Abstract
IntroductionWe evaluated emergency physicians’ (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.MethodsWe administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.ResultsThe response rate was 68% (366/535). Respondents’ median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests’ bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.ConclusionEPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.
Highlights
We evaluated emergency physicians’ (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients
EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head computed tomography (CT) to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful
The actual stroke risk was drawn from previously reported estimates placing the risk of stroke at 2-4% for undifferentiated dizzy patients and 0.5-1% of patients with isolated dizziness.[1,2,4,6,13,14]
Summary
Dizziness and vertigo symptoms accounted for 4% of ED visits overall in 2011.1 The total cost for these visits was estimated at $4 billion, which reflects the often-substantial resources involved in evaluating these patients in the ED with neuroimaging, specialty consultation, and hospital admission.[1,2] dizziness-related ED visits and use of imaging studies during these visits increased from 1995-2004, there was no corresponding increase in the diagnosis of cerebrovascular disease among these patients.[3] The prevalence of stroke was low in patients with dizziness as well: 3.2% of all ED patients with undifferentiated dizziness and only 0.7% of patients with isolated dizziness (dizziness, vertigo or imbalance without motor, sensory or language findings) were diagnosed with stroke or transient ischemic attack (TIA).[4]. The Pediatric Emergency Care Applied Research Network head injury clinical decision rule helps clinicians identify children at risk of clinically important brain injury after head trauma, in order to target the use of computed tomography (CT) imaging.[5]
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
