How do I assess a patient presenting with dizziness in the Emergency Department (ED)?

Diagnostic Approach to Dizziness in the Emergency Department

The most effective approach to assessing dizziness in the ED is to focus on timing and triggers rather than symptom quality, using targeted physical examination techniques including the HINTS exam for acute vestibular syndromes and appropriate positional testing for triggered symptoms. 1

Initial Assessment Framework

Step 1: Categorize by Timing and Triggers (not symptom quality)

• Acute Vestibular Syndrome (AVS): Continuous dizziness lasting days
• Spontaneous Episodic Vestibular Syndrome: Recurrent spontaneous episodes
• Triggered Episodic Vestibular Syndrome: Dizziness provoked by specific triggers 1, 2

Step 2: Focused History

• Duration and onset of symptoms
• Associated symptoms (nausea, vomiting, headache, hearing loss)
• Triggers (positional changes, specific movements)
• Cardiovascular risk factors
• Medication review
• Previous episodes 1, 3

Step 3: Targeted Physical Examination

For All Patients:

• Vital signs including orthostatic blood pressure measurements
• Cardiovascular examination
• Complete neurological examination 1

For Acute Vestibular Syndrome:

• HINTS examination (Head-Impulse, Nystagmus, Test of Skew)
  • Normal head impulse test
  • Direction-changing nystagmus
  • Skew deviation
  • Any of these findings suggests central cause (stroke) 1, 2

For Triggered Episodic Vestibular Syndrome:

• Dix-Hallpike maneuver for posterior canal BPPV
• Supine roll test for horizontal canal BPPV 1, 2

Red Flags Requiring Urgent Evaluation

• Age ≥65 years (OR=6.13 for central causes) 4
• Ataxia (OR=11.39 for central causes) 4
• Focal neurological symptoms (OR=11.78 for central causes) 4
• History of stroke (OR=3.89 for central causes) 4
• Diabetes mellitus (OR=3.57 for central causes) 4
• Abnormal HINTS examination 1, 2
• Sudden onset of severe symptoms 2
• Associated headache, especially new or severe 1

Diagnostic Testing

Laboratory Testing

• Not routinely indicated for all dizzy patients
• Order selectively based on clinical suspicion:
  • Blood glucose, electrolytes, CBC, toxicology screen 1

Imaging

• MRI brain (without contrast) is indicated for:

  • AVS with abnormal HINTS examination
  • AVS with neurological deficits
  • High vascular risk patients with AVS even with normal examination
  • Chronic undiagnosed dizziness not responding to treatment 1

• Avoid routine neuroimaging for typical BPPV with positive Dix-Hallpike test 1

Management Based on Diagnosis

BPPV (most common peripheral cause)

• Canalith repositioning procedures:
  • Epley maneuver for posterior canal BPPV
  • Semont maneuver as alternative for posterior canal BPPV
  • Barbecue roll maneuver for horizontal canal BPPV 1, 3

Vestibular Neuritis

• Symptomatic treatment
• Consider short course of vestibular suppressants
• Early vestibular rehabilitation 1, 3

Central Causes (Stroke/TIA)

• Immediate neurological consultation
• Admission for observation and management
• Neuroimaging (preferably MRI with DWI) 1, 2

Orthostatic Hypotension

• Volume repletion
• Medication adjustment
• Compression stockings
• Patient education on positional changes 1

Disposition Considerations

• Admission criteria:

  • Suspected central neurological cause
  • Severe symptoms preventing adequate oral intake
  • Inability to ambulate safely
  • New focal neurological deficits 1, 4

• Safe discharge criteria:

  • Diagnosed peripheral vestibular disorder with improving symptoms
  • Able to ambulate safely or with assistance
  • Adequate symptom control
  • Clear follow-up plan 1

• Follow-up recommendations:

  • Provide fall prevention counseling
  • Inform about recurrence rates (15% per year for BPPV)
  • Consider specialist referral for persistent symptoms 1

Remember that misdiagnosis of dizziness is common, particularly missing stroke in patients with AVS. The traditional approach of categorizing by symptom quality (vertigo vs. lightheadedness) is outdated and less accurate than focusing on timing and triggers 2, 5.