Pediatric Peripheral Vertigo

Emergency Protocol

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Ondansetron

Antiemetic • > 1 month old

0.15 mg/kg/dose (Max 8mg/dose)

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Oral (Syrup 4mg/5ml): --ml
NOT IN < 2 YEARS

Dimenhydrinate

Vestibular sedative • > 2 years

5 mg/kg/day (Distributed every 8 hours)

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Hydroxycin

Antihistamine • > 12 months

1 mg/kg/day (Distributed every 8 hours)

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Oral (Syrup 2mg/ml): --ml
RESTRICTED USE

Sulpiride

Neuroleptic • > 10 years

5 - 10 mg/kg/day (Distributed every 8-12 hours)

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Oral (Sol. 5mg/ml): --ml

Important Clinical Note

If the patient improves his discomfort with the Ondansetron isolated (which has an excellent safety profile), it is preferable avoid adding vestibular sedatives so as not to interfere with central compensation. Limit use to 3-4 days maximum.

Metoclopramide: Very restricted use in pediatrics due to risk of extrapyramidalism.

The main objective in the emergency room is etiological treatment, since the vast majority of peripheral conditions are treatable or self-limiting.

Acute Otitis Media / Labyrinthitis

Inflammatory or infectious involvement of the labyrinth, frequently secondary to AOM.

  • Treatment: Systemic antibiotic therapy (e.g. Amoxicillin or Amoxicillin-Clavulanine at high doses 80-90 mg/kg/day).
  • ENT action: Evaluation for myringotomy if poor evolution or purulent labyrinthitis.

Traumatic Brain Injury / Barotrauma

High suspicion of Perilymphatic fistula if it associates sensorineural hearing loss and vertigo after TBI or sudden pressure change.

  • Management: Absolute rest.
  • Position: Headboard raised to 30º.
  • Derivation: Surgical evaluation URGENT by Otorhinolaryngology (ENT).

Foreign Body / Earwax

It can cause vertigo due to direct pressure on the tympanic membrane.

Management: Instrumented extraction or lavage (if there is no contraindication).

BPPV in children

Very rare in pediatrics. Brief vertigo triggered by changes in posture.

Management: Replacement maneuvers (Epley/Semont). Does not require drugs.

General Measurements in Box

IV fluid therapy

Indicated if there are signs of dehydration or oral intolerance due to uncontrollable vomiting.

Atmosphere

Recumbent rest, quiet room, dim lighting. Avoid sudden head movements.

Rehabilitation

A posteriori (external consultations) if there is residual instability.

Referral Criteria to ENT / Red Flags

Although most cases of childhood peripheral vertigo are discharged from the emergency room, request urgent evaluation by a specialist if:

  • Suspected Perilymphatic Fistula: History of TBI or barotrauma associated with hearing loss.
  • Sudden Hearing Loss: Confirmed and not related to plugging or obvious AOM.
  • Refractoriness: There is no response to intensive IV symptomatic treatment in the box.
  • Neurological Doubts: Presence of atypical nystagmus (vertical, non-suppressible pure rotary), neurological focality, or absolute inability to walk that does not improve. (Suspicion of central cause).