Vertigo Helper — ER Documentation

Clinical Disclaimer: This tool is a decision-support aid only and does not replace physician assessment. Always apply clinical judgment. Based on GRACE-3 guidelines and expert consensus.

Step 1 — Screen for Central Features (Red Flags)

1 Red Flag Screening

Check all that apply. If any are present, a central cause is suspected.

Focal weakness or paresthesia (face or limbs) Any of the "Deadly D's": Diplopia, Dysarthria, Dysmetria, Dysphonia, Dysphagia iThe Deadly D'sDiplopia — double vision
Dysarthria — slurred speech
Dysmetria — inability to judge distance/scale of movement
Dysphonia — difficulty producing voice
Dysphagia — difficulty swallowing Inability to stand or walk unaided (new onset) Spontaneous purely vertical or torsional nystagmus at rest New significant, sustained headache or neck pain

Step 2 — Categorize the Vertigo

2 Timing, Triggers & Nystagmus

Select the category that best matches the patient's presentation.

Vertigo Pattern A — Triggered Episodic Vertigo (t-EVS / BPPV likely)
Short episodes (<2 min), initiated by head movement (e.g., rolling in bed), no nystagmus at rest B — Acute Vestibular Syndrome (AVS)
Constant, ongoing vertigo (hours to days), worsened by head movement, with spontaneous or gaze-evoked nystagmus at rest C — Acute Imbalance
Constant dizziness, but no nystagmus at rest

✅ Triggered Episodic Vertigo — BPPV Likely

Perform Dix-Hallpike Test iDix-Hallpike Maneuver1. Patient seated, turn head 45° to one side
2. Rapidly lower to supine with head hanging 20° off table edge
3. Observe eyes for upbeat-torsional nystagmus (latency 2–10s, fatigues in <60s)
4. Positive = affected side is the downward ear
5. Repeat for opposite side if first negative

Positive Dix-Hallpike → Diagnosis: Posterior Canal BPPV

Treatment: Perform Epley Maneuver (canalith repositioning). Discharge with return precautions.

⚠️ Do NOT perform the HINTS exam for this category. HINTS is validated only for Acute Vestibular Syndrome (constant vertigo with nystagmus at rest). In episodic positional vertigo, HINTS results are unreliable and may be falsely reassuring. CT scan is also not indicated for isolated BPPV.

Acute Imbalance — Assess Gait

! Gait Assessment

Patient has constant dizziness without nystagmus. Assess for objective gait instability.

Gait Finding Objective new difficulty walking / Cannot walk unaided Normal gait

Step 3 — HINTS+ Examination

3 HINTS+ Battery (4 Components)

Only perform if nystagmus is present at rest. All 4 must be peripheral to safely diagnose vestibular neuritis. Any single central finding warrants stroke workup.

1. Head Impulse Test (HIT) iHead Impulse Test1. Patient fixates on your nose
2. Rapidly turn head ~20° to each side
3. Abnormal = corrective saccade (eyes lag behind, then "catch up")
4. In vestibular neuritis, HIT is abnormal toward the affected side
5. A normal HIT in AVS is concerning for central cause

2. Nystagmus (Gaze Testing)

3. Test of Skew (Alternate Cover)

4. Plus: Hearing (Finger Rub)

🛑 STOP: Central Cause Suspected

✅ Triggered Episodic Vertigo — BPPV Likely