The Timing-and-Triggers Approach to the Patient With Acute Dizziness (Stroke CME) -

The Timing-and-Triggers Approach to the Patient With Acute Dizziness (Stroke CME)
Enlarge Image
Delivery Method:

Publication Date: december 2019 (Volume 21, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 12/01/2022.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Stroke CME credits, subject to your state and institutional approval.


Jonathan A. Edlow, MD, FACEP
Vice-Chairman, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Professor of Emergency Medicine, Harvard Medical School, Boston, MA

Peer Reviewers

Petra Duran-Gehring, MD, RDMS, FACEP
Associate Professor, Department of Emergency Medicine, Director of Emergency Ultrasound, University of Florida College of Medicine- Jacksonville, Jacksonville, FL
Christopher Lewandowski, MD
Clinical Professor of Emergency Medicine, Wayne State University School of Medicine; Executive Vice Chair, Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
Vasisht Srinivasan, MD
Clinical Instructor, Department of Emergency Medicine; Fellow, Division of Critical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, Cincinnati, OH


Acute dizziness is a common presentation in the emergency department. Due to newer research, the diagnostic approach to dizziness has changed, now focusing on its timing and triggers of instead of the patient’s symptom quality (vertigo versus lightheadedness). Each timing-and-triggers category has its own differential diagnosis and diagnostic approach, which will aid emergency clinicians in distinguishing benign causes of dizziness from life-threatening causes. Brain imaging, even with magnetic resonance imaging, has important limitations in ruling out stroke presenting with dizziness. Benign paroxysmal positional vertigo can be treated with repositioning maneuvers at the bedside, offering cost-effective management options.

Excerpt From This Issue

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT. His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and “feeling like I am drunk,” and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal. The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days. That sounds reasonable, but you wonder if there is something else that needs to be considered...

The 70-year-old woman in room 3 complains of “lightheadedness” that has been going on for 5 days. It goes away at times, and gets worse when she gets out of bed. The dizziness has woken her from sleep several times. She has hypertension and high cholesterol. Her vital signs are normal. Sitting up in the stretcher, she is asymptomatic but feels apprehensive about moving her head. There is no nystagmus in primary gaze. You wonder if you should order a CT or if there is a better diagnostic test...

Product Reviews

This is one of the best articles I have read in my entire career. In fact, I keep a copy in my work bag the review when I am seeing these patients. I thought the organization and explanations were outstanding and worth every second of reading.
- 06/17/2020
This article has changed my emergency practice life! Will be more confident and orderly in my physical exam! Best article of the year!
- 05/26/2020
Most important monograph of the year. Should be mandatory reading for EVERY ED physician.Would save hundreds of millions of dollars on unnecessary imaging, unnecessary admissions, and minimize missed strokes.
- 05/14/2020
I have been a member for years and this is by far the best issue you have ever put out. Thank you.
- 05/08/2020
Dr Edlow did an excellent review of a difficult topic. This is user friendly and I will begin utilizing this immediately.
- 05/05/2020
I am now comfortable incorporating the HINTS exam into my clinical practice.  I feel much more comfortable with narrowing the differential diagnosis of the 'dizzy' patient. This article did an incredible job of tackling a historically tricky area of emergency medicine and creating a useful framework for the average ER doc to follow.
- 03/13/2020
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.