GRACE-3 guidelines for dizziness and vertigo management in ED, issued by SAEM
USA: The GRACE-3 panel has developed 15 evidence-based recommendations based on the timing and triggers of dizziness while recognizing that alternative diagnostic approaches exist.
The SAEM (Society for Academic Emergency Medicine) GRACE (Guidelines for reasonable and appropriate care in the emergency department) address the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department (ED) in the US based upon research and expert consensus.
Acute dizziness or vertigo is a common ED presentation, accounting for 2.1%–3.6% of visits per year, with an estimated annual cost approximating $10 billion in the United States, a large proportion of which is related to imaging. The GRACE-3 clinical practice guideline has been developed to address the critical need for evidence-based recommendations for patients presenting in the emergency department with acute dizziness and vertigo.
Most acutely dizzy patients in the ED present in one of three patterns that drive the differential diagnosis, diagnostic testing, and interpretation of many of these tests.
Grading of Recommendations Assessment, Development, and Evaluation (GRACE) was used to develop the GRACE-3 clinical practice guideline. The GRACE-3 panel developed 15 evidence-based recommendations based on the triggers and timing of dizziness; recommendations from the guideline are given below:
Training Emergency Clinicians to Perform Bedside Eye Movement Examinations
- Emergency clinicians should receive training for diagnosing and treating patients with acute dizziness.
Diagnosis of AVS
- In patients with nystagmus, trained clinicians should use HINTS testing to distinguish central (stroke) from peripheral (inner ear, usually vestibular neuritis) diagnoses.
- In patients with nystagmus, the hearing should be assessed by finger rub to distinguish central from peripheral diagnoses.
- In patients without nystagmus, assess the severity of gait unsteadiness to distinguish central from peripheral diagnoses.
- Routine use of non-contrast brain CT or CTA is not recommended in patients with or without nystagmus.
- In patients with or without nystagmus, the routine of use MRI or MRA as the first-line diagnostic test is not recommended if a clinician trained in HINTS is available.
- MRI/MRA use is recommended to distinguish between central and peripheral diagnoses in patients whose HINTS result is central or equivocal.
Diagnosis of s-EVS
- Clinicians should perform a history and physical exam with emphasis on cranial nerves, visual fields, eye movements, limb coordination, and gait assessment to distinguish between central (TIA) and peripheral (vestibular migraine, Menière disease) diagnoses.
- Use of CT is not recommended to distinguish between central and peripheral diagnoses.
- If concern for TIA, use CTA or MRA to diagnose large vessel pathology.
Diagnosis of the Triggered Episodic Vestibular Syndrome
- The use of the Dix-Hallpike test is recommended to diagnose posterior canal BPPV.
- Routine use of CT or CTA is not recommended.
- Routine use of MRI or MRA is not recommended for posterior canal BPPV by a positive Dix-Hallpike test.
Treatment of Acutely Dizzy Patients in the ED
- Use shared decision-making with patients regarding short-term steroid treatment for vestibular neuritis within the first three days of symptoms.
- Epley manoeuvre should be used for patients diagnosed with posterior canal BPPV.
Reference:
https://www.saem.org/publications/grace/grace-3
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