Oh vertigo still makes me dizzy, but the work of Peter Johns had helped so much to not make me hate treating these patients. Peter has already been on the show discussing all things Vertigo in episode 316. Another clinician that changed my dizziness practice, is Jon Edlow, lead author of the recent GRACE-3 paper that sparked this episode. Today, we delve into some of the subtle points on the evaluation of the dizzy patient in the ED.
Peter Johns, MD
Since completing his emergency medicine residency at the University of Toronto in 1989, Dr. Johns has worked at the Ottawa Hospital in Ottawa Canada. Over the past 20 years, he has become a passionate teacher of vertigo. His accomplishments include a YouTube channel about vertigo with over 5 million views, and co-authorship of the vertigo chapter in the most recent edition of Tintinelli’s textbook of Emergency Medicine. @peterjohns84
Training emergency clinicians to perform bedside eye movement examinations
- Recommendation 1: Emergency clinicians should receive training in bedside physical examination techniques for patients with the AVS (HINTS) and diagnostic and therapeutic maneuvers for BPPV (Dix–Hallpike test and Epley maneuver), since untrained ED physicians do not reliably apply or accurately interpret results of this bedside eye movement examination [ungraded good practice statement].
Diagnosis of the AVS
- Recommendation 2: In adult ED patients with AVS with nystagmus, we recommend routine use of the three-component head impulse, nystagmus, test of skew (HINTS) examination for clinicians trained in its use* to distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, FOR) [high certainty of evidence].
- Recommendation 3: In adult ED patients with AVS with nystagmus, we suggest assessing hearing at the bedside by finger rub to identify new unilateral hearing loss as an additional criterion to aid in the identification of stroke, even if the three-component HINTS examination result suggests a peripheral vestibular diagnosis (conditional recommendation, FOR) [moderate certainty of evidence].
- Recommendation 4: In adult ED patients with AVS without nystagmus, we suggest assessing severity of gait unsteadiness to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (conditional recommendation, FOR) [moderate certainty of evidence].
- Recommendation 5: In adult ED patients with AVS with or without nystagmus, we recommend against routine use of noncontrast CT of the brain or CTA to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, AGAINST; see “Implementation considerations”) [high certainty of evidence].
- Recommendation 6: In adult ED patients with AVS with or without nystagmus, if a clinician trained in use of HINTS is available, we recommend against routine use of MRI of the brain or cerebral vasculature (MRA) as the first-line diagnostic test (prior to physical examination) to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, AGAINST; see “Implementation considerations”) [high certainty of evidence].
- Recommendation 7: In adult ED patients with AVS and central or equivocal HINTS results, we recommend use of stroke protocol MRI (with DWI and MRA) to further help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses. (strong recommendation, FOR; see “Implementation considerations” regarding timing of MRI) [high certainty of evidence].
Diagnosis of the s-EVS
- Recommendation 8: In adult ED patients with s-EVS, the writing committee believes that routine use of a detailed history and physical examination with emphasis on cranial nerves including visual fields, eye movements, limb coordination, and gait assessment helps to distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses [ungraded good practice statement].
- Recommendation 9: In adult ED patients with s-EVS, we recommend against routine use of CT to help distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses (strong recommendation, AGAINST) [moderate certainty of evidence].
- Recommendation 10: In adult ED patients with s-EVS and concern for TIA, we suggest use of CTA or MRA of the head and neck to rule out posterior circulation vascular pathology (conditional recommendation, FOR) [moderate certainty of evidence].
Diagnosis of the t-EVS
- Recommendation 11: In adult ED patients with t-EVS, we recommend routine use of the Dix–Hallpike test to diagnose pc-BPPV (strong recommendation, FOR) [moderate certainty of evidence].
- Recommendation 12: In adult ED patients with t-EVS, we recommend against routine use of CT or CTA (strong recommendation, AGAINST) [moderate certainty of evidence].
- Recommendation 13: In adult ED patients with t-EVS diagnosed with typical pc-BPPV by a positive Dix–Hallpike test with the characteristic nystagmus, we suggest against routine use of MRI or MRA (conditional recommendation, AGAINST) [moderate certainty of evidence].
Treatment of acute vestibular neuritis
- Recommendation 14: In adult ED patients with a clinical diagnosis of vestibular neuritis, we suggest shared decision making with patients to weigh risks and benefits of short-term steroid treatment for those presenting within 3 days of symptom onset (conditional recommendation, FOR) [very low certainty of evidence].
Treatment of pc-BPPV
- Recommendation 15: In adult ED patients with pc-BPPV diagnosed by a positive Dix–Hallpike test, we recommend the Epley† canalith repositioning maneuver be performed at the time of diagnosis (strong recommendation, FOR) [moderate certainty of evidence].
Questions we Discussed…
What's your take on Grace-3?
Let's talk about Central Features Search before HiNTS
- Focal Weakness or Paresthesias
- Dangerous D's: diplopia, dysarthria, dysmetria, dysphonia, dysphagia (GRACE-3 Adds dysesthesia and dubs ‘dem the Deadly D's)
- Vertical Nystagmus at rest (not during Dix Hallpike–that is expected in BPPV)
- Unable to walk unaided
- New significant headache or neck pain (cerebral hemorrhage or vertebral artery dissection)
No Nystagmus, no HiNTS?
No nystagmus, no HiNTS for you (See Peter's video below)
Grace-3 Diagnostic Approach
Let's really nail down what we should see in an abnormal Head Impulse Test
In acute vestibular syndrome, the affected ear is one opposite of the direction of the fast-beating nystagmus
If you turn the head towards the affected ear, you should see a catch-up saccade in Vestibular Neuritis
So if you are doing the Head Impulse Test the way Peter advises, then if you start with the head facing 45 degrees off midline in the same direction of the nystagmus, then when you rapidly turn the head to the midline, you should see a catch-up saccade.
Do we have to do both directions on the Head Impulse?
Talk about Test of Skew & Diagonal skew
How Bad does Gait Need to Be to Worry?
Truncal ataxia or the inability to walk unaided are the breakpoints for badness
Is Romberg helpful?
Key Point: Vertical or Torsional Nystagmus during Dix Hallpike is NOT CENTRAL
it is expected!
During the Dix Hallpike in BPPV, having the patient look towards the upwards ear should give vertical nystagmus and when the pt looks at the downwards ear, they should have torsional nystagmus
adds hearing check to pick up an AICA stroke. The entire labyrinth is infarcted; this will give a false result on head impulse testing
So what to do with Dizziness/Vertigo, but no Nystagmus at Rest
1. Look even more carefully for nystagmus
Should we have Frenzel Goggles or blank piece of paper–both to overcome visual fixation
Blank Piece of Paper Test – Put it on either side and tell them to look through the paper as if it is not there.
2. Exam for central causes
Do not use HiNTS!
3. Worry about stroke if the gait is altered!!!
If all of the above and the gait are normal, likely will be vestibular migraine, BPPV, or general medical cause
Why can't it be easy… Central Paroxysmal Positional Vertigo????
Clinical clues that suggest the possibility of a central mimic (CPPV) rather than typical BPPV
In adult ED patients with t-EVS, who have additional neurological symptoms or signs (e.g., acute headache, visual disturbance, unilateral hearing loss, diplopia, new inability to walk independently), that are not seen in typical BPPV, consider CPPV. CPPV is very uncommon in an all-comer ED population but can be suspected based on additional neurologic symptoms or atypical nystagmus patterns for BPPV (see text). In those with nystagmus that is atypical for BPPV, consider MRI to diagnose central causes. Clinicians familiar with BPPV variants (including apogeotropic hc-BPPV or anterior canal BPPV) may elect to try bedside maneuvers to treat those variants or refer to a specialist without performing MRI.
Presence of symptoms or signs that are not seen in BPPV
- Prominent acute headache
- Abnormal cranial nerve or cerebellar function/(new) inability to walk
Atypical nystagmus characteristics or symptoms during positional tests
- Downbeating nystagmus that is persistent (Peter saw this on Dix Hallpike in 1 of the 2 cases he diagnosed)
- Nystagmus that starts instantaneously, persists for longer than 90 s, or lacks a crescendo–decrescendo pattern of intensity
- Prominent nystagmus with mild or absent associated dizziness or vertigo
Poor response to therapeutic maneuvers
- Repetitive vomiting during positional maneuvers
- Unable to cure patient with canal-specific CRM
- Frequent recurrent symptoms
from Edlow on BPPV in the ED (10.1111/acem.14558)
Review: How to Send a Patient with Constant Dizziness Home without an MRI and Allow You to Sleep at Night
from Peter's video below:
- No new or presumed new central features on a full neuro exam
- Specifically checked for the Dangerous D's: diplopia, dysarthria, dysmetria, dysphonia, dysphagia
- Gait is not intensely abnormal (able to walk unaided)
If the Patient has Nystagmus
- Catch-up saccade on HI when the head is turned in the opposite direction of nystagmus (use only if the pt has nystagmus)
- No vertical/torsional nystagmus at rest
- No direction changing nystagmus (beats to left when looking left and right when looking right)
With or Without Nystagmus
- Normal Test of Skew (no vertical or diagonal skew deviation)
- No new hearing loss
- No new headache or neck pain accompanying the dizziness
Peter's Recent Dizziness Confusion Video
Vestibular Migraine Video
Potential Errors from GRACE-3
The STANDING protocol [10.3389/fneur.2017.00590] represents a simplification of this entire workup. The GRACE-3 folks were positive about it, but did not put it into their recs because it diverted from the diagnostic criteria of AVS/s-EVS/t-EVS. I think most ED folks would be well served to take a look (except for the Frenzel requirement).
STANDING Protocol Adaptation from GRACE-3
The GRACE-3 Folks say they have made an APP that will be hosted here
Other People's Takes
Additional New Information
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