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Clinical controversies: No need for scans in dizzy patients : Emergency Medicine News

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CT, dizziness, diagnosis

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Few conditions present in the ER that make the average ER doctor hesitate. We tackle everything from cardiac arrest and trauma to strokes and foreign bodies in every orifice, but we choose to let someone else see a patient who presents with vertigo. Why?

One of the reasons is the lack of proper education. Diagnostic workup and management of vertigo is so poorly taught in medical school and residency, with many learners graduating without performing a proper Dix-Hallpike or Epley maneuver. (Head and neck otolaryngol surgery. 2013;148[3]:425; https://bit.ly/3tIIGUb.)

Instead, we feel more comfortable ordering tests. Many of them. We order lots of tests to save time in the ER, where we feel pressured to see as many patients as possible and rule out badness at the same time. Chemistry and blood charts, troponins, ECG, chest X-rays and even urine studies in someone with vertigo. Everything will probably be back to normal.

The most important test

Meanwhile, the most important diagnostic test is at the bedside. History and physical examination diagnose vertigo and distinguish it from other etiologies of vertigo. Ordering labs in complex patients or those whose presentation is unclear is forgivable, but neuroimaging is also routinely ordered.

What if you discovered that a test had a diagnostic yield of less than 5%? Do you still want to order it regularly? Would you be comforted if the test was negative and thought the patient was okay?

The diagnostic yield of computed tomography for people with vertigo in the emergency department is 2%. (emergency radiol. 2013;20:45.) Other studies confirm this low accuracy. (Medical emergency J. 2005;22[4]:312; https://bit.ly/3sRGHNY; Laryngoscope. 2013;123[9]:2250; Rev. Neurol. 2019;68[8]:326.)

However, he is ordered quite frequently to the emergency room for assessments of vertigo and dizziness. Many use it to rule out a posterior stroke, posterior fossa hemorrhage, or a large intracranial mass. (Am J EmergMedium. 2011;30[5]:665; https://bit.ly/3sSPsYj.)

We are terrified of missing a hemorrhage, stroke, and large masses, but these are rare causes of vertigo. The key to not missing them is a complete, physical history. I consulted Peter Johns, MD, the vertigo guru, before writing this article, and he agreed: Don’t order CT scans for every vertigo patient. Instead, look for red flags or central features: new headache or neck pain, focal paresthesia or motor weakness, inability to walk unaided, spontaneous vertical nystagmus, or one of the deadly D’s: dysarthria, diplopia, dysmetria, dysphonia, and dysphagia.

And the MRI? You might be tempted to use it on your vertigo patients if you are lucky enough to have access to MRI in your ER. However, the diagnostic yield is still quite low if the patient has no central signs.

A definitive diagnosis

You will find that most of your patients with vertigo do not have any features of concern, allowing you to move forward with bedside testing. The appropriate bedside test depends on the duration of symptoms and the presence or absence of spontaneous nystagmus. Imaging is not indicated if a definitive diagnosis of BPPV is made by the Dix-Hallpike test or if vestibular neuritis is detected using the HINTS examination.

Advanced imaging is not the answer for most of our vertigo patients. It wastes time and money, and of course radiation exposure should not be ignored either. Foolishly, those who order these tests are falsely reassured about the negative results.

We spend countless hours reading reviews covering the most advanced trauma and stroke management care, and hundreds of articles devoted to how many troponins we should order from someone with chest pain. Given that dizziness accounts for approximately four percent of all emergency department visits, we should research best practices for these patients as well as appropriate bedside maneuvers to diagnose their condition. (Eur J Emerg Med. 1995;2[4]:201.)

Check out Dr. Johns YouTube channel for amazing videos. (https://bit.ly/3pNGc5U.) Your patients will thank you.

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Dr. Briggsis an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host and editor of EM Board Bombs (https://www.emboardbombs.com), a cross-platform educational tool designed to prepare for counseling and focus on what you need to know to practice emergency medicine. Follow him on Twitter@blakebriggsmd.