136 Spin Cycle: Diagnosis and Treatment of Vertigo in the Emergency Department Setting

Abstract

Vertigo is a common clinical manifestation in the emergency department (ED). It is important for clinicians to determine if the peripheral cause of vertigo is benign paroxysmal positional vertigo (BPPV), a disorder accounting for 20% of all vertigo cases. However, the Dix-Hallpike test—the standard for BPPV diagnosis—is not common in the ED setting. If no central origin of the vertigo is determined, patients in the ED are typically treated with benzodiazepine, antihistamine, or anticholinergic agents. Studies have shown that these pharmaceutical treatment options may not be the best for patients with BPPV. The purpose of this study is to analyze ED provider habits in the diagnosis and treatment of vertigo. This was a retrospective cohort analysis of consecutive adult patients with a discharge diagnosis of peripheral vertigo. Patients were seen at seven emergency departments (EDs) over a 5-month study period (October 2018 – March 2019). Spanning 13 counties in Michigan, affiliated institutions included three rural medical centers, three university-affiliated hospitals and a children’s tertiary care facility. Data collected included demographics, clinical features, diagnostic testing, imaging, and ED treatment. Chi-squared and t-tests were used to compare these two groups across key demographic and outcome variables. The study hypothesis was that the Dix-Hallpike test and the Epley maneuver are underutilized by ED clinicians. A total of 250 adult ED patients met the inclusion criteria; average age 59.2 +/- 19.7 years. The mean duration of vertiginous symptoms was 42.5 +/- 90.3 hours. Only 17.2% (43/250) of patients had a Dix-Hallpike test performed in the ED. Overall 45.6% had a computed tomography (CT) of the head ordered. Pharmaceutical treatment was given to 89.6% of patients in the ED; the most common drugs were meclizine, scopolamine, and diazepam. Canalith repositioning maneuvers (ie, Epley maneuver) were used in 14 patients (5.6%) with good results in the majority of these patients (9/14). Eight patients (3.2%) were referred to the neurology clinic for follow-up. BPPV is the most common cause of vertigo, occurring spontaneously in the 50-to-70-year age group. Omission of a simple clinical test, the Dix-Hallpike test, can result in patients undergoing unnecessary, expensive investigations. Although ED providers commonly prescribe drug therapy for vertiginous symptoms, well over 90% of these patients could be successfully treated with canalith repositioning, a simple outpatient maneuver that moves the particles back into the utricle.