Abstract
BackgroundDizziness is a common presenting symptom in the emergency department (ED). The HINTS exam, a battery of bedside clinical tests, has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo. The present study sought to assess practice patterns in the assessment of patients in the ED with peripherally-originating vertigo with respect to utilization of HINTS and neuroimaging.MethodsA retrospective cohort study was performed using data pertaining to 500 randomly selected ED visits at a tertiary care centre with a final diagnostic code related to peripherally-originating vertigo between January 1, 2010 - December 31, 2014.ResultsA total of 380 patients met inclusion criteria. Of patients presenting to the ED with dizziness and vertigo and a final diagnosis of non-central vertigo, 139 (36.6%) received neuroimaging in the form of CT, CT angiography, or MRI. Of patients who did not undergo neuroimaging, 17 (7.1%) had a bedside HINTS exam performed. Almost half (44%) of documented HINTS interpretations consisted of the ambiguous usage of “HINTS negative” as opposed to the terminology suggested in the literature (“HINTS central” or “HINTS peripheral”).ConclusionsIn this single-centre retrospective review, we have demonstrated that the HINTS exam is under-utilized in the ED as compared to neuroimaging in the assessment of patients with peripheral vertigo. This finding suggests that there is room for improvement in ED physicians’ application and interpretation of the HINTS exam.
Highlights
Dizziness is a common presenting symptom in the emergency department (ED)
Acute vertigo presents a particular challenge to ED physicians, who must differentiate vertigo caused by central nervous system pathology from that caused by disorders of the peripheral vestibular
Patient population and data acquisition We reviewed data pertaining to all patients who presented to The Ottawa Hospital (TOH) ED between January 1, 2010- December 31, 2014 who received one of the following final diagnostic codes (ICD-10): Meniere’s disease (H810), Benign paroxysmal vertigo (H811), Other peripheral vertigo (H813), Dizziness and Giddiness (R42)
Summary
The HINTS exam, a battery of bedside clinical tests, has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo. The HINTS exam was developed as a means of assessing patients with the acute vestibular syndrome (AVS), defined as acute onset and persistent vertigo, gait instability, nausea/ vomiting, nystagmus, and head motion intolerance [9]. This battery of bedside clinical tests consists of three examinations: the head impulse test (HI-), characterization of spontaneous nystagmus (-N-), and test of skew (-TS) [10]. The exam can be performed at the bedside in approximately 1 min and requires no extra equipment or tools
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