALS for further assessment, and the patient is transported under a stroke alert. The hospital confirms a posterior circulation stroke, which was caught just in time for intervention.

If You Choose Option D (Transport Promptly Without Further Assessment):

You prioritize transport, but without gathering key details like recent blurry vision or gait instability, ALS is not activated. The patient deteriorates en route, with worsening disorientation. Imaging later reveals a posterior stroke, and the limited information delays her care.

Debrief and Key Reveal

The key to this case is recognizing the subtle and atypical signs of a posterior circulation stroke. These strokes often present differently than the classic anterior strokes assessed by the Cincinnati Stroke Scale. Symptoms like dizziness, nausea, ataxia, blurry vision, or confusion should raise suspicion for a posterior stroke, especially in elderly patients with risk factors like hypertension.

What You Should Have Done:

1. Perform Thorough Stroke Assessments:

• Start with the Cincinnati Stroke Scale, but if negative, consider other tools like the RACE score to assess for large vessel occlusion (LVO).

  
  

• Look for subtle signs like ataxia, blurry vision, or gait instability, which are red flags for posterior strokes.

2. Think Beyond Dehydration or Vertigo:

While dizziness and nausea can stem from benign causes, combine these symptoms with other findings (e.g., high BP, confusion) to keep a high index of suspicion for stroke.

3. RACE Score for Large Vessel Occlusion (LVO):

Perform a RACE (Rapid Arterial oCclusion Evaluation) score or another LVO-focused stroke scale.

RACE evaluates symptoms beyond the Cincinnati Stroke Scale, incorporating factors like gaze deviation, leg weakness, and aphasia, which are indicative of posterior and large-vessel strokes.

High RACE scores warrant a stroke alert and transport to a thrombectomy-capable stroke center if available.

4. Investigate the Scene and Patient History:

Check for medication non-compliance, recent vision changes, or other neurological complaints. Environmental factors like a near-empty fridge may hint at poor nutrition or underlying systemic issues.

5. Call ALS Early:

Posterior strokes can progress rapidly and are challenging to diagnose. ALS support with cardiac monitoring, advanced stroke scales, and rapid transport to a stroke-capable facility is critical.

Behind the Research

Gait and balance disturbances are critical indicators of stroke, particularly in cases involving the posterior circulation, which supplies blood to areas of the brain responsible for coordination and spatial orientation. Strokes in this region can lead to symptoms such as dizziness, unsteady gait, and loss of balance, often without the classic signs like facial droop or arm weakness. This makes gait and balance assessments vital in stroke evaluation.

Research underscores the importance of these assessments. A study published in the Journal of NeuroEngineering and Rehabilitation highlights that improper gait patterns and impaired balance are common post-stroke, significantly affecting mobility and safety. (NeuroEngineering Journal)

Another study in the Journal of Physical Therapy Science emphasizes that balance abilities are crucial for effective gait, indicating that balance impairments can directly impact walking capabilities. (J-STAGE)

For practical insights, the American Stroke Association offers post-stroke exercise videos focusing on improving balance and movement, which can be valuable resources for both patients and healthcare providers.(American Stroke Association)

Incorporating gait and balance evaluations into stroke assessments enhances the detection of strokes that might not present with typical symptoms, ensuring timely and appropriate intervention.

Clinical Pearl: The Narrowing tPA Window

The efficacy of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is highly time-sensitive. While guidelines permit tPA administration up to 4.5 hours after symptom onset, its effectiveness diminishes with each passing minute. Delays can lead to increased neuronal death and reduced functional recovery.

A study published in JAMA found that earlier tPA administration correlates with better outcomes, emphasizing that "time is brain." Factors such as patient age, comorbidities, and pre-existing conditions can further influence the therapeutic window, making rapid assessment and intervention critical.

Key Takeaway:

Every minute counts in stroke management. Healthcare providers should prioritize swift evaluation and treatment to maximize tPA's benefits and improve patient outcomes.

Closing Thoughts

Dizziness and nausea in elderly patients can be deceptive. This case reminds us to dig deeper, think critically, and look beyond the obvious. The key to saving lives often lies in the details we uncover during a thorough assessment.

Want to learn more about strokes check out my YouTube channel and this video - Practical Stroke Management for EMS Providers

Have a safe and insightful weekend, and as always, feel free to share your thoughts or questions about this scenario.

Stay frosty out there!

ALS Block: Advanced Care in the Case of Dizziness and Vomiting

For ALS providers, this case offers a significant opportunity to elevate patient care by leveraging advanced diagnostic tools and interventions. While BLS crews are adept at recognizing stroke-like symptoms and managing transport, ALS plays a critical role in identifying subtle signs of a posterior stroke, stabilizing the patient, and guiding prehospital care.

What Should ALS Providers Know?

1. Posterior Circulation Strokes Are Subtle but Deadly:

Dizziness, vomiting, gait instability, and blurry vision are hallmark signs of posterior circulation strokes, which often present without the classic facial droop or arm drift seen in anterior circulation strokes.

These strokes can progress rapidly, leading to severe disability or death if left untreated. Time is critical.

2. Hypertension as a Clue:

In this case, the patient’s BP of 182/110 mmHg is a red flag, consistent with a stroke or hypertensive crisis. ALS should monitor for signs of worsening neurological symptoms and manage blood pressure cautiously en route, following local protocols.

What Should ALS Providers Have Done?

1. Perform a 12-Lead ECG:

Dizziness and nausea can sometimes mask cardiac events, such as posterior myocardial infarction, which may present atypically in elderly patients. A 12-lead ECG can rule out cardiac involvement.

2. Initiate Neurological Monitoring:

ALS should monitor for worsening ataxia, gaze deviation, or mental status changes. This includes using Glasgow Coma Scale (GCS) scoring and repeated assessments for changes in neurological status.

3. Guide BLS Through Scene Dynamics:

ALS providers should ensure the BLS crew has gathered key details, such as last known well time, medical history, and medications. These details are critical for hospital teams during stroke workup.

4.Manage Nausea and Protect the Airway:

Patients with vomiting and altered mental status are at risk of aspiration. Administer ondansetron for nausea if protocol permits and then be prepared to manage the airway with suction or advanced techniques if the patient deteriorates.

5. Alert the Stroke Team:

Based on the findings of the RACE score and patient presentation, ALS should notify the receiving hospital of a suspected stroke, prioritizing a thrombectomy-capable center. This ensures the stroke team is mobilized before arrival.

How Can ALS Guide BLS Providers?

1. Enhance Stroke Recognition:

Teach BLS crews to recognize posterior circulation signs, like dizziness, ataxia, and blurry vision, as potential stroke indicators. Encourage them to think beyond the Cincinnati Stroke Scale when symptoms don’t fit the typical mold.

2. Emphasize Gathering Critical Information:

Reinforce the importance of collecting last known well time, medication use, and subtle symptoms like transient vision loss or balance changes. These details are vital for ALS and hospital teams to make fast, accurate decisions.

3. Encourage Early ALS Activation:

Help BLS crews understand when ALS backup is essential. In cases with high BP, neurological symptoms, or atypical presentations, earlier ALS involvement can prevent delays in definitive care.

Takeaway for ALS Providers

Your advanced training, tools, and diagnostic capabilities are critical in cases like this. By recognizing subtle signs of stroke, performing targeted neurological assessments, and collaborating closely with BLS crews, you ensure the patient receives timely and effective care. Posterior strokes may not scream for attention, but your expertise can give these patients a fighting chance.

The Geek Corner: Understanding Posterior Circulation Strokes

Posterior circulation strokes (PCS) involve the vertebrobasilar arterial system, which supplies blood to critical brain regions, including the brainstem, cerebellum, thalamus, and occipital lobes. These areas are essential for functions such as coordination, balance, vision, and vital autonomic processes.

Pathophysiology:

The vertebral arteries merge to form the basilar artery at the brain's base, collectively known as the posterior circulation. Occlusions or stenosis in these arteries can lead to ischemia in the supplied regions, resulting in diverse and often subtle symptoms. Common causes include atherosclerosis, embolism, and arterial dissection. Notably, the posterior circulation's complex anatomy and collateral pathways can sometimes mask the severity of ischemia, complicating diagnosis.

Clinical Presentation:

Symptoms of PCS can vary widely but often include:

• Dizziness and Vertigo: Due to cerebellar or vestibular involvement.

• Ataxia: Reflecting cerebellar dysfunction, leading to coordination and balance issues.

• Visual Disturbances: Such as homonymous hemianopia, resulting from occipital lobe involvement.

• Cranial Nerve Deficits: Including dysarthria and dysphagia, indicating brainstem involvement.

These symptoms can be transient or fluctuating, making PCS challenging to diagnose. Traditional stroke scales may not effectively detect PCS, underscoring the need for comprehensive neurological assessments.

Diagnostic Challenges:

The variability in PCS presentation often leads to misdiagnosis or delayed diagnosis. Studies indicate that PCS is three times more likely to be misdiagnosed compared to anterior circulation strokes. Advanced imaging techniques, such as MRI with diffusion-weighted imaging, are crucial for accurate diagnosis.

Management:

Timely recognition and treatment are vital. Interventions may include intravenous thrombolysis (tPA) and endovascular thrombectomy, depending on the occlusion's location and timing. Given the posterior circulation's critical structures, prompt reperfusion is essential to prevent severe disability or death.