This study investigates how evaluation of patients presenting to emergency departments (ED) with dizziness has changed over time.

Approximately 4% of ED visits are for dizziness. Distinguishing peripheral from central causes of vertigo is essential to identify those resulting from posterior circulation infarctions. The HINTS (Head Impulse, Nystagmus, Test of Skew) examination has been shown to accurately identify posterior circulation strokes in acute vestibular syndrome and is superior to CT-brain imaging. Positional testing can identify those with benign paroxysmal positional vertigo.

We performed a retrospective review of patients presenting with vertigo to a tertiary-level ED in 2013 (n=820) and 2017 (n=1197). For each, we determined if the HINTS examination and positional testing were performed and if neuroimaging was ordered. Chi-square tests were performed comparing the proportion of dizziness presentations where these elements were used in 2013 and 2017.

Testing for nystagmus increased from 33.7% in 2013 to 39.3% in 2017. Use of the head impulse test, test of skew, and the complete HINTS exam all rose from < 1% in 2013 to approximately 8% in 2017 (p<0.01). Positional testing had a 9.9% use rate in 2013 and did not change significantly in 2017 (p=0.725). CT-brain imaging had a high 37.0% use rate in 2013 and did not change significantly in 2017 (p=0.259). We also found that a large proportion of visits with a HINTS exam excluding a central cause also included CT-brain imaging (46.0%).

The HINTS examination was performed in a small proportion of patients with dizziness. While the proportion in 2017 increased compared to 2013, the low proportion overall indicates a great need for increased education and awareness among ED providers. Additionally, the high use of CT-brain imaging when the HINTS exam had already excluded a central cause of dizziness demonstrates incomplete provider understanding HINTS exam.