Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms

Mamata V Kene, Dustin W Ballard, David R Vinson, Adina S Rauchwerger, Hilary R Iskin, Anthony S Kim, Mamata V Kene, Dustin W Ballard, David R Vinson, Adina S Rauchwerger, Hilary R Iskin, Anthony S Kim

Abstract

Introduction: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.

Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.

Results: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.

Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

Figures

Figure 1
Figure 1
Current use of consultation and neuroimaging to evaluate dizziness in the emergency departmenta. aSurvey question 5: percentages indicate percent of respondents choosing a given answer. MRA-magnetic resonance angiogram MRI-magnetic resonance imaging CT-computed tomography
Figure 2
Figure 2
Respondents’ reporting of their perceived current use of bedside tests and clinical prediction rules to evaluate for posterior stroke among emergency department patients with dizzinessa. aSurvey question 4, a-g, statement i HINTS-Head impulse, nystagmus, test of skew ABCD2-to predict 30 day risk of stroke after transient ischemic attach
Figure 3
Figure 3
Agreement with feeling confidence in use of specific diagnostic aids and history and exam elementsa. aSurvey question 4, a-g, statement ii HINTS-Head impulse, nystagmus, test of skew ABCD2-to predict 30 day risk of stroke after transient ischemic attack
Figure 4
Figure 4
Ideal posttest probability for a CPR to be useful in evaluating patients with dizziness.a,b a9 missing responses bSurvey question 8: first two choices were not an option for the question about clinical utility MRA-magnetic resonance angiogram MRI-magnetic resonance imaging CT-computed tomography

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Source: PubMed

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