Acute Dizziness and Vertigo in the Emergency Department

Publication Date: May 10, 2023
Last Updated: May 12, 2023

Summary of Recommendations

Training Emergency Clinicians to Perform Bedside Eye Movement Examinations

Emergency clinicians should receive training for diagnosing and treating patients with acute dizziness. (U, U)
620

Diagnosis of AVS

In patients with nystagmus, trained clinicians should use HINTS testing to distinguish central (stroke) from peripheral (inner ear, usually vestibular neuritis) diagnoses. (S, H)
620
In patients with nystagmus, assess hearing by finger rub to distinguish central from peripheral diagnoses. (C, M)
620
In patients without nystagmus, assess severity of gait unsteadiness to distinguish central from peripheral diagnoses. (C, M)
620
In patients with or without nystagmus, do not routinely use non-contrast brain CT or CTA. (S, H)
620
In patients with or without nystagmus, do not routinely use MRI or MRA as the first-line diagnostic test if a clinician trained in HINTS is available. (S, H)
620
In patients whose HINTS result is central or equivocal, use MRI/MRA to distinguish between central and peripheral diagnoses. (S, H)
620

Diagnosis of s-EVS

Clinicians should perform a history and physical exam with emphasis on cranial nerves, visual fields, eye movements, limb coordination, and gait assessment to distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses. (U, U)
620
Do not use CT to distinguish between central and peripheral diagnoses. (S, H)
620
If concern for TIA, use CTA or MRA to diagnose large vessel pathology. (C, M)
620

Diagnosis of the Triggered Episodic Vestibular Syndrome

Use the Dix-Hallpike test to diagnose posterior canal BPPV. (S, M)
620
Do not routinely use CT or CTA. (S, M)
620
For posterior canal BPPV by a positive Dix-Hallpike test, do not routinely use MRI or MRA. (C, M)
620

Treatment of Acutely Dizzy Patients in the ED

Use shared decision-making with patients regarding short-term steroid treatment for vestibular neuritis within the first three days of symptoms. (C, VL)
620
Use the Epley maneuver for patients diagnosed with posterior canal BPPV. (S, M)
620

Recommendation Grading

Abbreviations

  • AVS: Acute Vestibular Syndrome
  • BPPV: Benign Paroxysmal Positional Vertigo
  • ED: Emergency Department
  • s-EVS: Spontaneous Episodic Vestibular Syndrome
  • t-EVS: Triggered Episodic Vestibular Syndrome

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Acute Dizziness and Vertigo in the Emergency Department

Authoring Organization

Society for Academic Emergency Medicine

Publication Month/Year

May 10, 2023

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Target Patient Population

Patients seeking emergency care for acute vertigo or dizziness

Target Provider Population

Emergency physicians and other allied providers caring for patients in the emergency department

Inclusion Criteria

Male, Female, Adolescent, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D014717 - Vertigo, D004244 - Dizziness

Keywords

dizziness, BPPV, vertigo, emergency, Acute vestibular syndrome, Spontaneous episodic vestibular syndrome, Triggered episodic vestibular syndrome, benign paroxysmal positional vertigo

Source Citation

Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30(5):442-486. doi: 10.1111/acem.14728. PMID: 37166022.

Supplemental Methodology Resources

Data Supplement