Guideline for Vertigo in the ER

 

A couple of years ago, I did a four part series here discussing the potential benefits of developing a Clinical Practice Guideline for Acute Vertigo. This would be most applicable to Emergency Department (ED) and Primary Care Physicians (PCP), as very few patients are still in the acute phase by the time they make it to a vestibular lab. There is much evidence to suggest that there may be more efficient ways to evaluate patients that present with acute, recent onset vertigo. There is also evidence that ED physicians recognize this, but also have concerns about adopting new protocols.

 Several months after I concluded my series, the article “Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms” was published. The authors of this article surveyed ED physicians to get an idea how they felt about a new practice guideline replacing their current methods of assessing a patient with acute vertigo. Here are a few highlights from that article:

Less than half of ED physicians use the Epley maneuver to treat BPPV, and less than one out of three use the HINTs protocol to examine for nystagmus, skew deviation, or abnormal head thrust. Both of these techniques have a better than 90% success rate at treating BPPV effectively, and separating peripheral from central vertigo when performed by experienced specialists. That level of confidence has not carried over to the ED.

The majority  of ED physicians (74%) routinely use cranial CT scan when stroke is suspected. Although an equal number of physicians (75%) agreed that CT scan was overused in the evaluation of vertigo. Read about CT scans for dizziness here.

The majority rely on patient medical history and quality of symptoms in establishing risk of stroke. ED physicians express confidence in using cranial nerve exam and limb weakness to separate stoke from benign vertigo. One out of four routinely request neurology consult when stroke is suspected.

ED physicians surveyed agreed that a decision guideline would have to reduce the risk of missed stroke to .05% for them to feel comfortable using it as an alternative to current techniques.

The authors recognize that the risk of stroke as a cause for acute vertigo is quite low (2 to 4%), so any technique to help identify those with stroke more efficiently will only apply to a small group of patients.

 

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About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.