One symptom that emergency providers know well is dizziness. As many as 4 million patients visit the ED every year with this complaint, but pinning down precisely why a patient is suffering from dizziness often is not immediately apparent.

There is a wide range of possible causes, ranging from something as simple as dehydration to a much more serious underlying neurological cause, such as stroke. Experts suggest 15% of patients who present to the ED with dizziness have a serious, underlying issue that requires immediate care. It is critical for frontline providers to recognize these cases and to accelerate care accordingly.

But because of COVID-19, many of these patients with dizziness may be seeking care virtually, both through primary care settings and many EDs that have established telemedicine infrastructure. It has become increasingly important for practitioners to be able to recognize whether there is a serious underlying cause via two-way video hookup.

Appreciating the need for more guidance in this area, an international task force comprised of physician-scientists from 10 countries developed consensus-based guidelines to help frontline providers diagnose and triage patients with dizziness over a telehealth or virtual platform.1

Facilitate Expertise

Aasef Shaikh, MD, PhD, a research scientist from the Cleveland Functional Electrical Stimulation Center at the Louis Stokes Cleveland Veterans Administration Medical Center, led this task force.

“There are not many doctors who specialize in dizziness,” Shaikh laments. “Emergency physicians are trained in distinguishing one form [of dizziness] from another, but still there are not enough people who are qualified enough to manage dizzy patients.”

Shaikh explains there has been a supply-and-demand mismatch. There are few specialists in this area, referred to as neurotologists, yet there is high demand for services.

“This all became worse when COVID-19 came through. We already had very limited space, and then we needed to see patients and prioritize them based on their need to come into the hospital,” says Shaikh, chair of brain health at the University Hospitals Neurological Institute in Cleveland.

The pandemic accelerated the specialty’s plans to introduce a virtual way of practicing, something that could be used especially for patients who would otherwise have to travel a long distance for care.

“I get patients who see me from Texas, Florida, Georgia, and sometimes from overseas,” Shaikh reports. “We noticed firsthand that this was working very well, so then we talked about developing a set of guidelines.”

The recommendations are designed to serve two purposes. “One purpose is to help ED physicians or other frontline clinicians to determine who really needs urgent, immediate care — who needs to come into the hospital,” Shaikh explains. “The second part of the guidelines is to tell people how to examine [a patient with dizziness], and what to look for virtually.”

Often, when patients with dizziness present to an ED, neurology will be consulted if there is any question about the underlying cause. However, if a neurologist is unavailable, the patient will be transferred to where this type of service is available.

“If you have a virtual way to [access this expertise] ... you will save a lot of expense in patient transportation or in triaging the patient,” Shaikh notes.

Look for Tip-Offs

There are general signs frontline providers should watch for when examining a patient with dizziness, either virtually or in person. “One is how miserable the patient is — miserable in a way that the patient cannot get up from the bed and walk without any assistance,” Shaikh says. “[For that] patient, I would definitely suspect that something major is wrong in the brain, and that could potentially be a patient who is [at risk] for a stroke.”

A second indication that something serious is going on is what Shaikh describes as perception of motion. This may not just be abnormal movements of the eyes, but rather the patient’s own feeling he or she is moving or spinning while seated. “It is vertigo, but frequently we correlate the vertigo with involuntary movement of the eyes,” Shaikh says. “If that is present, that is suggestive of certain types of [stroke], or some kind of structural deficit in the brain.” Shaikh notes that even if clinicians resolve eye movement issues, a patient still may perceive vertigo.

With practice, emergency providers can become better at assessing dizziness. Shaikh says the key is “you want to know what not to miss rather than what to diagnose.”

While virtual examinations are important to ensuring expert care is accessible to all patients, Shaikh says in-person encounters remain important. “If someone calls me 100 miles from my hospital, I am able to address their question in a very effective way using these guidelines that we have published. But that does not mean that everything I do would happen virtually,” he says.

REFERENCE

  1. Shaikh AG, Bronstein A, Carmona S, et al. Consensus on virtual management of vestibular disorders: Urgent versus expedited care. Cerebellum 2020; Aug 14:1-5. doi: 10.1007/s12311-020-01178-8. [Online ahead of print].