Kevin M. Klauer, DO, EJD, FACEP, is Chief Medical Officer–hospital-based services and Chief Risk Officer for TeamHealth as well as the Executive Director of the TeamHealth Patient Safety Organization. He is a clinical assistant professor at the University of Tennessee and Michigan State University College of Osteopathic Medicine. Dr. Klauer served as editor-in-chief for Emergency Physicians Monthly publication for five years and is the co-author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals. Dr. Klauer also serves on the ACEP Board.
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4 Responses to “Myths in Emergency Medicine: Diagnostic Imaging for Dizziness”
March 22, 2015
Alan J. Sorkey MDGood to know that CT scan are worthless in these cases. I will be sure to send a copy of this article to the patient I recently saw with dizziness and an acute brainstem infarct on CT scan. He had just been sent home from a stroke center with no CT scan.
How does this balance with the malpractice payout for missed stroke diagnosis? How about factoring in the time spent in responding to patient complaints and to peer review.
Take-home point: CT is not worthless in the evaluation of dizziness. It is what the patient expects, it is what the peer review panel (in retrospect) will expect. A normal CT makes for a happy patient and protects the doctor, very worthwhile in my opinion.
March 22, 2015
Chuck PilcherSince a large percentage of posterior fossa strokes are from vertebral artery dissections, what is the value of CT Angiograms?
March 22, 2015
Jonathan EdlowAlthough it is good to see an emphasis on the diagnosis of the dizzy patient, Dr. Klauer is perpetuating another myth – that “nystagmus is unreliable”. He is right that the mere presence of any kind of nystagmus does not help to differentiate peripheral from central causes of the acute vestibular syndrome. However that is akin to saying that “the presence of EKG changes is unreliable” for diagnosing an ACS. All abnormalities are not created equal; a flat T wave does not have the same significance as ST segment elevation.
It’s the same with nystagmus. Its mere presence does not always help – but the KIND of nystagmus is VERY helpful to the diagnostician in sorting out the cause of dizziness. Some of the source for this comes from the Chase article but this article (I was an author) only described presence or absence of nystagmus (unfortunately, this is the way more EPs chart it), but it’s not meaningful.
In a patient with ongoing dizziness, one should be hesitant to diagnose vestibular neuritis or labyrinthitis if there is NO nystagmus. The nystagmus is “direction-fixed” – i.e., the fast component always beats to the same side no matter what direction the patients is looking in.
On the other hand, direction-changing nystagmus is this setting means that there is a central process (probably stroke). So does torsional or vertical nystagmus. Patients with peripheral causes will have direction-fixed horizontal nystagmus.
In positional (episodic) dizziness, these rules shift. Emergency physicians must learn some of the details about nystagmus as it can really help us to make a confident diagnosis.
The presence/absence of nystagmus but more importantly, its quality, is very helpful in making a specific diagnosis in dizzy patients.
April 23, 2015
strength in numbers: dizziness | DAILYEM[…] Cribbed from this March ACEP Now article: […]