Initial Management of Dizziness in the Emergency Department
The initial approach to managing dizziness in the Emergency Department should focus on rapidly distinguishing between benign peripheral vestibular conditions and potentially life-threatening central causes using a timing and triggers diagnostic approach, rather than relying solely on symptom quality. 1
Initial Assessment
- Perform a rapid evaluation within 10 minutes of arrival to the emergency department, following the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) 2
- Establish cardiac monitoring for all patients with dizziness, as cardiovascular causes may present with dizziness 2
- Obtain vital signs immediately, as abnormal vital signs may indicate serious underlying conditions 2
- Categorize the patient's dizziness based on timing and triggers rather than symptom quality (vertigo, presyncope, disequilibrium) 1
Diagnostic Categorization
1. Acute Vestibular Syndrome (continuous dizziness lasting days)
- Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) to distinguish between peripheral causes (vestibular neuritis) and central causes (stroke) 3
- A normal head impulse test, direction-changing nystagmus, or presence of skew deviation suggests central etiology requiring immediate neuroimaging 1
- Consider MRI with diffusion-weighted imaging rather than CT for suspected posterior circulation strokes 4
2. Spontaneous Episodic Vestibular Syndrome (recurrent episodes without triggers)
- Evaluate for associated symptoms that help differentiate vestibular migraine from transient ischemic attack 1
- Consider neuroimaging in patients with vascular risk factors or neurological symptoms 4
3. Triggered Episodic Vestibular Syndrome (episodes provoked by specific triggers)
- Perform the Dix-Hallpike and supine roll tests to diagnose benign paroxysmal positional vertigo (BPPV) 1
- A positive Dix-Hallpike test with characteristic nystagmus confirms BPPV and may allow for immediate treatment with repositioning maneuvers 3
Red Flags Requiring Immediate Attention
- New-onset neurological deficits (facial weakness, diplopia, dysarthria, ataxia) suggesting stroke 1
- Severe, sudden-onset headache that could indicate subarachnoid hemorrhage 5
- Abnormal vital signs, especially hypotension or tachycardia, which may indicate cardiovascular causes 2
- Direction-changing nystagmus not triggered by position changes, suggesting central pathology 3
Imaging Considerations
- MRI with diffusion-weighted imaging is preferred over CT for suspected central causes of dizziness 4
- CT has low sensitivity (approximately 2% positivity rate) for isolated dizziness but may detect hemorrhage, mass lesions, or ischemic stroke 4
- Consider immediate neuroimaging when acute brain lesions are suspected, especially in patients with:
- History of malignancy
- Immunocompromised status
- Persistent headache
- New focal neurological findings
- Age over 40 years 4
Common Pitfalls to Avoid
- Relying solely on symptom quality (vertigo vs. presyncope) to determine etiology, which can lead to misdiagnosis 1
- Overreliance on CT imaging, which has poor sensitivity for posterior fossa strokes 4
- Misdiagnosing central vertigo as peripheral, which occurs in up to 35% of cases 6
- Failing to perform appropriate bedside tests like HINTS examination in acute vestibular syndrome 3
Management Based on Diagnosis
- For BPPV: Perform appropriate repositioning maneuvers based on the canal involved 3
- For vestibular neuritis: Consider symptomatic treatment with antiemetics and vestibular suppressants 5
- For central causes: Urgent neuroimaging and neurology consultation 4
- For presyncope: Evaluate for cardiac arrhythmias and orthostatic hypotension 5
By following this structured approach to dizziness in the ED, clinicians can more accurately distinguish between benign and serious causes, reduce misdiagnosis rates, and ensure appropriate management for patients with this common complaint.