Abstract Details

Dizziness comprises approximately 4% of US ED visits. While most causes of vertigo are peripheral, central causes of vertigo are not uncommon, such as posterior circulation strokes which result in significant morbidity and mortality. Multiple studies have confirmed that a targeted history and examination including symptom timing, triggers, duration, and the HINTS exam (head impulse test, nystagmus, ocular alignment), can help distinguish peripheral from central causes of vertigo. This study investigated how elements of this approach were implemented by different providers in the ED setting.

This study compares residents, attendings, and advanced practice providers (APPs) in their evaluation for neurologic and vestibular causes of dizziness in the ED.

A retrospective review was performed on 2,017 patients presenting for urgent and emergent evaluation of dizziness in 2017. Presentations with non-neurologic etiologies (e.g. chest pain, hypoglycemia), and multiple presentations by the same patient were excluded. We investigated if providers inquired about timing (acute monophasic or acute episodic), duration, triggers, and if they performed the HINTS exam, positional testing, and neuroimaging. Chi-square tests were performed comparing the proportion of residents, attendings, and advanced practice providers (APPs) who performed each element. 

All pertinent elements of the history were obtained by only 12.7% of attendings, 20.2% of residents, and 15.9% of APPs. The HINTS examination was performed by 7.5% of attendings, 13.2% of residents, and 1.3% of APPs. Positional testing was performed by 7.7% of attendings, 18.6% of residents, and 2.5% of APPs. CT scans were ordered by 48.2% of attendings, 35% of residents, and 14.6% of APPs.

The majority of providers, regardless of type, did not obtain important elements of the history and physical examination but continued to order CT scans which are insensitive for posterior circulation infarctions. This suggests a significant research-practice gap and a potential area for quality improvement in the ED.