›Stabilization and safety
›Airway compromise from vomiting or aspiration risk
›If active emesis with inability to protect airway, escalation for airway management
›Hemodynamic instability
›If shock or syncope, alternate diagnosis pathway
›Severe dehydration
›IV isotonic fluids with reassessment
›Time of symptom onset
›Last known well for stroke pathway
›Posterior circulation stroke exclusion priority
›If focal neurologic deficit, immediate stroke protocol activation
›Dangerous mimics
›Posterior circulation ischemic stroke
›If central signs on oculomotor testing, urgent MRI brain with diffusion if available
›Intracranial hemorrhage
›If thunderclap headache or severe hypertension with neurologic change, noncontrast CT head
›Meningitis or encephalitis
›If fever or meningismus, infection pathway
›Toxic exposure
›If intoxication or polypharmacy, tox and medication adverse effect pathway
›Acute coronary syndrome
›If chest pain or diaphoresis, cardiac pathway
Key bedside decision points
›Syndrome patterning
›Acute vestibular syndrome definition
›Continuous vertigo for hours to days
›Spontaneous nystagmus
›Nausea or vomiting
›Gait unsteadiness
›Episodic positional vertigo pattern
›Brief attacks triggered by head position changes
›Auditory symptoms pattern
›Hearing loss or tinnitus suggesting labyrinthitis or Ménière disease
›Central vs peripheral triage
›HINTS family testing for acute vestibular syndrome in appropriate setting
›Head impulse pattern
›Nystagmus pattern
›Test of skew pattern
›New unilateral hearing loss for HINTS plus
›Monitoring and reassessment
›Serial neurologic status
›New focal deficits triggering stroke escalation
›Fall risk controls
›Assisted ambulation only until stable gait
›Hydration and electrolyte status
›Ongoing emesis triggering IV rehydration and antiemetics