62 How can the ED dizziness and vertigo patient evaluation be documented when BPPV is diagnosed?

By Illinois Digital News On Feb 12, 2024

The Optimal Diagnosis and Treatment of Emergency Department Patients with Dizziness and Vertigo: The GRACE-3 Guideline Recommendations

Edward Sloan, MD, MPH, FACEP
Professor Emeritus
Department of Emergency Medicine, University of Illinois at Chicago
FERNE President and Board Chair. No financial conflicts.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department
Jonathan A. Edlow, MD et al Acad Emerg Med. 2023;30:442–486.

Educational Objective

(1) Enhance the understanding of the SAEM GRACE-3 recommendations that explain the role of the history, exam, neuroimaging, and advanced procedures in the assessment of ED dizziness and vertigo patients.

GRACE-3: Training
1. Emergency clinicians should receive training for diagnosing and treating patients with acute dizziness.
(Ungraded good practice statement)

GRACE-3: The AVS Patient

GRACE-3: AVS Diagnosis and HINTS
2. In patients with nystagmus, trained clinicians should use HINTS testing to distinguish central (stroke) from peripheral (inner ear, usually vestibular neuritis) diagnoses.
(Strong recommendation FOR, High certainty of evidence)

GRACE-3: AVS Diagnosis and Hearing Testing
3. In patients with nystagmus, assess hearing by finger rub to distinguish central from peripheral diagnoses.
(Conditional recommendation FOR, Moderate certainty of evidence)

GRACE-3: AVS Diagnosis and Gait Testing
4. In patients without nystagmus, assess severity of gait unsteadiness to distinguish central from peripheral diagnoses.
(Conditional recommendation FOR, Moderate certainty of evidence)

GRACE-3: AVS Diagnosis and CT or CTA Testing
5. In patients with or without nystagmus, do not routinely use non-contrast brain CT or CTA.
(Strong recommendation AGAINST, High certainty of evidence)

GRACE-3: AVS Diagnosis MRI or MRA if HINTS Testing Available
6. In AVS patients with or without nystagmus, do not routinely use MRI or MRA as the first-line diagnostic test if a HINTS trained clinician is available.
(Strong recommendation AGAINST, High certainty of evidence)

GRACE-3: AVS Dx MRI/MRI Testing if HINTS Result Suggests Central
7. In patients whose HINTS result is central or equivocal, use MRI/MRA DWI to distinguish between central and peripheral diagnoses.
(Strong recommendation FOR, High certainty of evidence)

GRACE-3: The s-EVS Patient
(Dizziness Episodes Not Brought on By Any Clear Trigger)

GRACE-3: s-EVS Dx
8. 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.
(Ungraded good practice statement)

GRACE-3: s-EVS Diagnosis and CT Use
9. Do not use CT to distinguish between central and peripheral diagnoses.
(Strong recommendation AGAINST, Moderate certainty of evidence)

GRACE-3: s-EVS Dx and TIA Diagnosis
10. If there is concern for a TIA, use CTA or MRA to diagnose large vessel pathology.
(Conditional recommendation FOR, Moderate certainty of evidence)

GRACE-3: The t-EVS Patient
(Brief Episodes of Dizziness Clearly Triggered by Something, e.g., Moving the Head

GRACE-3: t-EVS and Dix-Hallpike Test
11. Use the Dix-Hallpike test to diagnose posterior canal BPPV.
(Strong recommendation FOR, Moderate certainty of evidence)

GRACE-3: t-EVS and CT/CTA Testing
12. Do not routinely use CT or CTA.
(Strong recommendation AGAINST, Moderate certainty of evidence)

GRACE-3: t-EVS, Dix-Hallpike, pc-BPPV, and MRI/MRA Testing
13. For posterior canal BPPV (pc-BPPV) diagnosed by a positive Dix-Hallpike test, do not routinely use MRI or MRA.
(Conditional recommendation AGAINST, Moderate certainty of evidence)

GRACE-3: Treatment of Acute Vestibular Neuritis

GRACE-3: Steroid Use in Treating Vertigo Patients
14. Use shared decision-making with patients regarding short-term steroid treatment for vestibular neuritis within the first three days of symptoms.
(Conditional recommendation FOR, Very low certainty of evidence)

GRACE-3: Treatment of pc-BPPV

GRACE-3: Rx of the Acutely Dizzy ED Patient with the Epley Maneuver
15. Use the Epley maneuver for patients diagnosed with posterior canal BPPV at the time of diagnosis.
(Strong recommendation FOR, Moderate certainty of evidence)

The Foundation for the Education and Research in Neurological Emergencies (FERNE) is an independent not-for-profit organization committed to the following principle:

Patients with neurologic emergencies deserve expert emergency care which is supported by quality scientific research and state-of-the-art education.