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Dizziness in the Emergency Department (ED)

Timothy C. Hain, MD Page last modified: January 24, 2019

How much dizziness is there in the ED and how much does it cost ?

Dizziness accounts for 3.5% to 11% of ED visits (Crespi, 2004; Lammers et al, 2011). Of these visits, the majority are from cardiac (heart) or general medical causes. The proportion of costs for ER visits is similar (4% according to Saber et al ,2013). The table below comes from Dr. Newman-Toker's study, and provides the proportion of diagnoses in ED patients. (Newman-Toker et al, 2008)

Newman-Toker and associates (2008) report was based on on dizziness visits to US emergency departments: cross-sectional analysis 9472 dizziness cases in the US. sampled over 13 years. This is about 2 orders of magnitude more patients than were previously studied.

Concerning costs of ED care, HCUP-CCS key diagnostic groups for those presenting with dizziness and vertigo included the following (fraction of dizziness visits, cost-per-ED-visit, attributable annual national costs): otologic/vestibular (25.7%; $768; $757 million), cardiovascular (16.5%, $1,489; $941 million), and cerebrovascular (3.1%; $1059; $127 million) (Saber et al, 2011). According to Newman-Toker, the costs of US E.D. dizziness presentations now exceed $10 billion/year, largely owing to a combination of frequent neuroimaging obtained in about half, and admissions for nearly 20% (Newman Toker, 2016). This figure presumably includes all of the causes above -- many of which are general medical rather than vestibular or stroke.

Emergency departments do not perform well in diagnosing dizziness.

It is well understood that Emergency Departments are not very accurate in diagnosing dizziness. This is not surprising as they are in a hurry, and ED practitioners must be generalists as well. EDs are also incredibly expensive, and the process of evaluating dizziness can be extraordinarily expensive compared to seeing an expert in the outpatient arena.

Kerber (2009) commented concerning the source of error in ED departments that "a common theme among these misconceptions is an overreliance on the patient's description of symptoms and an overreliance on CT scans (Kerber, 2009). Royl et al (2011) noted that on follow-up 43% of all ER diagnoses (of dizziness) were corrected: 6% of benign ER diagnoses were corrected to serious diagnoses, 23% of serious ER diagnoses were revised to benign. The most frequent corrections concerned patients with an ER diagnosis of stroke or vestibular neuronitis. It is not only ED physicians -- neurology consultants make many mistakes too. Misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting". (Moeller., et al., 2008).

It is not just CT scans - - It is very common for doctors in the ED to obtain a CT angiogram and/or an MRI for patients with dizziness. For example, a patient of mine developed severe vertigo recently. He went to the ED, and instead of examining him for dizziness (perhaps they don't know how ?), they obtained a CT angiogram, and an MRI. He subsequently saw a physical therapist, who noticed that his eyes were jumping (nystagmus), and his HIT test was positive. The physical therapist diagnosed him with vestibular neuritis, which I confirmed in the outpatient setting. Why do ED doctors do this ? Perhaps they are in a hurry, and sending the patient for a test saves their time. It may also reduce their malpractice risk - -getting an MRI means they won't miss a stroke. Patients expect "tests", and this fulfills their need to have their anxiety treated. This is not always good for their patients though - - here there were about $5000 of tests, for a disorder that can and was detected easily with a physical examination.

According to the literature, another reason ED errors are made so oftenbecause of inappropriate emphasis of ED physicians on symptom quality. According to Stanton et al (2007), "In a multivariate model, those ranking quality first (particularly resident physicians) more often reported high-risk reasoning that might predispose patients to misdiagnosis (e.g., in a patient with persistent, continuous dizziness, who could have a cerebellar stroke, resident physicians reported feeling reassured that a normal head computed tomogram indicates that the patient can safely go home) (odds ratio, 6.74; 95% CI, 2.05-22.19). " Newman-Toker also criticized using "quality" of symptom historical measures to make diagnoses in dizziness patients (2007).

While we agree that this is perhaps part of the problem, we think there are more obvious reasons such as the ED doctors may not know much about dizziness, they have no compelling motivation to save other people's money, they are usually in a hurry, they are very motivated to reduce malpractice risk, and perhaps they hope to alleviate anxiety with tests.

We think that the problem is not really solvable for the ED physician -- there are always going to be mistakes, and there is always going to be a need to save time and avoid risk of litigation. Here are the reasons:

ED physicians should do better with vestibular neuritis --this is not so hard. (see following)

Next we will review common categories of dizziness, and then offer an approach to dizziness in the ED.

OTOLOGIC DIZZINESS (i.e. dizziness from the ear -- about 1/3 of all dizzy patients in the ED)

Otologic dizziness is generally safe, and these patients can almost always be discharged from the ED, possibly with some symptomatic treatment.

The key to recognizing otologic vertigo is recognizing nystagmus (involuntary jumping of the eyes), and excluding people with neurological symptoms (such as weakness of the body on one side) and severe headache. Kerber (2011) reported that even when the ED documents nystagmus, it is usually useless. The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits.