Dizziness in the Emergency Department –Part II

 

What typically happens when a patient goes to the Emergency Room for the complaint of dizziness?

When a patient presents with the complaint of vertigo or dizziness in the Emergency Room,  the most common diagnostic procedures performed are blood tests (including CBC, ECG, Glucose, BUN and Creatinine), Pulse Oximetry, Chest X-Ray, Urinalysis, Cardiac monitoring and CT/MRI (Kerber et al., 2008).  Electrocardiography is the most often performed diagnostic procedure (45% of dizzy patients), with imaging (most often CT scanning) performed on 17 to 24% of these patients (Kerber et al., 2008; Newman-Toker et al., 2008b).  The diagnostic yield of these tests is very low and is discussed in detail in previous posts.

            Diagnosis is often achieved through patient complaint as opposed to results of diagnostic testing in the ED.   However, as noted last week, 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 beyond simply being classified as “dizzy.”   Less than 10% undergo any type of vestibular screening exam such as inspection for positional nystagmus or vestibular-ocular reflex deficit (Polensik, 2008).

Even when a specific vestibular diagnosis is applied, evidence suggests that management strategies employed in the ED are not supported by published clinical guidelines or evidence based medicine.  Newman-Toker et al. (2009) reviewed the records of 9,472 ED patients, and found that 7.4% were given a vestibular related diagnosis. Based on this percentage, they estimate that roughly 2.5 million ED visits were given a vestibular related diagnosis in the United States over the 13 year study period.  They specifically reviewed the management decisions involving patients diagnosed with BPPV and acute peripheral vestibulopathy (such as vestibular neuronitis or labyrinthitis).  These are very different vestibular conditions requiring very different treatments.  It was noted that management decisions employed differed very little between the two groups (BPPV and acute peripheral vestibulopathy).  Neuro-imaging (mostly CT scanning) and use of vestibular suppressant medication was used with equal frequency in both groups.  Recent published clinical guidelines recommend against the use of these two management strategies in patients diagnosed with BPPV.  They (Newman-Toker et al, 2009) conclude that ED physicians would benefit from increased knowledge of effective management strategies for specific vestibular disorders.

This is not news to Emergency Department physicians.  They are aware of the inefficiencies of current evaluation protocols, and have shown interest in new techniques and guidelines that would allow more efficient and accurate assessment of the dizzy patient presenting in the ED.  A recent large survey of ED physicians reveals that the patient presenting with vertigo is a top priority when asked which adult clinical problem* would most benefit from a well designed clinical rules guideline (Eagles et al., 2008).

*The febrile toddler topped the list of ER patients for which ER physicians would like specific guidelines.

References:

Eagles, D., Stiell, I., Clement, C., Brehaut, J., Kelly, A., Mason, S., et al. (2008). International survey of emergency physicians’ priorities for clinical decision rules. Acad Emerg Med, 15(2), 177-182.

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.

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.

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.