TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo

Dizziness is a common symptom with diverse causes, including ear-nose-throat, internal, neurological, or psychiatric origins. While for most parts treatable in nonemergency settings, it can also signal time-critical conditions, like an unnoticed stroke, requiring prompt diagnosis and treatment to prevent lasting harm or death. The aim of this study was to evaluate the validity of the Manchester Triage System in classifying patients presenting with dizziness based on final diagnoses and patient outcomes, as no specific flow chart exists for this symptom in the MTS.

Monocentric, retrospective observational study. To test the validity of the MTS in the triage of dizziness patients, the treatment level was used as a surrogate parameter. We grouped the patients into outpatient, normal ward and intermediate care/intensive care unit (IMC/ICU) patients. Furthermore, we analyzed the dizziness patients in subgroups based on the origin of their dizziness to identify potential improvements for the MTS. Patients with dizziness and stroke, who represent the most vulnerable group of dizziness patients, were also evaluated separately.

During the observation period, 2958 patients presented at the ED with the symptom dizziness and 52 017 without, who formed the reference group. When examining the relationship between triage level and subsequent treatment level, a larger deviation is observed compared to the reference group. The receiver operating characteristics (ROC) regarding hospital admission in general showed an area under the curve (AUC) in the subgroup with dizziness due to a central nervous system causes (n=838) of 0.69 (95% CI 0.65 - 0.72) and in the subgroup of dizziness by other organic cause (n=901), an AUC of 0.64 (95% CI 0.60 - 0.68). The reference group had an AUC 0.75 (95% CI 0.75 - 0.76) here. In relation to admission to IMC/ICU, the results were similar. The sensitivity of the MTS in terms of an adequate initial assessment of dizziness patients with stroke or transient ischemic attack (TIA) was 0.39, the specificity was 0.91 (reference group sensitivity 0.72, specificity 0.82).

In terms of construct validity, the present study revealed that the use of MTS as a priority triage assessment tool was found to be less accurate in emergency patients with dizziness, particularly those diagnosed with stroke/TIA, when compared to other emergency patients.

Patients with dizziness commonly present to Emergency Departments (ED) and 6% of these patients will be diagnosed with acute stroke. The TriAGe+ score comprises of eight clinical parameters and stratifies patients into four risk groups. The Japanese authors reported that the tool performed well, so our aim was to validate this diagnostic tool in our ED in Hong Kong.

A single-center retrospective observational study was conducted in the ED of our university hospital in Hong Kong. The primary outcome was the diagnosis of an acute cerebrovascular event. Receiver operator characteristic (ROC) analysis was performed to determine the best cut-off score. Secondary outcomes included univariable and multivariable analyses of stroke predictors.

455 patients aged 18 years or above with dizziness or vertigo at ED triage were recruited between 19 July and 30 September 2021. The overall prevalence of stroke was 11.9%. The median TriAGe+ score was 7 (IQR = 4–9). The AUC was 0.9. At a cut-off >5, sensitivity was 96.4% (95%CI: 87.3–99.5) and the negative likelihood ratio was 0.09 (95%CI: 0.02–0.3). At a cut-off >10, specificity was 99.8% (95%CI: 98.6–100.0), and the positive likelihood ratio was 237.6 (95%CI: 33.1–1704). On multivariable analyses, atrial fibrillation, blood pressure, gender, dizziness (not vertigo) and no history of dizziness, vertigo or labyrinth/vestibular disease were found to be positively associated with stroke outcomes significantly.

The TriAGe+ score is an efficient stroke prediction score for patients presenting to the ED with dizziness.

Definimos el vértigo como la ilusión de movimiento de uno mismo o del entorno, aunque cada paciente puede experimentar sensaciones distintas. Podemos clasificarlo según el tiempo de duración de la crisis, la frecuencia temporal, el tiempo de evolución o los desencadenantes. Muchas de las patologías que afectan al oído interno no tienen definido el mecanismo fisiopatológico que los origina; sin embargo, sabemos que las infecciones víricas pueden ocasionar laberintitis serosas o neuritis vestibular, que traumatismos craneales o posturas anómalas pueden ocasionar vértigo posicional paroxístico benigno (VPPB) y el envejecimiento de los receptores vestibulares puede desencadenar el presbivértigo.

El diagnóstico se basa en una anamnesis detallada, exploración física que explore los reflejos vestibuloocular y vestíbulo espinal, pruebas complementarias como audiometría o videonistagmografía y finalmente pruebas de imagen, principalmente la resonancia magnética.

La fase aguda se tratará con medicamentos que disminuyan las náuseas y vómitos, siendo los principales los sedantes vestibulares, que no deben ser usados durante más de 3 días. Hay tratamientos específicos para cada patología, como es el caso del VPPB, donde realizaremos maniobras de recolocación.

En urgencias realizaremos exploraciones a pie de cama del paciente, el protocolo HINTS es el que ha demostrado tener más sensibilidad y especificidad.

Vertigo is defined as the illusion of movement of oneself or one's surroundings, although each patient may experience different sensations. It can be classified according to the duration of the crisis, how often it occurs, the time it has been ongoing, or the triggers. Many diseases that affect the inner ear do not have a defined pathophysiological mechanism that causes them. However, it is known that viral infections can cause serous labyrinthitis or vestibular neuritis, that cranial trauma or abnormal postures can cause benign paroxysmal positional vertigo (BPPV), and that aging of the vestibular receptors can trigger presbyvertigo.

The diagnosis is based on a detailed case history; a physical examination that explores the vestibulo-ocular and vestibulo-spinal reflexes; additional tests such as audiometry or videonystagmography; and finally imaging tests, mainly magnetic resonance imaging.

The acute phase will be treated with drugs that decrease nausea and vomiting. The main drugs are vestibular sedatives, which should not be used for more than three days. There are specific treatments for each disease, such as in the case of BPPV, in which repositioning maneuvers are performed.

In the emergency department, examinations are performed at the patient's bedside. The HINTS examination has been demonstrated to have the greatest sensitivity and specificity.

Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity.

This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence.

PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined.

An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.

La démarche clinique est une spécificité de la kinésithérapie vestibulaire. Elle émane d’un consensus interprofessionnel et d’une pratique quotidienne à laquelle le kinésithérapeute est confronté lorsqu’il prend en charge le patient vertigineux. Cette démarche est soumise à des algorithmes décisionnels basés sur les principes de diagnostic différentiel, de diagnostic d’exclusion et de drapeaux rouges essentiels à leurs exécutions. Elle débute à l’étape de l’interrogatoire, se poursuit pendant l’évaluation clinique et instrumentales, et tout au long de la rééducation. Les drapeaux rouges spécifiques au champ otoneurologique sont intégrés dans le déroulement des algorithmes décisionnels, afin d’exposer aux thérapeutes les connaissances nécessaires au bon déroulement du bilan clinique et à une pratique factuelle de la prise en charge rééducative.

The clinical approach is a specificity of vestibular physiotherapy. It comes from an interprofessional consensus and from a daily practice that the physiotherapist is confronted with when he takes care of the patient with vertigo. This approach is subject to decisional algorithms based on the principles of differential diagnosis, exclusion diagnosis and red flags essential to their execution. It begins at the interview stage, continues during clinical and instrumental assessment, and throughout rehabilitation. The red flags specific to the otoneurological field are integrated into the decision-making algorithms, in order to provide therapists with the knowledge necessary for the proper conduct of the clinical assessment and for evidence-based practice in rehabilitation management.