Last week, we explored various techniques to view nystagmus, and I made the suggestion that every Emergency Room in the country should have a pair of video goggles available. To better understand why I made this suggestion, let’s take a look at what happens most often when a patients goes to the Emergency Room with the complaint of “dizziness.”
Dizziness accounts for 3 to 5 % of all Emergency Department (ED) visits, but increases to as high as 10% of adults visits to the ED. In the Medicare population (age 65+) the percentage of ED visits incorporating a complaint of dizziness is as high as one in four. The percentage of ED visits related to dizziness doubled between 1995 and 2004 (Kerber, Meurer, West, Fendrick, 2008). With the aging U.S. population, there is reason to believe the number of dizziness related ED visits will continue to grow.

It is estimated that 18% of patients complaining of dizziness are seen in the ED (Polensik et al., 2008). Assessment protocols may vary between ED’s, but there is evidence that vestibular disorders are often missed or misdiagnosed using the most common protocols. Despite the fact that previous studies reveal that between 24 and 43% of dizzy patients presenting in the ED have a peripheral vestibular disorder, vestibular screening procedures are not a standard part of the ED evaluation for dizziness (Newman-Toker, Camargo, Hsieh, Pelletier, & Edlow, 2009). A recent review indicates that approximately 40% of dizzy patients presenting to the ED are never asked to provide details or give a description of their symptoms. Less than 10% undergo any type of vestibular screening exam such as inspection for positional nystagmus or vestibular-ocular reflex deficit (Polensik, 2008).

This may help explain the disproportionately low incidence of Benign Paroxysmal Positional Vertigo (BPPV) reported in the ED as compared to that reported in specialty clinics. The incidence of BPPV in the ED is reported at less than one percent in a cross-sectional study, while BPPV accounts for between 20 and 25% percent of diagnosis made in many vestibular clinics. Of course, in addition to different test protocols, the ED likely sees different patients with perhaps more acute symptoms than typically associated with BPPV. Nonetheless, many patients with BPPV are referred on for neuro-imaging or specialty evaluation without undergoing any type of positional test at the primary care level (Phillips, Fitzgerald, & Bath, 2009).

To be fair, and this is a philosophical point, the Emergency Department physicians are primarily concerned with life threatening conditions, so maybe it is unreasonable to expect that they practice and produce results expected of specialists. It is, however, very possible and desirable that simple, inexpensive screening techniques become accepted and routinely used in the ED.

References:
Kerber, K., Meurer, W., West, B. & Fendrick, M. (2008). Dizziness presentation in U.S. emergency departments, 1995-2004. Acad Emerg Med, 15(8), 744-750.

Newman-Toker, D., Camargo, C. Hsieh, Y., Pelletier, A. & Edlow, J. (2009). Disconnect between charted vestibular diagnoses and emergency department management decisions: A cross-sectional analysis from a nationally representative sample. Acad Emerg Med, 16(10), 970-977.

Phillips, J, Fitzgerald, J. & Bath, A. (2009). The role of vestibular assessment. J Laryn Otol, 1, 1-4

Polensek, S., Sterk, C. & Tusa, R. (2008). Screening for vestibular disorders: A study of clinicians’ compliance with recommended practices. Med Sci Monit, 14((5), 238-242.