01Approach to the Critical Patient/attcp43

Red flags requiring immediate action

›Central cause exclusion priorities

›Spontaneous nystagmus at rest before positional testing

›Suggests vestibular neuritis or central lesion, not BPPV

›Initiate HINTS exam if acute vestibular syndrome present

›Persistent downbeat nystagmus on Dix-Hallpike

›Structural brain disorder until proven otherwise

›Urgent MRI brain with posterior fossa protocol

›Focal neurological deficits

›Diplopia, dysarthria, dysphagia, dysmetria, dysesthesia

›Activate stroke pathway if acute onset within 24 hours

›Severe gait ataxia disproportionate to vertigo severity

›Cannot safely ambulate even with support

›Escalate to neuroimaging and neurology consultation

›Hemodynamic and fall risk priorities

›Orthostatic hypotension with presyncope

›SBP drop >20 mmHg or HR rise >20 bpm on standing

›IV fluid resuscitation if clinically volume depleted

›High fall risk state

›Elderly patient unable to ambulate safely

›Observe until ambulation confirmed safe prior to discharge

›Intractable vomiting with dehydration

›Initiate IV antiemetic therapy

›IV fluid replacement if unable to tolerate oral intake

Key early branching

›BPPV versus central positional vertigo

›Classic BPPV: brief (<60 seconds), transient upbeat-torsional nystagmus with latency

›Perform Epley maneuver

02History/hx62

Presenting symptoms

›Classic positional trigger

›Spinning sensation when lying down, sitting up, or rolling over in bed

›Episodes last <1 minute, typically 10-30 seconds

›Longer episodes suggest alternative diagnoses

›Triggered by tilting head back or looking up

›Hair salon or dental chair position as precipitant

›Nausea and vomiting during episodes

›Diaphoresis and pallor common during acute episode

›Recurrent brief episodes versus continuous dizziness

›Continuous vertigo at rest favors vestibular neuritis or central lesion

Alarm features in history

›Neurological symptoms requiring exclusion

›New or worsening headache with vertigo

›Posterior fossa pathology or vestibular migraine

›Diplopia, facial weakness or numbness, limb weakness

›Deadly Ds: diplopia, dysarthria, dysphagia, dysmetria, dysesthesia

›Hearing loss with vertigo

›Consider labyrinthitis, Ménière disease, or stroke

›Syncope or presyncope with dizziness

›Cardiac arrhythmia or orthostatic hypotension as alternative

Onset and context

›Precipitating events

›Recent head trauma

›Leading risk factor for BPPV in young adults

›Prolonged recumbency

›Post-surgical recovery or extended bed rest

›Recent upper respiratory tract infection

03Physical Exam/exam52

Vital signs and orthostatic assessment

›Orthostatic blood pressure and heart rate

›Seated and standing measurements

›Orthostatic hypotension: SBP drop >20 mmHg or HR rise >20 bpm

›Excludes hemodynamic contribution to dizziness

›Resting heart rate and rhythm

›Irregular pulse triggers ECG

Pre-positional neurological assessment

›Spontaneous nystagmus evaluation

›Patient seated upright, looking straight ahead

›Must confirm absence of spontaneous nystagmus before Dix-Hallpike

›Spontaneous nystagmus at rest is NOT consistent with BPPV

›Cranial nerve examination

›Facial sensation and movement symmetry

›Palate elevation and uvula position

›Extraocular movements and saccades

›Cerebellar testing

›Finger-to-nose coordination

›Heel-to-shin coordination

›Rapid alternating movements

Dix-Hallpike maneuver

›Technique for posterior canal BPPV

›Patient seated, head turned 45 degrees toward tested ear

›Rapidly lower to supine with head hanging 20-30 degrees below horizontal

›Movement must be brisk, completed within 1-2 seconds

›Positive result criteria

›Transient upbeat-torsional nystagmus

›Upper poles of eyes beat toward the dependent ear

04Differential Diagnosis/ddx47

Central causes requiring exclusion

›Posterior circulation stroke or TIA

›ICD-10: I63.9 (cerebral infarction), G45.9 (TIA)

›Acute vertigo with neurological signs

›HINTS exam: normal head impulse, direction-changing nystagmus, skew deviation

›Can mimic BPPV in early presentation

›Central positional vertigo (CPPV)

›Persistent downbeat nystagmus without torsional component

›No response to canalith repositioning maneuvers

›Caused by stroke, tumor, or demyelination

›Accounts for up to 12% of positional nystagmus cases

›Vestibular migraine

›ICD-10: G43.D0

›Episodic vertigo with migrainous features

›Episodes often minutes to hours, longer than BPPV

›Headache, photophobia, phonophobia, or aura

›OR = 4.40 association between migraine and BPPV occurrence

Peripheral vestibular causes

›Vestibular neuritis

›ICD-10: H81.2

›Continuous spontaneous vertigo lasting days

›Spontaneous nystagmus at rest, positive head impulse test

›Often follows viral upper respiratory infection

›Ménière disease

›ICD-10: H81.0

›Episodic vertigo lasting 20 minutes to 12 hours

›Fluctuating sensorineural hearing loss, tinnitus, aural fullness

›Ipsilateral association with BPPV

05Laboratory Tests/lt26

Routine labs

›Standard laboratory testing

›Routine labs generally NOT required for classic BPPV

›GRACE-3 guidelines recommend against routine laboratory workup

›Clinical diagnosis based on history and Dix-Hallpike

›Selective testing when clinical picture unclear

›Serum glucose: hypoglycemia as alternative cause of dizziness

›Complete blood count: anemia contributing to dizziness

›Basic metabolic panel: electrolyte abnormalities and dehydration

›TSH: thyroid dysfunction as confounder

Vitamin D testing

›Vitamin D (25-OH) level

›Indication

›Recurrent BPPV (greater than 2-3 episodes)

›Guides supplementation decision

›Clinical significance

›BPPV patients have significantly lower vitamin D levels versus controls

›WMD = -2.84 ng/mL in meta-analysis

›Supplementation reduces recurrence: RR = 0.45

›Target

›Vitamin D sufficiency: 25-OH level >50 nmol/L (20 ng/mL)

Additional selective testing

›Testing for alternative diagnoses

›Avoid routine troponin in older patients with isolated dizziness

›High false-positive rate in this clinical context

›Lipid panel and fasting glucose

›Cardiovascular risk stratification for recurrent BPPV patients

›Complete blood count with differential

06Diagnostic Tests/dt67

Scoring Systems

›HINTS exam (Head Impulse, Nystagmus, Test of Skew)

›Indication and appropriate context

›Acute vestibular syndrome (continuous vertigo), NOT for BPPV

›Used to differentiate peripheral from central AVS

›Performance characteristics

›Sensitivity 97% for central causes when performed by trained clinicians

›Specificity 96% for central causes in acute vestibular syndrome

›Components

›Head impulse test: normal response (no corrective saccade) suggests central cause

›Nystagmus: direction-changing nystagmus in different gaze positions suggests central

›Test of skew: vertical ocular misalignment suggests brainstem pathology

›Dix-Hallpike test performance

›Diagnostic accuracy

›Sensitivity approximately 79% for posterior canal BPPV

›Specificity approximately 75% for BPPV

›Positive result: transient upbeat-torsional nystagmus with latency

›Enhancement strategies

›Frenzel lenses remove visual fixation suppression

›Video-oculography (VOG) goggles improve nystagmus detection

›Subjective BPPV (symptoms without visible nystagmus) more common without these aids

›BPPV variant classification

›Canal involvement distribution

›Posterior canal: 85-95% of cases

›Horizontal canal: 5-15% of cases

›Anterior canal: rare

MRI

›Brain MRI indications

›When to order MRI for positional vertigo

›Atypical nystagmus on Dix-Hallpike: persistent, downbeat without torsion

›No response to repeated canalith repositioning maneuvers

›Associated neurological signs or symptoms

›Concern for central positional vertigo

›Preferred protocol

›MRI brain with posterior fossa sequences

›FIESTA or CISS sequences for internal auditory canal assessment

›DWI/ADC for acute infarct detection

›ACR Appropriateness Criteria

›MRI brain usually appropriate for new unexplained vertigo with neurological features

›Not appropriate for typical BPPV presentation

›Posterior fossa findings on MRI

›Cerebellar infarct may present identically to BPPV

›Nodular lesions at cervicomedullary junction cause persistent downbeat nystagmus

›Acoustic neuroma on IAC images if unilateral hearing loss present

CT

›CT imaging indications and limitations

›GRACE-3 guideline recommendation

›Strongly recommend against routine CT or CTA for triggered episodic vertigo

›CT is insensitive for posterior fossa pathology

›Not appropriate for evaluation of BPPV

›Limited indications for CT

›Head trauma with suspected temporal bone fracture

›Bony erosion of semicircular canals

›Superior semicircular canal dehiscence (CT temporal bone with fine cuts)

›CT temporal bone protocol

›High-resolution 0.5 mm cuts through petrous bones

›Multiplanar reconstructions for canal dehiscence assessment

›CT angiography

›Not indicated for BPPV evaluation

›Consider only if vertebrobasilar insufficiency or dissection suspected based on clinical features

Ultrasound

›Ultrasound role in BPPV evaluation

›No direct diagnostic role for inner ear pathology

›Ultrasound cannot image labyrinthine structures

›Not indicated in standard BPPV evaluation

›Selective point-of-care ultrasound applications

›IVC assessment if volume status unclear and patient unable to tolerate oral fluids

›Cardiac echo if cardiac cause of dizziness suspected

›Transcranial Doppler

›Not routinely indicated for BPPV

›Consider only if vertebrobasilar insufficiency clinically suspected

07Disposition/dispo37

Discharge criteria

›Standard discharge criteria for BPPV

›Diagnosis confirmed

›Classic history with positive Dix-Hallpike showing typical nystagmus

›No alarm features or red flags identified

›Treatment response

›Successful Epley maneuver performed

›Residual mild symptoms acceptable if no red flags and safe ambulation confirmed

›Safe for discharge

›Able to ambulate safely without assistance

›No focal neurological deficits

›Reliable follow-up available

›Appropriate support at home if elderly

Admission indications

›Criteria for observation or inpatient admission

›Unable to safely discharge

›Intractable vomiting with inability to tolerate oral intake

›Severe gait instability with high fall risk

›Elderly patient living alone with residual significant imbalance

›Diagnostic uncertainty requiring further workup

›Atypical features raising concern for central pathology pending MRI

›Failure to respond to repeated repositioning maneuvers

›Predictors of ED admission

›Age >54 years associated with higher admission rates

›Need for IV antiemetics or benzodiazepines in ED

Specialist consultation and referral

›Consultation triggers in the emergency setting

›Neurology consultation

08Treatment/t85

Epley maneuver (canalith repositioning procedure)

›Primary treatment for posterior canal BPPV

›Technique

›Head turned 45 degrees toward affected side in seated position

›Rapidly lower patient to supine with head hanging 20-30 degrees below horizontal

›Hold each position for minimum 20 seconds

›Rotate head 90 degrees to opposite side

›Hold minimum 20 seconds

›Rotate body and head another 90 degrees to face down position

›Hold minimum 20 seconds

›Slowly return patient to sitting position

›Efficacy

›88-98% resolution at 1 month

›NNT = 3 at 1 week

›Repeat 2-3 times in one session if nystagmus persists on repeat Dix-Hallpike

›Evidence level

›Cochrane systematic review 2025 confirms efficacy when performed by family doctors or emergency physicians

›ACEP Level A recommendation for canalith repositioning in posterior canal BPPV

Alternative repositioning maneuvers

›Semont maneuver

›Indication

›Alternative for patients with neck or shoulder problems

›Unable to tolerate Epley due to cervical spine limitations

›Efficacy

›Equivalent efficacy to Epley maneuver

›Semont-Plus maneuver comparable in randomized clinical trial (JAMA Neurology 2023)

›Barbecue roll (Lempert maneuver)

›Indication

›Horizontal canal BPPV

›Direction specific variant guides modification

›Technique

›Patient supine, rotate 90 degrees toward unaffected side

›Continue rotating in 90-degree increments

›Complete 270-degree rotation over 3-4 positions

›Prognosis

›Horizontal canal BPPV often resolves spontaneously

›Median spontaneous resolution 7 days versus 17 days for posterior canal

Antiemetic therapy

›Acute nausea and vomiting management

›Ondansetron

›4 mg IV or 4-8 mg oral disintegrating tablet

›First-line antiemetic for acute nausea during ED visit

›Safe in pregnancy at standard doses (second and third trimester)

›Metoclopramide

›10 mg IV as alternative antiemetic

›Risk of extrapyramidal side effects, particularly in young adults and elderly

›Prochlorperazine

›5-10 mg IV or IM

›Caution: risk of akathisia and extrapyramidal side effects

Vestibular suppressants (limited role)

›Medications NOT recommended as primary treatment

›Meclizine

›NOT effective for BPPV

›Guidelines recommend against routine use

›Causes unnecessary sedation and increases fall risk

›Benzodiazepines and antihistamines

›Generally not indicated for BPPV

›Interfere with central vestibular compensation

›Increase fall risk, particularly in elderly

›Limited indication for vestibular suppressants

›Short course (2-3 days only) for residual symptoms

›Only after confirmed successful Epley with negative post-treatment Dix-Hallpike

›ACEP Level C recommendation to limit use

Vitamin D supplementation

›Recurrence prevention

›Indication

›Vitamin D deficiency confirmed on 25-OH testing

›Recurrent BPPV episodes

›Efficacy

›Supplementation reduces recurrence: RR = 0.45 versus control

›Systematic review and meta-analysis Frontiers in Neurology 2025

›Dosing

›Standard vitamin D3 supplementation per deficiency protocol

›1000-2000 IU daily for maintenance

›50,000 IU weekly for 8 weeks if severely deficient

Self-treatment and vestibular rehabilitation

›Home Epley maneuver

›Indication

›Confirmed diagnosis with prior in-person instruction

›Future recurrences management

›Efficacy

›Comparable efficacy to expert-administered when patients receive proper instruction

›Contraindication

›Not appropriate without confirmed diagnosis and in-person training

›Vestibular rehabilitation

›Indication

›Residual imbalance after repositioning maneuver

›Recurrent BPPV with functional impairment

›Efficacy

›Safe and effective; best outcomes when combined with repositioning maneuvers

›Reduces fall risk; residual dizziness associated with 5.7x increased odds of falls

09Special Populations/sp66

Pregnancy

›BPPV in pregnancy

›Prevalence and risk

›BPPV can occur during any trimester

›Dizziness is common in pregnancy; BPPV must be distinguished from orthostatic hypotension

›Fetal safety is primary concern with positioning maneuvers

›Dix-Hallpike modification

›Modified positioning with left lateral tilt to avoid aortocaval compression after 20 weeks

›Avoid prolonged supine positioning in second and third trimester

›Epley maneuver safety

›Generally considered safe in pregnancy with position modification

›Performed with uterine displacement support if needed

›Medication safety

›Ondansetron: use with caution in first trimester; acceptable second and third trimester

›Meclizine: Category B, limited data but generally avoided in first trimester

›Benzodiazepines: avoid in pregnancy due to neonatal risk

›Vitamin D supplementation

›Safe and beneficial in vitamin D deficient pregnant patients

›Standard prenatal supplement dosing generally adequate

Geriatric

›BPPV in elderly patients

›Epidemiology and risk

›Peak incidence ages 50-60 years

›Highest morbidity in elderly due to fall risk

›Residual dizziness associated with 5.7x increased odds of falls

›Presentation differences

›May present with vague imbalance rather than classic spinning vertigo

›Higher rate of comorbid conditions complicating diagnosis

›Spontaneous nystagmus may be subtle or attenuated

›Dix-Hallpike considerations

›Cervical spine disease may limit head positioning

›Perform with caution and slower movement

›May need modified maneuver with less head extension

›Fall risk assessment

›Mandatory functional assessment before discharge

›Home safety evaluation and fall prevention counseling

›Consider occupational therapy referral for high-risk patients

›Medication considerations

›Avoid meclizine and benzodiazepines due to high fall risk

›Anticholinergic burden of vestibular suppressants increases fall risk

›Ondansetron preferred for acute nausea management

›Discharge planning

›Confirm adequate home support before discharge

›Age >54 years associated with higher admission rates in ED studies

›Vestibular PT referral strongly recommended for recurrent cases

Pediatrics

›BPPV in children

›Epidemiology

›BPPV is less common in children than adults

›Benign paroxysmal vertigo of childhood (BPV) is a distinct migraine variant

›Head trauma is leading identifiable cause in pediatric BPPV

›Distinguishing features in children

›BPV of childhood: attacks without nystagmus in young children, migrainous family history

›Classic posterior canal BPPV occurs in adolescents

›Vestibular migraine increasingly recognized in pediatric population

›Dix-Hallpike in children

›Technique same as adults but requires cooperation

›Frenzel lenses or VOG goggles especially helpful in children to detect subtle nystagmus

›Epley maneuver in children

›Safe and effective in cooperative children

›Positioning may require parental assistance

›Medication considerations

›Weight-based antiemetic dosing

›Ondansetron 0.15 mg/kg IV (maximum 4 mg per dose)

›Avoid antihistamines and benzodiazepines as primary management

›When to consider central pathology in children

›Lower threshold for neuroimaging given posterior fossa tumors in pediatric population

›MRI preferred over CT to avoid radiation exposure

›Neurological signs mandate urgent MRI

10Background/b59

Epidemiology

›Prevalence and incidence

›BPPV is the most common cause of vertigo

›Lifetime prevalence 2.4%

›Peaks between ages 50-60 years

›Affects women 2-3 times more frequently than men

›Recurrence rates

›Recurrence rate approximately 22% at 5 years

›Approximately 70% of recurrences within first year

›Long-term study: 47% recurrence over 7 years

›Annual recurrence approximately 15-22%

›Morbidity and functional impact

›Residual dizziness associated with 5.7x increased odds of falls

›Significant impact on quality of life and driving safety

›Leading vestibular diagnosis in emergency departments and primary care

Pathophysiology

›Canalithiasis mechanism

›Otoconia (calcium carbonate crystals) dislodge from utricular macula

›Free-floating particles enter semicircular canal (canalithiasis)

›Head movement displaces particles and creates endolymph flow

›Inappropriate cupular deflection generates false vestibular signal

›Canal involvement patterns

›Posterior canal most affected: 85-95% of cases

›Horizontal canal: 5-15% of cases

›Anterior canal: rare

›Nystagmus generation

›Posterior canal: upbeat-torsional nystagmus (ampullofugal flow)

›Horizontal canal geotropic: nystagmus beats toward ground

11Patient Discharge Instructions/pdi47

copy discharge instructions

›Diagnosis explanation

›You have been diagnosed with benign paroxysmal positional vertigo (BPPV)

›This is a common inner ear condition caused by small calcium crystals out of position

›It causes brief spinning when you change head position

›It is not dangerous and is highly treatable

›Treatment performed today

›The Epley maneuver (a series of head movements) was performed to reposition the crystals

›Many patients feel better immediately; some take 24-48 hours for full improvement

›Mild residual unsteadiness for days to weeks after treatment is normal

›Activity instructions

›Fall precautions

›Use nightlights at home, especially at night

›Sit on edge of bed for 30 seconds before standing

›Avoid sudden head movements until symptoms resolve

›Do not drive if you feel dizzy or unsteady

›Sleeping position (first 1-2 nights)

›Try not to sleep on the affected ear side tonight

›Sleep with head slightly elevated if possible

›Get up slowly and carefully in the morning

›Activity restrictions

›Avoid activities at heights if still experiencing dizziness

›Avoid dental chair or hair salon reclined positions until symptoms fully resolved

›Medications

›Antiemetic prescription if provided

›Take only as needed for nausea, not on a scheduled basis

›Do not take over-the-counter meclizine (Antivert, Bonine) for BPPV

›It is not effective for this condition and increases fall risk

12References/r60

Guidelines and key sources

›GRACE-3 Emergency Department Dizziness Guidelines 2023

›Edlow JA, Carpenter C, Akhter M, et al.

›Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department

›Academic Emergency Medicine 2023

›https://onlinelibrary.wiley.com/doi/10.1111/acem.14728

›Key recommendations: against routine CT/CTA for triggered episodic vertigo; for Dix-Hallpike testing and canalith repositioning

›AAO-HNS Clinical Practice Guideline: BPPV (Update) 2017

›Bhattacharyya N, Gubbels SP, Schwartz SR, et al.

›Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

›Otolaryngology Head and Neck Surgery 2017

›https://journals.sagepub.com/doi/10.1177/0194599816689667

›Key recommendations: Epley maneuver Class I; against vestibular suppressant routine use

Clinical trials and systematic reviews

›Cochrane Review: Epley Maneuver 2025

›Calheiros Cruz Vidigal TI, Rando Matos Y, Flores Mateo G, et al.

›Epley Maneuver, Performed by Family Doctors or Emergency Physicians, for Benign Paroxysmal Positional Vertigo in Adults

›Cochrane Database of Systematic Reviews 2025

›https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD016020/full

›Key findings: NNT = 3 at 1 week; 88-98% resolution at 1 month

›JAMA: BPPV Diagnosis and Treatment 2026

›Kerber KA, Carender W, Meurer WJ.

›Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

›Journal of the American Medical Association 2026

›https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.1927

›Semont-Plus versus Epley Maneuver 2023

›Strupp M, Mandala M, Vinck AS, et al.

›The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study

Evidence & Review

Evidence & Review