Initial Approach to Dizziness with Falls

Immediate Assessment Framework

• The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying patients into one of three vestibular syndromes: Acute Vestibular Syndrome (AVS), Triggered Episodic Vestibular Syndrome, or Spontaneous Episodic Vestibular Syndrome, to distinguish benign peripheral vestibular disorders from dangerous central causes like stroke 1
• The American College of Emergency Physicians suggests asking specific questions in order of priority, including age, previous falls, duration of episodes, triggers, time spent on floor/ground after fall, loss of consciousness or altered mental status, near-syncope or orthostatic symptoms, associated symptoms, feeling unsteady when standing or walking, and worry about falling 2, 3

Fall Risk Stratification

• The American Academy of Otolaryngology-Head and Neck Surgery recommends using the Get Up and Go test, Tinetti Balance Assessment, and Berg Balance Scale to assess fall risk in patients with positive responses to screening questions 3
• Among elderly patients with undiagnosed BPPV, 75% had fallen within the prior 3 months, highlighting the importance of fall risk assessment 3, 4

Imaging Decisions

• The American College of Radiology recommends no imaging for brief episodic vertigo with typical BPPV features and positive Dix-Hallpike, or for acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1
• MRI brain (without contrast) is indicated for abnormal neurologic examination, HINTS examination suggesting central cause, high vascular risk patients with acute vestibular syndrome, unilateral or pulsatile tinnitus, and asymmetric hearing loss 1

Immediate Management Based on Diagnosis

• The American Academy of Otolaryngology-Head and Neck Surgery recommends the Epley maneuver immediately for BPPV, with a 90-98% success rate 1
• For suspected posterior circulation stroke, activate stroke protocol immediately and consider urgent neurology consultation 1

Safety Assessment Before Discharge

• The American College of Emergency Physicians recommends that patients demonstrate ability to rise from bed independently, steady ambulation out of examination area, and understanding of fall precautions before discharge 2, 3, 5
• Counsel patients specifically about sitting or lying down immediately when feeling dizzy, using assistive devices if balance affected, avoiding driving during acute episodes, and home safety modifications 5