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I’m Still STANDING – Can this New Algorithm Distinguish Peripheral vs Central Vertigo?

February 17, 2023

Written by Aaron Lacy

Spoon Feed
After a training session, both interns and senior emergency providers (EPs) could accurately distinguish between central and peripheral vertigo using the 4-step STANDING algorithm.

Why does this matter?
Distinguishing between central and peripheral vertigo is fraught with challenges. Neuroimaging is not as sensitive as we would like, and there is question about emergency providers utilizing the HINTS exam accurately. Does this step-by-step algorithm provide a guide to help distinguish between central or peripheral vertigo?

All these vertigo articles are making me dizzy
Interns were trained using videos and a supervised session on the 4-step STANDING algorithm for differentiating the etiology of vertigo. 312 patients with acute vertigo presenting to the ED were first evaluated by an intern and then a senior EP. Using the algorithm, the patients were classified into either a worrisome (central disease), benign (peripheral disease), or inconclusive category. The reference test of comparison was a brain MRI.

Outline of tortured STANDING acrostic, adapted from cited article

The algorithm showed good sensitivity (84.8% [75.6-93.9] and 89.8% [82.1-97.5]), specificity (88.9% [85.1-92.8] and 91.3% [87.8-94.8]), and agreement (0.77) between interns and seniors.

My takeaway: While this algorithm is nice, the key is that the EPs underwent a training session. There is more evidence that EPs can accurately use HINTS, but after formal training. Given how challenging it can be to diagnose and treat vertigo, more formalized training for EPs is likely indicated.

Another Spoonful
Here is a link to the validation study of the STANDING algorithm with instructions on how to complete it.

Editor’s note: STANDING is a hideous acrostic. Personally, I would have gone with ‘NASTY-HEIST’ or ‘NERDIEST.’ Anyway, the 4 steps are: nystagmus presence+direction, head-impulse test, and stance/gait. NYPD HITS anyone? In STANDING, nystagmus is determined using Frenzel glasses, so NERDIEST may be the best acrostic after all. ~Clay Smith

Effectiveness and reliability of the 4-step STANDING algorithm performed by emergency interns and seniors for predicting central causes of vertigo. Acad Emerg Med. 2023 Jan 11. doi: 10.1111/acem.14659. Online ahead of print.