Purpose
Dizziness is a debilitating symptom reported by 5% of adults per annum and accounts for 2.5% of visits to the Emergency Department (ED) in the US.
The terms dizziness and vertigo are used interchangeably in modern literature and research has focused on categorising symptom timing and trigger to aid diagnosis.
Of dizzy patients presenting in the ED 71% have benign peripheral vestibular dysfunction which closely mimics those with posterior stroke (3-5%). When patients present with “sudden” and “persistent” vertigo the chance of posterior infarct increases to ~25%.
Despite the publication of physical assessment tools such as HINTS+, TiTrATE and the Dix-Hallpike, pitfalls to diagnosis such as overreliance on imaging remain.
It is proposed that a clinical assessment tool, together with an education package, will embed evidence-based assessment in the ED and enable physicians, specialist nurses and physiotherapists to triage and treat this complex condition.
Approach
Systematic key word literature review across PubMed and Cochrane Library online databases 2008 - 2018 inclusive. Literature review was weighted towards recent systematic reviews.
Outcomes
The key clinical assessments for identifying stroke in the dizzy patient were identified and amalgamated into a clinical prompt tool; named the Lamb - Vertigo Assessment Tool (Lamb-VAT).
Clinical assessments within the tool include; subjective questioning of symptom onset, trigger and duration (TiTrATE), identification of risk factors for stroke (ABCD2), lying and standing BP, electrocardiogram, medication review, Dix-Hallpike and the HINTS+ assessment of head impulse, nystagmus Interpretation, test of skew and finger rub.
The development of the Lamb-VAT is the first step in establishing a standardised tool to identify stroke in the dizzy ED patient. Future research will focus on developing the education package in a single site feasibility study before validating the tool in a multi-site trial.
Implications
The development of the tool is an attempt to standardise the approach to assessing dizzy patients in the ED. It is conceivable that once a standardised approach is found to be both feasible and valid that it could be used widely throughout the NHS. Physiotherapists working in the ED could undertake the education package alongside front-line physicians and specialist nurses to enable them to manage this complex condition with structure and clarity.
Funding acknowledgements
No funding required for this research |
Additional notes
This work was presented at Physiotherapy UK 2019 |