The Timing-and-Triggers Approach to the Patient With Acute Dizziness

Points and Pearls Excerpt

• Although dizziness is a common complaint in the ED, an exact cause is often unclear.
• Use a “timing-and-triggers” approach to the diagnosis of patients with dizziness; the classic “symptom-quality” approach (“What do you mean, ‘dizzy’?) should be avoided.
• The timings-and-triggers approach to dizziness sorts patients into one of 3 groups (1) acute vestibular syndrome (AVS), (2) the spontaneous episodic vestibular syndrome (s-EVS), and (3) the triggered episodic vestibular syndrome (t-EVS), each of which is tightly associated with a specific differential diagnosis.
• Brief episodes of dizziness that wake a patient up from sleep are nearly always BPPV.

Most Important References

• Edlow JA. Managing patients with acute episodic dizziness. Ann Emerg Med. 2018;72(5):602-610.
• Edlow JA, Gurley KL, Newman-Toker DE. A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med. 2018;54(4):469-483. (Review article)
• Edlow JA. Diagnosing patients with acute-onset persistent dizziness. Ann Emerg Med. 2018;71(5):625-631. (Review article)
• Paul NL, Simoni M, Rothwell PM, et al. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65-71. (Prospective population-based study; 1141 stroke patients) 
• Atzema CL, Grewal K, Lu H, et al. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol. 2015;79(1):32-41. (Retrospective population-based cohort; 41,794 discharged ED dizzy patients)
• Kerber KA, Meurer WJ, Brown DL, et al. Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology. 2015;85(21):1869-1878. (Prospective surveillance study; 272 discharged dizzy ED patients)
• Arch AE, Weisman DC, Coca S, et al. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668-673. (Retrospective cohort study; 485 patients)
• Kerber KA, Morgenstern LB, Meurer WJ, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med. 2011;18(6):619-626. (Chart review; 1091 patients)
• Grewal K, Austin PC, Kapral MK, et al. Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study. Stroke. 2015;46(1):108-113. (Retrospective cohort study; 41,794 patients)
• Oostema JA, Chassee T, Baer W, et al. Brief educational intervention improves emergency medical services stroke recognition. Stroke. 2019;50(5):1193-1200. (Results of 30-minute web-based training of EMS providers)