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STANDING Algorithm for Acute Vertigo

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STANDING Algorithm for Acute Vertigo

  • See Also
  1. HiNTs Exam
  2. Horizontal Head Impulse Test
  3. Nystagmus
  4. Skew Deviation
  5. Dix-Hallpike Maneuver
  6. McClure-Pagnini Test
  7. Vertigo
  8. Vertigo Causes
  9. Acute Vestibular Syndrome
  10. Peripheral Causes of Vertigo
  11. Central Causes of Vertigo
  12. Vertigo Management
  13. Vestibular Neuronitis
  14. Benign Paroxysmal Positional Vertigo
  15. Dizziness
  • Indications
  1. Acute Vertigo Assessment in the Emergency Department
    1. Assists with triage of acute Vertigo patients (which are at risk for central Vertigo)
  1. Absent
    1. Go to Step 4 - Assess Walking
  2. Spontaneous Vertigo
    1. Go to Step 2 - Assess Nystagmus Direction
  3. Positional Vertigo (typically BPPV)
    1. Confirm that patient is able to stand or walk without assistance (if not, go to Step 5)
    2. Test Specifically for BPPV findings
      1. McClure-Pagnini Test or Supine roll test (tests in horizontal plane for lateral canal)
      2. Dix-Hallpike Maneuver (tests in sagittal and Coronal Plane for posterior canal)
    3. Author's bedside strategy for BPPV testing (not part of official STANDING algorithm)
      1. Epley Maneuver (test right and left sides, treat for posterior canal BPPV, up to 90% of cases)
      2. Other maneuvers if Epley Maneuver is not effective
        1. Barrel Roll Maneuver (test and treat lateral canal BPPV, 5-10% of cases)
        2. Deep Head Hanging Maneuver (test and treat anterior canal BPPV, uncommon to rare)
  1. Multidirectional or Vertical
    1. Go to Step 5 - Evaluate for Central Vertigo
  2. Unidirectional Vertigo (left or right)
    1. Go to Step 3 - Perform Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
  1. Positive Test or Abnormal Test
    1. ABSENT corrective saccades
    2. Go to Step 5 - Evaluate for Central Vertigo
  2. Negative Test or Normal Test
    1. PRESENT quick corrective saccade movements to catch-up (HiNTs-Peripheral)
    2. Typically consistent with Vestibular Neuronitis
    3. Confirm that patient is able to stand or walk without assistance (if not, go to Step 5)
  • Approach
  • Step 4 - Stand or Walking without assistance
  1. Inability to stand or walk without assistance
    1. Go to Step 5 - Evaluate for Central Vertigo
  2. Able to stand or walk without assistance
    1. Less likely to be central Vertigo (esp. if other steps are normal)
  • Approach
  • Step 5 - Central Vertigo Evaluation
  1. See Vertigo due to Central Causes
  2. See Acute Vestibular Syndrome
  3. Head Imaging for CVA
  • Resources
  1. Standing Algorithm and Triage Application (Italian Journal of Emergency Medicine)
    1. https://www.itjem.org/2019/11/21/standing-algorithm-triage-application-new-approach-identify-classify-patients-acute-vertigo-different-emergency-care-setting/
  • References
  1. Vanni (2014) Acta Otorhinolaryngol Ital 34(6):419-26 +PMID: 25762835