A Smarter Way to Handle Dizziness in the Emergency Room

Dizziness is one of the most frequent—and frustrating—reasons patients rush to the emergency department. It can mean something as benign as dehydration or as serious as a stroke. For decades, clinicians have tried to pin down causes of dizziness by classifying it into vague categories like vertigo, presyncope, disequilibrium, or just plain “nonspecific.” But that approach often leads to more confusion than clarity.

A recent review by Dr. Ileok Jung and Dr. Ji-Soo Kim from Seoul National University Bundang Hospital offers a smarter, more practical way to assess dizziness that’s already changing emergency room protocols.

The New Approach: Ask the Right Questions First

Instead of asking “what kind of dizziness is it?”, the new model starts by asking when and how dizziness occurs. The framework breaks down into four categories:

1. Acute Prolonged Spontaneous Dizziness/Vertigo– Sudden and persistent episodes lasting hours to days.– Common causes: Vestibular neuritis or stroke.

2. Recurrent Spontaneous Dizziness/Vertigo– Comes and goes without clear triggers.– Often linked to conditions like Meniere’s disease or vestibular migraine.

3. Recurrent Positional Vertigo– Triggered by head movements or changes in position.– Usually benign paroxysmal positional vertigo (BPPV), which can be treated bedside.

4. Chronic Persistent Dizziness and Imbalance– Long-standing unsteadiness or dizziness, possibly related to psychological or neurological conditions.

   
   

Why Imaging Isn’t Always the Answer

One of the biggest revelations? Bedside exams are often more reliable than brain scans when it comes to diagnosing stroke in dizzy patients. Despite advances in MRI and CT technology, small strokes in the brainstem or cerebellum can be missed. Clinical skills—like observing eye movements and balance—remain essential.

This is especially true for isolated vascular vertigo, a form of stroke that mimics inner ear disorders. With better training in neurotology (the neurological study of balance and hearing), emergency doctors are now able to catch these tricky cases more often, and more accurately.

The Takeaway: Better Diagnosis Starts at the Bedside

The most powerful tool in diagnosing dizziness isn’t always found in the radiology department—it’s at the bedside. A thorough history, targeted physical exam, and a structured approach can help clinicians quickly identify serious conditions like stroke, while also avoiding unnecessary tests and hospital admissions.

As our understanding of dizziness evolves, so too does our responsibility to stay up-to-date. This new diagnostic framework not only improves patient care—it empowers emergency teams to make faster, more accurate decisions when it matters most.

Reference: Jung I, Kim JS. Approach to dizziness in the emergency department. Clin Exp Emerg Med. 2015;2(2):75-88.