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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; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
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").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Shah VP, Oliveira J E Silva L, Farah W, Seisa MO, Balla AK, Christensen A, Farah M, Hasan B, Bellolio F, Murad MH. Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3. Acad Emerg Med 2022; 30:552-578. [PMID: 36453134 DOI: 10.1111/acem.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND History and physical examination are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical examination findings. METHODS This study involved a patient-intervention-control-outcome (PICO) question: (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical examination findings; and (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was assessed. RESULTS From 6309 titles, 460 articles were retrieved, and 43 met the inclusion criteria: general neurologic examination-five studies, 869 patients, pooled sensitivity 46.8% (95% confidence interval [CI] 32.3%-61.9%, moderate certainty) and specificity 92.8% (95% CI 75.7%-98.1%, low certainty); limb weakness/hemiparesis-four studies, 893 patients, sensitivity 11.4% (95% CI 5.1%-23.6%, high) and specificity 98.5% (95% CI 97.1%-99.2%, high); truncal/gait ataxia-10 studies, 1810 patients (increasing severity of truncal ataxia had an increasing sensitivity for central etiology, sensitivity 69.7% [43.3%-87.9%, low] and specificity 83.7% [95% CI 52.1%-96.0%, low]); dysmetria signs-four studies, 1135 patients, sensitivity 24.6% (95% CI 15.6%-36.5%, high) and specificity 97.8% (94.4%-99.2%, high); head impulse test (HIT)-17 studies, 1366 patients, sensitivity 76.8% (64.4%-85.8%, low) and specificity 89.1% (95% CI 75.8%-95.6%, moderate); spontaneous nystagmus-six studies, 621 patients, sensitivity 52.3% (29.8%-74.0%, moderate) and specificity 42.0% (95% CI 15.5%-74.1%, moderate); nystagmus type-16 studies, 1366 patients (bidirectional, vertical, direction changing, or pure torsional nystagmus are consistent with a central cause of vertigo, sensitivity 50.7% [95% CI 41.1%-60.2%, moderate] and specificity 98.5% [95% CI 91.7%-99.7%, moderate]); test of skew-15 studies, 1150 patients (skew deviation is abnormal and consistent with central etiology, sensitivity was 23.7% [95% CI 15%-35.4%, moderate] and specificity 97.6% [95% CI 96%-98.6%, moderate]); HINTS (head impulse, nystagmus, test of skew)-14 studies, 1781 patients, sensitivity 92.9% (95% CI 79.1%-97.9%, high) and specificity 83.4% (95% CI 69.6%-91.7%, moderate); and HINTS+ (HINTS with hearing component)-five studies, 342 patients, sensitivity 99.0% (95% CI 73.6%-100%, high) and specificity 84.8% (95% CI 70.1%-93.0%, high). CONCLUSIONS Most neurologic examination findings have low sensitivity and high specificity for a central cause in patients with acute vertigo or dizziness. In acute vestibular syndrome (monophasic, continuous, persistent dizziness), HINTS and HINTS+ have high sensitivity when performed by trained clinicians.
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Affiliation(s)
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Wigdan Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | - April Christensen
- Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Magdoleen Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
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