What is the emergency department treatment for a 55-year-old man presenting with vomiting, nausea, and persistent vertigo?

Emergency Department Treatment for Acute Persistent Vertigo with Nausea and Vomiting

For a 55-year-old man presenting with persistent vertigo, nausea, and vomiting in the emergency department, the immediate priority is to rule out posterior circulation stroke using the HINTS examination (if trained personnel are available) or urgent MRI, while simultaneously providing symptomatic relief with antiemetics such as metoclopramide 10 mg IV or prochlorperazine 10 mg IV. 1

Immediate Diagnostic Approach

Risk Stratification for Stroke

• This patient's age (55 years) places him in a high-risk category for posterior circulation stroke, which accounts for approximately 25% of acute vestibular syndrome presentations overall and rises to 75% in high-vascular-risk cohorts. 1, 2
• Assess immediately for vascular risk factors including hypertension, diabetes, atrial fibrillation, or prior stroke—any of these mandate urgent MRI even if the neurologic exam appears normal, because 11–25% of such patients harbor a posterior circulation stroke. 1
• Critically, 75–80% of patients with stroke-related acute vestibular syndrome present without focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke. 1, 2

HINTS Examination (If Trained Personnel Available)

• If a specially trained practitioner is available, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting stroke compared to only 46% for early MRI. 1, 2
• However, when performed by non-experts (typical emergency physicians), HINTS results are unreliable and should NOT be used to exclude stroke—proceed directly to MRI for high-risk patients regardless of HINTS findings. 1

Red Flags Requiring Urgent MRI

Obtain immediate MRI brain without contrast (not CT, which misses most posterior circulation strokes) if ANY of the following are present: 1, 2

• Age >50 with any vascular risk factors
• New severe headache accompanying vertigo
• Focal neurologic deficits (dysarthria, limb weakness, sensory loss, diplopia, dysphagia, Horner's syndrome)
• Severe postural instability with inability to stand or walk
• Pure vertical nystagmus (up-beating or down-beating) without torsional component
• Direction-changing nystagmus without head position changes
• Baseline nystagmus present without provocative maneuvers
• Normal head-impulse test (suggests central cause)
• Skew deviation on alternate cover testing
• Sudden unilateral hearing loss

Symptomatic Treatment (After Excluding Life-Threatening Causes)

Antiemetic Therapy

• Administer metoclopramide 10 mg IV OR prochlorperazine 10 mg IV immediately for nausea and vomiting—both provide antiemetic effects and synergistic analgesia if headache is present. 1
• The intravenous route is preferred when multiple vomiting episodes have occurred. 1

Vestibular Suppressants (Use Sparingly)

• Avoid routine use of vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) in the emergency department, as they do not correct underlying pathology and may delay central compensation. 3
• If used, limit to brief acute symptom relief during severe distress only. 3
• Do NOT prescribe vestibular suppressants if BPPV is diagnosed, as they are not indicated and prevent recovery. 1, 3

Diagnostic Testing for Peripheral Causes

Dix-Hallpike Maneuver

• Once stroke has been excluded (or deemed low probability), perform the Dix-Hallpike maneuver bilaterally to diagnose or exclude BPPV. 1, 3
• Positive findings include: 5–20 second latency, torsional up-beating nystagmus toward the affected ear, crescendo-decrescendo pattern that resolves within 60 seconds, and fatigability with repeat testing. 1, 3
• If positive, perform the Epley maneuver immediately—this achieves 80% success after 1–3 treatments and 90–98% with additional maneuvers. 1, 3

Laboratory Testing

• Check fingerstick glucose immediately, as hypoglycemia is the most frequently identified unexpected abnormality in dizzy patients. 1
• Consider basic metabolic panel only if history or examination suggests specific abnormalities (e.g., dehydration from vomiting). 1
• Avoid routine comprehensive laboratory panels, as they rarely change management in isolated vertigo. 1

Imaging Decisions

When NOT to Image

• Do NOT order imaging if: 1, 3
  • Typical BPPV confirmed by positive Dix-Hallpike test
  • No red-flag features present
  • Age <50 with no vascular risk factors
  • Normal neurologic exam with peripheral HINTS pattern (by trained examiner)

When to Image

• MRI brain without contrast (with diffusion-weighted imaging) is mandatory for any red-flag features listed above. 1, 2
• CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts—it should NOT be used instead of MRI when stroke is suspected. 1
• CT may be appropriate only as initial imaging in acute settings when MRI is unavailable or significantly delayed, recognizing its severe limitations. 1

Disposition and Follow-Up

• If imaging reveals stroke, activate stroke protocols immediately and admit for neurology consultation. 1, 2
• If BPPV is confirmed and successfully treated, discharge with counseling about recurrence risk (which is common) and fall prevention. 1, 3
• If vestibular neuritis is diagnosed (acute persistent vertigo with normal neurologic exam and peripheral HINTS pattern), consider short course of corticosteroids and arrange vestibular rehabilitation therapy. 1, 4
• Reassess within 1 month to document resolution or persistence of symptoms. 1, 3

Critical Pitfalls to Avoid

• Never assume a normal neurologic exam excludes stroke—up to 80% of posterior circulation strokes present without focal deficits. 1, 2
• Never rely on HINTS examination performed by non-experts to rule out stroke in high-risk patients. 1
• Never use CT instead of MRI when stroke is suspected—CT sensitivity for posterior fossa strokes is only 10–20%. 1
• Never prescribe meclizine for BPPV—it is not indicated and delays recovery. 3, 4
• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing, triggers, and associated symptoms instead. 1, 3