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

Table of Contents

 

About This Issue

Dizziness can be a challenging presentation in the urgent care setting. Traditionally, clinicians have relied on the symptom-based approach (“What do you mean, ‘dizzy?’), but evidence now supports the use of a “timing-and-triggers” approach to the dizzy patient. In this course, you will learn:

How the “timing-and-triggers” approach to dizziness more closely tracks with the approach to other chief complaints

Why the “nystagmus” test portion of HINTS should be performed first

The 5 questions you must answer “NO” to in order to rule out stroke

The warning signs of a central cause in a patient with triggered dizziness

The role of imaging in the diagnosis of the dizzy patient

The diagnostic and therapeutic maneuvers indicated for BPPV based on the canal involved and the mechanism

CODING & CHARTING: Learn how to select the appropriate level of service for patients presenting with acute dizziness in urgent care.

1. About This Issue
2. Acknowledgment
3. Abstract
4. Case Presentations
5. Selected Abbreviations
6. Introduction
7. Critical Appraisal of the Literature
8. Etiology, Relevant Anatomy, Physiology, and Pathophysiology
9. Differential Diagnosis, Diagnostic Approach, and Misdiagnosis
   1. Symptom-Quality Approach
   2. Timing-and-Triggers Approach
   3. Misdiagnosis
10. Urgent Care Evaluation
    1. Acute Vestibular Syndrome
       1. Head Impulse–Nystagmus–Test of Skew (HINTS) Testing
          1. Test 1: Nystagmus Testing
          2. Test 2: Skew Deviation Testing
          3. Test 3: Head Impulse Testing
          4. Test 4: Targeted Examination
          5. Test 5: Gait Testing
       2. Spontaneous Episodic Vestibular Syndrome
       3. Triggered Episodic Vestibular Syndrome
11. Diagnostic Studies
12. Treatment
13. Special Populations
14. Controversies and Cutting Edge
15. Disposition
16. Summary
17. Time- and Cost-Effective Strategies
18. Risk Management Pitfalls for Dizziness in the Urgent Care Setting
19. Case Conclusions
20. Additional Resources
21. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
22. Clinical Pathways
    1. Clinical Pathway for the ATTEST Approach to Urgent Care Patients With Acute Dizziness
    2. Clinical Pathway for Diagnostic Evaluation of Patients With an Acute Vestibular Syndrome
23. References

Acknowledgment

This content was adapted from: Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emerg Med Pract. 2019;21(12):1-24. Used with permission of EB Medicine.

Abstract

Acute dizziness is a common presentation in the urgent care setting. 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 vs lightheadedness). Each timing-and-triggers category has its own differential diagnosis and diagnostic approach, which will aid 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, elevating accurate clinical diagnosis to an even greater level of importance. Benign paroxysmal positional vertigo can be treated with repositioning maneuvers at the bedside, offering cost-effective management options.

Case Presentations

A previously healthy 44-year-old man presents to urgent care with dizziness that has been present for 6 hours...

• 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.
• Your colleague who examined him before you arrived reports that the patient’s head impulse test is normal.
• Hearing all of this, you consider treating with meclizine and having him follow-up with his PCP in 2 days, but you wonder if there is something else that needs to be considered...

A 70-year-old woman arrives at the clinic with a complaint of “lightheadedness” that has been going on for 5 days...

• She says the feeling 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 on the exam table, she is asymptomatic but feels apprehensive about moving her head. There is no nystagmus in primary gaze.
• You wonder if you should send her to the ED for a head CT or if there is a better diagnostic test...

A 58-year-old diabetic man presents with a chief complaint of syncope...

• On further questioning, he is reporting vertigo that is so severe it made him ease himself to the ground. There was no trauma, and it began abruptly 3 hours prior.
• Fingerstick glucose is 110 mg/dL.
• There is nystagmus on primary gaze that beats to the right, and when he looks to the right the amplitude of the nystagmus increases.
• He is very nauseated and has vomited 3 times. A head impulse test is positive. Skew deviation is absent and he is mildly unsteady but can walk unassisted.
• You wonder if this could be stroke and whether emergent transfer to the ED is needed...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Diagnostic Evaluation of Patients With an Acute Vestibular Syndrome

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

8. * Edlow JA, Carpenter C, Akhter M et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023;30(5):442-486. DOI: 10.1111/acem.14728

24. * Edlow JA. Diagnosing patients with acute-onset persistent dizziness. Ann Emerg Med. 2018;71(5):625-631. (Review article) DOI: 10.1016/j.annemergmed.2017.10.012

29. * 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) DOI: 10.1016/S1474-4422(12)70299-5

37. * 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) DOI: 10.1002/ana.24521

43. * 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) DOI: 10.1161/STROKEAHA.115.010613

49. * 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) DOI: 10.1111/j.1553-2712.2011.01093.x

50. * 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) DOI: 10.1161/STROKEAHA.114.007087

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Keywords: dizzy, dizziness, lightheaded, vertigo, BPPV, vestibular syndrome, benign paroxysmal positional vertigo, head impulse test, HIT, HINTS, ATTEST, GRACE-3, CPPV, nystagmus, posterior circulation, skew, saccade, gait, migraine, Dix-Hallpike, Epley, Semont, Lempert