Updated Guidelines on Acute Dizziness, Vertigo in the Emergency Department

The Society for Academic Emergency Medicine has released a new guideline on diagnosing and managing adults who present to the emergency department with acute dizziness and vertigo of less than 2 weeks’ duration.

Using the Grading of Recommendations Assessment Development and Evaluation approach, the researchers selected five questions on diagnosis and treatment of dizziness and vertigo. Using the population, intervention, comparison, and outcomes format, the questions included the use of neuroimaging vs bedside examination alone for diagnosis, changes in diagnosis for triggered episodes, spontaneous episodes, or prolonged episodes of dizziness and vertigo, as well as when treatment is necessary with steroids or the Epley maneuver.

These questions were then used to form 15 recommendations. Among the recommendations:

• Emergency medicine clinicians should be trained in the head impulse, nystagmus, test of skew (HINTS) bedside examination for patients with acute vestibular syndrome (AVS) as well as diagnostic and therapeutic approaches for benign paroxysmal positional vertigo (BPPV).
• To determine central from peripheral causes in patients with AVS, clinicians should use HINTS in patients with nystagmus, use finger rub in these patients to exclude stroke, not utilize brain computed tomography or routine magnetic resonance imaging, and more.
• Clinicians should consider short-term steroids to treat patients with vestibular neuritis.
• Clinicians should utilize the Epley maneuver in patients with posterior canal BPPV.

As the multidisciplinary panel notes, one limitation of the guidelines is that emergency medicine clinicians must learn to perform maneuvers and understand results but that no training program for these skills currently exist.

“Adoption of these guidelines should be tailored to local policies and practices and availability of specialists and telemedicine and video-oculography, which may differ in different locations,” the panel concluded. “As with any guideline, clinician judgement and the implementation considerations above need to be factored into the management of any individual patient.’

Reference:

Edlow JA, Carpenter C, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 4 (GRACE-3): acute dizziness and vertigo in the emergency department. J Acad Emerg Med. 2023;30(5):442-486. doi:10.1111/acem.14728.