4 results
LO50: Can clinical examination alone rule out a central cause for acute dizziness?
- R. Ohle, A. Regis, O. Bodunde, R. LePage, Z. Turgeon, J. Caswell, S. McIsaac, M. Conlon
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, pp. S25-S26
- Print publication:
- May 2019
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Introduction: The vast majority of patients presenting with dizziness to the emergency department (ED) are due to a benign self-limiting process. However, up to 5% have a serious central neurological cause. Our goal was to assess the sensitivity of clinical exam for a central cause in adult patients presenting to the emergency department with dizziness. Methods: At a tertiary care ED we performed a medical records review (Sep 2014- Mar 2018) including adult patients with dizziness (vertigo, unsteady, lightheaded), excluding those with symptoms >14days, recent trauma, GCS < 15, hypotensive, or syncope/loss of consciousness. 5 trained reviewers used a standardized data collection sheet to extract data. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database. Our outcome was a central cause defined as: ischemic stroke (IS), transient ischemic attack (TIA), brain tumour, intra cerebral haemorrhage (ICH), or multiple sclerosis (MS) diagnosed on either neurology assessment, computed tomography, magnetic resonance imaging, or diagnostic codes related to central causes found within ICES. A sample size of 1,906 was calculated based on an expected prevalence of 3% with an 80% power and 95% confidence interval to detect an odds ratio greater than 2. Univariate analysis and logistic regression were performed. Results: 3,109 were identified and 2,307 patients included (mean 57 years SD ± 20, Female 59.1%, Kappa 0.91). 62 central causes (IS 56.5%, TIA 14.5%, Tumour 11.3%, MS 9.7%, ICH 6.5%) of dizziness were identified. Imaging was performed in 945(42%) and neurology assessment in 42 (1.8%). ICES yielded no new diagnoses of a central cause for dizziness. Multivariate logistic regression found 11 high-risk findings associated with a central cause; history of IS/TIA (OR 3.8 95%CI 1.7-8.2), cancer (OR 3.2 95%CI 1.4-7.2), dyslipidemia (OR 2.3 95%CI 1.2-4.4), symptoms of visual changes (OR 2.1 95%CI 1.5-6.3), dysarthria (OR 9.1 95%CI 3-27.4), vomiting (OR 2 95%CI 1-3.7), motor deficit (OR 7.7 95%CI 2.9-20.2), sensory deficit (OR 28.9 95%CI 7.4-112.9), nystagmus (OR 3.3 95%CI 1.6-6.7), ataxia (OR 2.5 95%CI 1.3-4.9) and unable to walk 3 steps unaided (OR 3.4 95%CI 1.4-8.5). Absence of these findings had a sensitivity of 100% (95%CI 92.5-100%) for ICH, IS, Tumour and 95.2% (86.5-98.9) if including TIA and MS. Specificity was 51.5% (95%CI 49.4-53.6%). Conclusion: Clinical exam is highly sensitive for identifying patients without a central etiology for their dizziness.
P106: The HINTS exam: An often misused but potentially accurate diagnostic tool for central causes of dizziness
- A. Regis, R. LePage, O. Bodunde, Z. Turgeon, R. Ohle
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, p. S102
- Print publication:
- May 2019
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Introduction: Dizziness is a common presentation in emergency departments (ED), accounting for 2-3% of all visits. The HINTS (Head impulse test, Nystagmus, Test of skew) exam has been proposed as a accurate test to help differentiate central from peripheral causes of vertigo. It is only applicable to patients presenting with acute vestibular syndrome (acute onset dizziness or vertigo, ataxia, nystagmus, nausea and/or vomiting, and head motion intolerance). We aimed to assess the diagnostic accuracy of HINTS in detecting central causes of dizziness and vertigo in adult patients presenting with AVS. Methods: We performed a medical records review of all patients with a presenting complaint of dizziness to a tertiary care ED between Sep 2014 and Mar 2018. We excluding those with symptoms >14days, recent trauma, GCS <15, hypotensive, or syncope/loss of consciousness. Data were extracted by 5 trained reviewers using a standardized data collection sheet. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database to assess for any patients with a missed central cause. The primary outcome measure was a central cause of dizziness; cardiovascular accident (CVA), transient ischemic attack (TIA), brain tumour (BT) or multiple sclerosis (MS) as diagnosed on either computed tomography, magnetic resonance imaging, neurology consult or diagnostic codes within ICES. Results: 3109 patients were identified and 2309 patients met the inclusion criteria, of those 450 patients (44% male) were assessed using HINTS exam. Of those examined with HINTS, 7 patients (1.6% - 4 CVA 2 TIA 1 MS) were determined to have a central cause for their dizziness. HINTS had a sensitivity of 28.6% (95%CI 3.7 – 71%), specificity 95% (95%CI 92.6-96.9%). Of the individuals assessed with HINTS, only 16 presented with AVS (3.6%), of which three patients were found to have a central cause (CVA 2, TIA 1). HINTS in AVS for all central causes is 66.7% (95%CI 9.4-99.2%)sensitive but is 100%(95%CI 15.8-100%) for CVA alone (excluding TIA). Only 38%(16/42) of patients presenting with AVS were assessed using the HINTS exam. Conclusion: The current use of HINTS is inaccurate and it is used inappropriately in a large number of patients. Future studies should focus on the correct implementation of HINTS in the ED only in patients presenting with AVS.
P014: Does a positive Dix-Hallpike rule out a central cause of vertigo?
- O. Bodunde, A. Regis, R. LePage, Z. Turgeon, R. Ohle
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, p. S68
- Print publication:
- May 2019
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Introduction: Dizziness is a common presentation in emergency departments (ED), accounting for 2-3% of all visits. The majority are due to benign causes the most common of which is benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is used to diagnose BPPV with an affected posterior semicircular canal. A positive Dix-Hallpike exam should lead physicians to exclude central causes for a patient's symptoms and confirm no need for further imaging. The purpose of our study was to verify the accuracy of the Dix-Hallpike maneuver for ruling out a central cause of dizziness. Methods: We performed a medical records review of adult patients with dizziness/vertigo presenting to a tertiary care ED (September 2014 and March 2018). We included those with a suspicion for BPPV and underwent a Dix-Hallpike maneuver. We excluded patients who presented with dizziness for longer than two weeks, syncope, systolic hypotension <90 or a GCS <15. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database. Our outcome was a central cause defined as: ischemic stroke (IS), brain tumour, intra cerebral haemorrhage (ICH), or multiple sclerosis (MS) diagnosed on either neurology assessment, computed tomography, magnetic resonance imaging, or diagnostic codes related to central causes found within ICES. Results: 3109 patients were identified of these 469 patients underwent a Dix-Hallpike manoeuvre. Central causes of dizziness accounted for 1.1% of all diagnoses. Probability of a central cause for dizziness in those with a positive Dix-Hallpike was 1.3%(3/229). Only 85(18.1%) patients were appropriate for the Dix-Hallpike(intermittent, position-evoked vertigo without any neurological deficits). In appropriate patients the prevalence of central cause of dizziness was 3%(1/31). This patient had > 3 risk factors for stroke (age > 65, hypertension, diabetes, ischemic heart disease). A positive Dix-Hallpike in appropriate patients with <3 risk factors for stroke was 100% (95%CI 88.8% -100%) sensitive in ruling out a central cause for dizziness. Conclusion: The Dix-Hallpike manoeuvre is performed on a large number of inappropriate patients. When performed on appropriate patients with <3 risk factors for stroke a positive Dix-Hallpike can rule out a central cause of vertigo. Educating physicians as to the appropriate patient population could reduce unnecessary imaging and improve diagnostic accuracy.
LO51: Does my dizzy patient need a computed tomography of the head?
- R. LePage, A. Regis, O. Bodunde, Z. Turgeon, R. Ohle
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, p. S26
- Print publication:
- May 2019
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Introduction: Dizziness is among the most common presenting complaints in the emergency department (ED). Although the vast majority of these cases are the result of a benign, self-limiting process, many patients undergo computed tomography (CT) of the head. The objective of this study was to define the yield of and diagnostic accuracy of CT in dizziness in addition to defining high-risk clinical features predictive of an abnormal CT. Methods: At a tertiary care ED we performed a medical records review from Jan 2015-2018 including adult patients with a triage complaint of dizziness (vertigo, unsteady, lightheaded), excluding those with symptoms >14days, recent trauma, GCS < 15, hypotensive, or syncope/loss of consciousness. Five trained reviewers used a standardized data collection sheet to extract data. Our outcome was a central cause defined as: cerebrovascular accident (CVA), brain tumor (BT) or intracranial haemorrhage (ICH) diagnosed on CT or magnetic resonance imaging. Univariate analysis/logistic regression were performed and odds ratios reported. A sample size of 796 was calculated based on an expected prevalence of 5% with an 80% power and 95% confidence interval to detect an odds ratio greater than 2. Results: 2310 patients were recruited, 800 (35%) underwent CT head, 471(59%) female and a mean age of 62.8 years (+/−17.5 years). The top three diagnoses for patients undergoing CT were peripheral vertigo/benign positional vertigo (153 – 19%), vertigo not-otherwise-specified (137 – 17%) and dizziness not-otherwise-specified (137 – 17%). The number of CT scans considered abnormal was 30 (3.7%). The top three diagnoses for patients with an abnormal CT were CVA (22 – 75%), BT (9 – 26%) and ICH (6-17%). High risk clinical findings associated (p < 0.001) with an abnormal head CT were dysmetria, objective motor neurological signs, positive Rhomberg, ataxia and inability to walk 3 steps. Objective motor neurological signs (OR 8.4 [95% CI 3.27-21.72]) and ataxia (OR 3.4 [95% CI 1.62-7.41]) were both independently associated with an abnormal CT. Patients without any high risk findings on exam had a 0.7%(3/381 – 2 CVA,1 Tumour) probability of an abnormal CT. Sensitivity of CT for a central cause of dizziness was 71.43%(95%CI 55.4-84.3%), specificity 100%(95%CI 99.5-100%). Conclusion: Current rate of imaging in dizziness is high and inefficient. CT should be the first imaging test in those with high-risk clinical features, but a normal result does not rule out a central cause.