What are the immediate steps for a patient with sudden onset of balance issues?

Immediate Management of Sudden Onset Balance Issues

For a patient presenting with sudden onset of balance issues, immediately assess for stroke, cardiac arrest, or life-threatening arrhythmia by obtaining vital signs, performing a focused neurological examination, and obtaining a 12-lead ECG within 10 minutes of presentation. 1

Initial Triage and Life-Threatening Causes

Assess hemodynamic stability first:

• Check for unresponsiveness, abnormal breathing, or absent pulse—if present, presume sudden cardiac arrest and initiate high-quality CPR with chest compressions and attach a defibrillator immediately 1
• Measure blood pressure, heart rate, and oxygen saturation to identify hemodynamic instability requiring immediate intervention 1
• Obtain 12-lead ECG within 10 minutes to exclude acute coronary syndrome, arrhythmias, or conduction abnormalities that may cause presyncope or syncope 1, 2

Perform rapid neurological assessment:

• Use the FOUR score rather than Glasgow Coma Scale for patients with altered consciousness, as it provides more comprehensive assessment of brainstem function and is superior for intubated or severely affected patients 3
• Assess for focal neurological deficits (facial droop, arm drift, speech abnormalities) suggesting acute stroke 1
• Evaluate for sudden severe headache with neck stiffness suggesting subarachnoid hemorrhage or spontaneous intracranial hypotension 1

Stroke Protocol Activation

If stroke is suspected based on sudden onset with focal deficits:

• Activate stroke protocol immediately and obtain brain imaging (CT or MRI) emergently to differentiate ischemic from hemorrhagic stroke 1
• For ischemic stroke with large vessel occlusion, mechanical thrombectomy should be initiated within 6 hours (or up to 24 hours with perfusion mismatch) 1
• Admit to stroke unit or intensive care unit for continuous cardiac monitoring for at least 24 hours to screen for atrial fibrillation 1
• Maintain blood pressure below 185/110 mmHg if thrombolysis is considered, or below 220/120 mmHg for other acute ischemic stroke patients 1

Cardiac and Syncope Evaluation

For patients with presyncope, syncope, or palpitations:

• Place on continuous cardiac monitoring with defibrillator immediately available 2
• Perform carotid sinus massage in patients over 40 years old to evaluate for carotid sinus syndrome 1
• Measure orthostatic blood pressure (lying to standing) to identify orthostatic hypotension as cause 1
• If hemodynamically unstable tachycardia is present, perform immediate synchronized cardioversion regardless of rhythm type 2

Benign Paroxysmal Positional Vertigo Assessment

For patients describing rotational vertigo triggered by head position changes:

• Perform Dix-Hallpike maneuver bilaterally to diagnose posterior canal BPPV, which is positive in up to one-third of patients with atypical histories 1
• The maneuver involves rotating the patient's head 45 degrees to one side while seated, then rapidly moving them to supine position with head hanging 20 degrees below horizontal 1
• Observe for characteristic rotatory nystagmus and reproduction of vertigo symptoms lasting less than 60 seconds 1
• Avoid Dix-Hallpike in patients with significant vascular disease, cervical stenosis, severe kyphoscoliosis, Down syndrome, or severe rheumatoid arthritis due to stroke risk 1

Urgent Specialist Referral Criteria

Immediate neurology consultation is required for:

• Falling level of consciousness requiring ICU assessment for airway protection and management of raised intracranial pressure 1
• Suspected acute encephalitis with altered mental status, fever, or seizures—obtain brain MRI and lumbar puncture with CSF PCR results within 24-48 hours 1
• Any suspicion of inherited cardiac conditions (long QT syndrome), structural heart disease, or TLoC during exercise 1

Urgent cardiology consultation for:

• Recurrent ischemia, elevated troponin, hemodynamic instability, or major arrhythmias suggesting acute coronary syndrome 2
• Chest pain with tachycardia requiring serial troponins at presentation and 6-12 hours after symptom onset 2

Disposition Based on Risk Stratification

High-risk features requiring admission:

• Abnormal ECG findings, age over 65, history of heart failure, or structural heart disease 1
• Neurological deficits, severe headache, or trauma 1
• Admit to monitored bed with serial ECGs and cardiac biomarkers 2

Low-risk patients with isolated dizziness:

• If "3 Ps" are present (posture-related during prolonged standing, provoking factors like pain, prodromal symptoms like sweating), this suggests uncomplicated vasovagal syncope and does not require extensive investigation 1
• Tilt-table testing is not necessary when initial assessment indicates uncomplicated faint 1
• Outpatient follow-up with balance assessment using validated tools like Timed Up-and-Go Test or Berg Balance Scale can be arranged 4, 5

Common Pitfalls to Avoid

• Do not assume brief seizure-like activity rules out syncope—myoclonic jerks commonly occur during vasovagal syncope and do not require neurological investigation or EEG 1
• Do not rely on single negative troponin—repeat measurement at 6-12 hours is mandatory before excluding acute coronary syndrome 2
• Do not perform routine EEG for syncope—it has low sensitivity and may lead to misdiagnosis of epilepsy 1
• Do not discharge patients with bilateral positive Dix-Hallpike without considering head trauma—bilateral posterior canal BPPV is more common after trauma 1