Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. 

Typically, patients with peripheral vertigo appear to have an acute change and may be very ill appearing, with nausea and vomiting and severe vertigo symptoms. Those with central vertigo typically have a more insidious onset, constant symptoms, and typically less severe symptoms. 

Symptoms of a central vertigo may be difficult to identify. Typically, there are some of the "5 D's"

• Dizziness
• Dysarthria
• Diplopia
• Dysphagia
• Dysmetria
• Ataxia

The NIH stroke scale it used to identify the severity of stroke like symptoms, and should be scored on the patient's initial presentation, without coaching or duplication. It is important to be consistent when scoring all patients, and identify all deficits. 

NIH stroke scale scores patients 0-42, with higher scores indicating increased severity.

Training for appropriate use of the NIH stroke scale is free, at http://nihss-english.trainingcampus.net/

iPhone applications, such as StatCoder, are available and free.

Adapted from Rosens, chp 16. 

Testing to consider in an elderly patient with altered mental status
ABG: hypoxia, CO2 retention, SOB
BMP/CMP: electrolyte abnormalities, hepatic encephalopathy
UA: infection, DKA, ingestion
PT/INT: hemorrhage, anemia, hypercoagulable
Lactate: ketotic state, ingestion, ischemia
TSH: thyroid storm, hypothyroid
Cardiac Enzymes: MI, ischemia, cardiogenic shock
CXR: infection, pneumothorax, CHF
CT head: hemorrhage, mass
MRI: edema, mass, ischemia
CTA: pulmonary emboli, aortic dissection
LP/CSF: infection, ICP

Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome.