Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice

Neely, Prue; Patel, Hemal H.; Wellings, Tom

doi:10.1111/1742-6723.13810

Cited by 12 publications

(34 citation statements)

References 13 publications

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“…The majority of patients presenting with BPPV in our study were discharged home. This is within the range reported in the literature that includes a high of 24% in Australia [ 3 ] and a low of 6% in Berlin [ 6 ]. The multivariable analysis showed that patients older than 54 years old were about five times more likely to be admitted to the hospital.…”

Section: Discussionsupporting

confidence: 88%

“…Dizziness could indicate a wide range of disorders from benign, yet disruptive ear problems such as vertigo, to serious neurological problems such as stroke. Vertigo is characterized by frequent, irritating and curable symptoms that could have central or peripheral causes with peripheral ones accounting for around 60% of all vertigo cases [ 2 , 3 ]. While vestibular migraine is the most common cause of episodic vertigo [ 4 ], benign paroxysmal positional vertigo (BPPV) is the primary cause of peripheral vertigo with a lifetime prevalence of 36%, lifetime incidence of 2.4% and an annual incidence of 0.6% [ 1 , 5 , 6 ].…”

Section: Introductionmentioning

confidence: 99%

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Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

et al. 2023

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Objective This study aims to assess the incidence of Emergency Department (ED) visits for benign paroxysmal positional vertigo (BPPV), describe patient characteristics, management practices and predictors of inpatient admission of BPPV patients. Methods This was a retrospective chart review of patients presenting with BPPV to a single ED between November 2018 and August 2020. Patients’ characteristics, ED management, discharge medications, disposition and unscheduled return visits were determined. Results In total, 557 patients were included. Average age was 49 years, 54.2% were females and 12.4% required hospital admission. In the ED, 51.1% received intravenous hydration, 33.8% received anti-emetics, 10.1% received benzodiazepines, 31.8% underwent canalith repositioning maneuvers (CRMs) and 56.7% were discharged on acetyl-leucine. Of discharged patients, 2.5% had unscheduled return visits. A higher likelihood of admission was associated with age above 54 years (aOR = 4.86, p<0.001, 95% CI [2.67, 8.86]), home use of proton pump inhibitors (PPIs) (aOR = 2.44, p = 0.03, 95% CI [1.08, 5.53]), use of anti-emetics and benzodiazepines in the ED (aOR = 2.34, p = 0.003, 95% CI [1.34, 4.07]) and (aOR = 2.18, p = 0.04, 95% CI [1.03, 4.64]), respectively. Conclusion While BPPV is a benign diagnosis, a significant number of patients presenting to the ED require admission. Predictors of admission include older age, PPIs use and ED treatment with anti-emetics and benzodiazepines. Although CRMs are the gold standard for management, CRMs usage did not emerge as protective from admission, and our overall usage was low.

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

et al. 2023

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“…Post-intervention data sets were statistically compared to re-analysed pre-implementation control data set first reported by our group Neely et al 5 Data were analysed using the Adjusted Wald Technique to calculate 95% CIs. Descriptive statistics were cross-analysed through Minitab (Minitab 19.2020.1 LLC) using a two-sample percentage defective test for pre vs post.…”

Section: Discussionmentioning

confidence: 99%

“…4 diagnosed and managed within Australian EDs. 5,6 In a recent observational study this group found that only 45% (95% confidence interval [CI] 35-54%) were diagnosed using correct tests and 31% (95% CI 23-41%) received the gold-standard treatment. 5 We aimed to synthesise current best available evidence surrounding the differential diagnosis of acute dizziness for use in Wyong Public Hospital (WPH) ED.…”

Section: Introductionmentioning

confidence: 99%

“…5,6 In a recent observational study this group found that only 45% (95% confidence interval [CI] 35-54%) were diagnosed using correct tests and 31% (95% CI 23-41%) received the gold-standard treatment. 5 We aimed to synthesise current best available evidence surrounding the differential diagnosis of acute dizziness for use in Wyong Public Hospital (WPH) ED. The Dizziness Project aimed to develop a dizziness resource algorithm that could assist emergency physicians in the diagnosis, treatment and specialist referral for both AVS and EVS.…”

Section: Introductionmentioning

confidence: 99%

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EVESTA: EmergencyVESTibularAlgorithm and its impact on the acute management of benign paroxysmal positional vertigo

Neely

Patel

McTaggart³

et al. 2022

Emerg Medicine Australasia

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Objective: To synthesise evidencebased research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations. Method: Current best practice models of care were synthesised into a single clinical, district-based peer-reviewed algorithm by a specialist focus group. An observational pre-and postimplementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups. Results: Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike-Dix performed by 27% (95% confidence interval [CI] 14-40%; defects preintervention 40%: post-intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2-30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18-48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15-45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post-project À4.23% (95% CI À7.20, À1.27%) (P = 0.041). Conclusion: Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidencebased treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.

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Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo

et al. 2022

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IMPORTANCE Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear.OBJECTIVE To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause.DATA SOURCES We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened. STUDY SELECTIONWe included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class. DATA EXTRACTION AND SYNTHESIS Following Preferred Reporting Items for SystematicReviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURESThe predefined primary outcome was change in 10-or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month. RESULTSOf the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias. CONCLUSIONS AND RELEVANCEModerately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.

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Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice

Cited by 12 publications

References 13 publications

Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

EVESTA: EmergencyVESTibularAlgorithm and its impact on the acute management of benign paroxysmal positional vertigo

Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo

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