Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3) – Acute Dizziness and Vertigo in the Emergency Department 

June 23, 2023

Written by Jason Lesnick

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The GRACE-3 group (SAEM) provides us with a guideline based on their review we covered previously with the evidence for evaluating and managing adult patients presenting to emergency departments for acute dizziness. Emergency clinicians need additional training in physical exam techniques related to acute dizziness in order to perform them effectively, which should be a specialty-wide goal for the future. 

Why does this matter?
Recommendations about management of adult ED patients presenting with dizziness is a welcome addition to improve our ability to accurately diagnose and treat these patients. This is also the first guideline from any society regarding acute dizziness. 

These guidelines are making my head spin
This one is a doozy (its 40+ pages), so I apologize! Acute dizziness is a common ED chief complaint – estimated to account for 2.1%-3.6% of visits per year. Thankfully, you never have to ask someone what they mean by “dizzy” again; this has been shown to be inaccurate, and the way patients describe their dizziness can change if asked again only minutes later. 

This guideline is an aspirational look at where we could be, and the authors admit as much. EM physicians can be trained to perform the HINTS exam and the STANDING algorithm and to apply them accurately to rule out posterior CVA. Unfortunately, prior studies we’ve covered show that EM physicians aren’t there yet. Details about how much and what type of training is necessary are currently lacking and will require future study. They also argue the specialty needs to become proficient in the Dix-Hallpike and Epley maneuvers (for posterior canal BPPV) and the supine roll test and barbeque roll maneuvers for the less common horizontal canal BPPV.

The authors suggest a timing and triggers approach to dizziness, as they say most patients will fit into one of three patterns but acknowledge this has not been validated. The three patterns are:

1. Acute vestibular syndrome (AVS) – acute onset of continuous, persistent dizziness or vertigo lasting > 24 hours 
2. Spontaneous episodic vestibular syndrome (s-EVS) – one or more discrete episodes of untriggered, spontaneous dizziness or vertigo 
3. Triggered (positional) episodic vestibular syndrome (t-EVS) – one or more discrete very brief episodes of triggered, positional dizziness or vertigo 

This document consists of 15 recommendations and is full of valuable pearls of information about common pitfalls as well as excellent explanations behind the explanations, and I would highly recommend reading it yourself. Here are the 15 recommendations, quoted in full.

“Training emergency clinicians to perform bedside eye movement examinations

Recommendation 1: Emergency clinicians should receive training in bedside physical examination techniques for patients with the AVS (HINTS) and diagnostic and therapeutic maneuvers for BPPV (Dix-Hallpike test and Epley maneuver), since untrained ED physicians do not reliably apply or accurately interpret results of this bedside eye movement examination (ungraded good practice statement].

Diagnosis of the AVS

Recommendation 2: In adult ED patients with AVS with nystagmus, we recommend routine use of the three-component head impulse, nystagmus, test of skew (HINTS) examination for clinicians trained in its use to distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, FOR) [high certainty of evidence).

Recommendation 3: In adult ED patients with AVS with nystagmus, we suggest assessing hearing at the bedside by finger rub to identify new unilateral hearing loss as an additional criterion to aid in the identification of stroke, even if the three-component HINTS examination result suggests a peripheral vestibular diagnosis (conditional recommendation, FOR) (moderate certainty of evidence].

Recommendation 4: In adult ED patients with AVS without nystagmus, we suggest assessing severity of gait unsteadiness to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (conditional recommendation, FOR) [moderate certainty of evidence].

Recommendation 5: In adult ED patients with AVS with or without nystagmus, we recommend against routine use of noncontrast CT of the brain or CT to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, AGAINST; see “Implementation considerations”) (high certainty of evidence].

Recommendation 6: In adult ED patients with AVS with or without nystagmus, if a clinician trained in use of HINTS is available we recommend against routine use of MRI of the brain or cerebral vasculature (MRA) as the first-line diagnostic test (prior to physical examination) to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses (strong recommendation, AGAINST; see “Implementation considerations”) [high certainty of evidence].

Recommendation 7: In adult ED patients with AVS and central or equivocal HINTS results, we recommend use of stroke protocol MRI (with DWI and MRA) to further help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses. (strong recommendation, FOR; see “Implementation considerations” regarding timing of MRI) [high certainty of evidence].

Diagnosis of the s-EVS

Recommendation 8: In adult ED patients with s-EVS, the writing committee believes that routine use of a detailed history and physical examination with emphasis on cranial nerves including visual fields, eye movements, limb coordination, and gait assessment helps to distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses [ungraded good practice statement].

Recommendation 9: In adult ED patients with s-EVS, we recommend against routine use of CT to help distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses (strong recommendation, AGAINST) (moderate certainty of evidence.

Recommendation 10: In adult ED patients with s-EVS and concern for TIA, we suggest use of CTA or MRA of the head and neck to rule out posterior circulation vascular pathology (conditional recommendation, FOR) (moderate certainty of evidence].

Diagnosis of the t-EVS

Recommendation 11: In adult ED patients with t-EVS, we recommend routine use of the Dix-Hallpike test to diagnose pc-BPPV (strong recommendation, FOR) [moderate certainty of evidence].

Recommendation 12: In adult ED patients with t-EVS, we recommend against routine use of CT or CTA (strong recommendation, AGAINST) [moderate certainty of evidence].

Recommendation 13: In adult ED patients with t-EVS diagnosed with typical pc-BPPV by a positive Dix-Hallpike test with the characteristic nystagmus, we suggest against routine use of MRI or MRA (conditional recommendation, AGAINST) (moderate certainty of evidence].

Treatment of acute vestibular neuritis

Recommendation 14: In adult ED patients with a clinical diagnosis of vestibular neuritis, we suggest shared decision making with patients to weigh risks and benefits of short-term steroid treatment for those presenting within 3 days of symptom onset (conditional recommendation, FOR) [very low certainty of evidence].

Treatment of pc-BPPV

Recommendation 15: In adult ED patients with pc-BPPV diagnosed by a positive Dix-Hallpike test, we recommend the Epley canalith repositioning maneuver be performed at the time of diagnosis (strong recommendation, FOR) [moderate certainty of evidence].”

Below are some highlights from the guideline: 

• The authors note that as of 2023, “HINTS testing is inaccurate,” and, “it is not standard of care, either in the legal sense of the term or common parlance sense.”
• Future technological advances should increase our ability to accurately diagnose and manage these patients. For example, video-oculography (VOG) could increase our accuracy in evaluating nystagmus. Frenzel lenses also could be advantageous to have in the department for evaluating these patients. 
• About half of ED patients with dizziness have general medical conditions; 33% have otological or peripheral vestibular causes, and 11% have neurological causes (of which about a third are cerebrovascular).
• Their analysis of MRI showed a pooled sensitivity of 79.8% for posterior CVA within the first 48 hours of admission. 
• Spontaneous nystagmus by itself is not able to differentiate central vs peripheral causes. In patients with AVS, vertical, torsional, or gaze-evoked direction-changing (i.e. right beating on right gaze and left beating on left gaze) indicates a central cause. Their pooled analysis of 16 studies showed specificity of nystagmus type to be 98.5% and sensitivity of 50.7%. 
• Their systematic review of 15 studies looking at sensitivity and specificity for test or skew showed 23.4% and 97.6%, respectively. 
• New unilateral hearing loss can help identify patients with AICA stroke. 

My personal take home is I agree with these aspirational guidelines, and I know one day we’ll be there. If you don’t feel 100% confident in your current diagnostic approach to the acutely dizzy patient, I highly recommend reading this entire guideline (or at least listen to SGEM #403)!

Source
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 May;30(5):442-486. doi: 10.1111/acem.14728.