Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Acad Emerg Med. 2009 Oct;16(10):970-7. doi: 10.1111/j.1553-2712.2009.00523.x.
The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders.
This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993-2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure.
A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV).
Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.
在急诊科（ED）最常见的前庭障碍是良性阵发性位置性眩晕（BPPV）和急性外周前庭病（APV；即前庭神经炎或迷路炎）。BPPV 和 APV 是两种非常不同的疾病，它们具有不同的临床表现，需要不同的诊断和治疗策略。BPPV 可以在不进行影像学检查的情况下诊断，并通过管石复位手法进行治疗。APV 有时需要磁共振成像（MRI）进行神经影像学检查以排除后颅窝中风模拟，并应使用前庭镇静剂和皮质类固醇进行治疗。我们试图确定急诊医师（EP）是否采用最佳实践来诊断和治疗这些常见的前庭障碍。
这是一项对国家医院门诊医疗调查（NHAMCS）中 ED 就诊的横断面研究。使用了美国 ED 就诊的加权样本（1993-2005 年）。至少 16 岁的患者，其最终 ED 诊断为 BPPV（国际疾病分类，第 9 版 [ICD-9]，386.11）或 APV（ICD-9 386.12 或 386.3x），构成了研究人群。在诊断为 BPPV 或 APV 的患者与对照组之间，影像学检查和药物治疗的频率是主要的观察指标。
在 13 年间共抽取了 9472 例头晕患者就诊（加权估计在该期间有 3360 万例美国 ED 就诊）。估计有 250 万例患者（7.4%）被诊断为前庭疾病，主要是 BPPV（加权 0.2 万例）或 APV（加权 190 万例）。被诊断为 BPPV（19%）和 APV（19%）的患者比对照组（7%；p<0.001）更有可能接受影像学检查（均为计算机断层扫描[CT]）。被诊断为 BPPV（58%）和 APV（70%）的患者比对照组（0.1%；p<0.001）更有可能接受美克洛嗪治疗。皮质类固醇的使用很少有记录（BPPV 为 2%，APV 为 1%）。
在 ED 中被诊断为前庭疾病的患者可能没有得到最佳治疗。被诊断为 BPPV 和 APV 的患者接受影像学检查（主要是 CT）的频率相同，这表明 CT（BPPV）过度使用，可能 MRI（APV）使用不足。大多数被诊断为 BPPV 的患者接受了美克洛嗪治疗，而这是不必要的。APV 的特定治疗（皮质类固醇）可能使用不足。教育计划和临床指南值得考虑。
