Edlow JA, Carpenter C, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30(5):442-486. doi: 10.1111/acem.14728.

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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Emergency Medicine
Comments from MORE raters

Emergency Medicine rater

An exhaustive review and admirable attempt to create uniformity and encourage ER training. Unfortunately, its detail may limit this article’s dissemination and ready use in a clinical setting. It is a good article for a book club, CME group, etc.

Neurology rater

These guidelines for vertigo are evidence-based but dense in information, as guidelines often are. Recommendations appropriately promote using bedside exams including HINTS, but practicing emergency medicine or neurology physicians might find the document itself, the algorithm, and mastering the bedside exam techniques daunting tasks.

Neurology rater

Useful guidelines that require more training of emergency teams to avoid errors or unnecessary tests for this condition.

Neurology rater

As a stroke and general neurologist, I recognize the importance of differentiating between posterior circulation ischemic strokes presenting within the thrombolysis window, thus improving outcomes, and posterior circulation vasogenic edema/tumors/autoimmune/infectious pathology or ICH, which may require inpatient medical treatment, decompressive occipital craniotomy, and more benign lesions like vestibular neuronitis, vestibular migraines, or inner/middle ear disorders that may give rise to acute vertiginous symptoms. Training ER physicians to discern neurological disorders from vestibulocochlear disorders with confidence and identifying the subgroup of patients requiring advanced/multi-modal neuroimaging from those requiring less acute interventions helps in reducing unnecessarily using CT/CTA/CT perfusion scans (radiation exposure to patients), wastage of healthcare resources, and physician and technician fatigue. These guidelines will go a long way in addressing several issues.