So I recently did an episode with Peter Johns on dizziness in the ED and the GRACE-3 guideline. It was a fantastic episode and it generated a bunch of questions. I sat down with the lead author of GRACE-3, Jon Edlow, to discuss these questions and other points of disambiguation about dizziness in acute care settings.
Jonathan Edlow
Dr. Edlow is a Professor of Medicine and Emergency Medicine at Harvard Medical School. He lectures nationally and internationally on topics such as stroke, TIA, subarachnoid hemorrhage, and various causes of weakness and dizziness. He is an internationally renowned expert on neurological emergencies. Dr. Edlow’s specialty areas include ED quality assurance, ED physical layout and facilities redesign, physician professional development, and the creation and implementation of clinical practice guidelines.
GRACE-3 Triage Protocol
ED Docs Accuracy with HiNTS or STANDING Protocols
- Gerlier, Camille, Audrey Fels, Hélène Vitaux, Carole Mousset, Alberto Perugini, Gilles Chatellier, and Olivier Ganansia. “Effectiveness and Reliability of the Four-Step STANDING Algorithm Performed by Interns and Senior Emergency Physicians for Predicting Central Causes of Vertigo.” Academic Emergency Medicine 30, no. 5 (2023): 487–500. https://doi.org/10.1111/acem.14659.
- Gerlier, Camille, Maëlle Hoarau, Audrey Fels, Hélène Vitaux, Carole Mousset, Wassim Farhat, Marine Firmin, et al. “Differentiating Central from Peripheral Causes of Acute Vertigo in an Emergency Setting with the HINTS, STANDING, and ABCD2 Tests: A Diagnostic Cohort Study.” Academic Emergency Medicine 28, no. 12 (2021): 1368–78. https://doi.org/10.1111/acem.14337.
- Nakatsuka, Millie, this link will open in a new tab Link to external site, and Emma E. Molloy. “The HINTS Examination and STANDING Algorithm in Acute Vestibular Syndrome: A Systematic Review and Meta-Analysis Involving Frontline Point-of-Care Emergency Physicians.” PLoS One 17, no. 5 (May 2022): e0266252. https://doi.org/10.1371/journal.pone.0266252.
- Vanni, Simone, Peiman Nazerian, Carlotta Casati, Federico Moroni, Michele Risso, Maddalena Ottaviani, Rudi Pecci, Giuseppe Pepe, Paolo Vannucchi, and Stefano Grifoni. “Can Emergency Physicians Accurately and Reliably Assess Acute Vertigo in the Emergency Department?” Emergency Medicine Australasia 27, no. 2 (2015): 126–31. https://doi.org/10.1111/1742-6723.12372.
all of the above point to good accuracy in the Hands (eyes?) of ED Docs
the one paper cited in the literature stating poor sensitivity for ED Docs included only 1 neuro-fellowship trained ED docs in a cohort of stroke and vascular neurologists. The data were not broken down for that ED fellow, poor accuracy was seen in the entire cohort as a group. So why did HiNTS fail in this study? They were doing HiNTS on patients without any nystagmus–see the Peter Johns' episode to understand why this is a total fail. [
Edlow's Response to the ?
there is evidence presented in the guideline that EPs can be trained to use the HINTS battery or components thereof,3, 4 with excellent sensitivity for stroke (98.0% [n = 48/49], 95% CI 89.1%–99.9%).3 A recent meta-analysis compared diagnostic accuracy of the bedside HINTS examination when performed either by subspecialists (three studies with neurootologists or neuroophthalmologists) or trained nonsubspecialists (seven studies representing a combination of general neurologists, neurology residents, and EPs); it found indistinguishable sensitivity for the two groups (subspecialists 94.3% [95% CI 88.2%–100.0%] vs. nonsubspecialists 95.0% [95% CI 91.2–98.9], p = 0.55) and only slightly higher specificity for subspecialists (subspecialists 97.6% [95% CI 94.9%–100.0%] vs. nonsubspecialists 89.1% [95% CI 83.0%–95.2%], p = 0.007).5 In other words, the important parameter appears to be the presence of HINTS training, not the examiner's specialty.
- 3 , , , et al. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: a diagnostic cohort study. Acad Emerg Med. 2021; 28: 1368–1378.
- 4 , , , et al. Differential diagnosis of vertigo in the emergency department: a prospective validation study of the STANDING algorithm. Front Neurol. 2017; 8: 590.
- 5 , , , et al. Impact of clinician training background and stroke location on bedside diagnostic accuracy in the acute vestibular syndrome—a meta-analysis. Ann Neurol Forthcoming 2023.
Other Papers Mentioned
Additional New Information
More on EMCrit
- EMCrit 358 – Dizziness Makes Me Dizzy Still! – GRACE-3 and more with Peter Johns
- CQiR – Dizzying Details in Detecting Posterior Stroke: Role of CTP in the Initial Diagnosis
- EMCrit 316 – Vertigo and Posterior Stroke with Peter Johns
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