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Emergency Medicine Australasia (2015) 27, 378–379
LETTERS TO THE EDITOR
Continuing lack of the diagnosis of benign paroxysmal positional vertigo in a tertiary care emergency department Dear Editor, Benign paroxysmal positional vertigo (BPPV) is a debilitating medical condition seen frequently in EDs and family medicine clinics.1 The patient commonly complains of short experience of ‘room spinning’ associated with certain activities, such as looking up and bending down. The underlying cause is believed to be the existence of ‘calcium carbonate’ crystals in the posterior, horizontal and anterior semicircular canals. BPPV can be diagnosed by a simple bedside Dix-Hallpike and log roll tests. Epley manoeuvre is one commonly used manoeuvre for treating posterior and anterior canal BPPV. Other head rotation manoeuvres commonly used for the treatment of horizontal canal includes the Gufoni, Vannuchi–Asprella and barbecue roll methods.2 The American Academy of Otolaryngology–Head and Neck Surgery does not advocate routine use of medications and radiological imaging as part of of BPPV management.3 The purpose of the present study was to see the current process for the diagnosis of BPPV in patients with dizziness and vertigo symptoms presenting to a tertiary care ED and whether this complied with the recommendations. This was a retrospective study of all patients with a discharge diagnosis of peripheral vertigo for a 6 month period, from July to December 2012. The electronic records of over 12 000 patients with a presenting complaint of dizziness were searched. Our ED is a high-volume department where over 500 000 new patients are seen per annum. The In-
stitutional Review Board (IRB) of Hamad Medical Corporation approved the study in March 2014 as a low-risk project. Out of 12 000 patients with presenting complaints of dizziness and vertigo, only 2727 were included in the study. The mean age of the study population was 41.52 ± 14.09 years with a median of 40 years. There were 1554 (57%) men and 1173 (43%) women. There were 521 (19.1%) offered brain CT. The ALOS in the ED was 3 h (range 45 min to 7 h). No patient (0%) was offered Dix–Hallpike test for the diagnosis of BPPV. This study showed that despite guidelines recommending the use of bedside manoeuvres for the diagnosis and the treatment of BPPV, very few patients get recommended assessment and treatment. CT scan is usually requested when there is a suspicion of a central cause of vertigo. In most cases of peripheral vertigo, there is no recommendation for brain CT.4 In our study, 521 (19.1%) of the patients underwent CT scan of the brain. All 521 CT scans were reported as normal. In our study, no patient (0%) was offered Dix– Hallpike manoeuvre for the diagnosis of BPPV. These results are comparable with a study where 36.5% of the patients with a diagnosis of peripheral vertigo were offered brain CT and 0.2% (8/3522) visits with dizziness symptoms were offered Epley and other manoeuvres.4 The ALOS was 3 h in our ED for these patients with peripheral vertigo. This considerable delay was mainly because of waiting for investigations, such as blood tests and brain CT in
some patients. The limitations included the capture method and retrospective nature of this study. It is possible that bedside tests were performed but not documented. However, in other studies the medical records have shown the true reflection of actual clinical tests.5 BPPV is a common medical problem managed by emergency physicians. Most patients experience poor quality of life during the illness. More research is needed to promote awareness about the management of BPPV among emergency physicians. This will lead to a better prognosis for the patient and significant savings in the healthcare industry.
Competing interests None declared.
References 1. Von Brevern M, Lezius F, Tiel-Wilck K et al. Benign paroxysmal positional vertigo: current status of medical management. Otolaryngol. Head Neck Surg. 2004; 130: 381–2. 2. Asprella Libonati G, Gufoni M. Parossistica vertigo from CSL: maneuvers of barbecue and varying others. In: Nuti D, Pagnini P, Neighbors C, eds. Actions of XIX the Day of Clinical Nistagmografia. Milan: Formenti, 1999; 321–36. 3. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol. Head Neck Surg. 2008; 139 (5 Suppl 4): S47–81. 4. Kerber KA, Burke JF, Skolarus LE et al. Use of BPPV processes in emergency department dizziness presenta-
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
379
LETTERS TO THE EDITOR
tions: a population-based study. Otolaryngol. Head Neck Surg. 2013; 148: 425–30. 5. Stange KC, Zyzanski SJ, Smith TF et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison
with direct observation of patients visits. Med. Care 1998; 36: 851–67.
Khalid BASHIR,1,2 Abdul R ABID,3 Ahmed FELAYA,1 Maarij MASOOD,1 Hossam A AHMAD1 and Peter CAMERON1
1 Emergency Department, Hamad Medical Corporation, Doha, Qatar; 2 Emergency Department, Bronglais Hospital, Aberystwyth, UK; and 3 Cardiology, Hamad Medical Corporation, Doha, Qatar doi: 10.1111/1742-6723.12418
Re: Comparison of the C-MAC video laryngoscope with direct Macintosh laryngoscopy in the emergency department Dear Editor, I read with interest the article by Vassiliadis et al.1 published in the April 2015 issue of the Emergency Medicine Australasia. I find some difficulty linking this study’s results with the stated key findings and conclusion, which favour use of the C-MAC videolaryngoscope in most situations. The rates of ultimate success of intubation are similar: 94.9% for the C-MAC videolaryngoscope (henceforth known as ‘VL’) and 95.1% for Macintosh (henceforth known as ‘DL’). Interestingly, the solution for failure with one is generally to use the other. There is a failure to properly acknowledge the higher complication rates occurring under VL in this study. The overall complication rate with VL was 38.5%, compared with 32.7% with DL (table 4). There was a large difference in the complication rates even with first-pass success in patients with standard airways (Cormack and Lehane grades I and II), with 24.6% of VL patients experiencing a complication (mostly oxygen desaturation) compared with 4.5% in the DL group (table 3). First-pass success VL patients with difficult airways (Cormack and Lehane grades III and IV) also had a higher complication rate (34.6%) than the similar DL group (29.4%). No acknowledge-
ment or attempted explanation is attached to these findings. As first-pass success with laryngoscopy is mainly a surrogate marker for lower complication rates, the marginally better first-pass success with VL (85.0%) compared with DL (81.6%) becomes meaningless in this regard. The author’s conclusion of benefit thus seems to hang solely on ‘the chance of intubation success increased by more than threefold by using a C-MAC VL in the setting of a grade III/IV oral view (total of 109) over DL (OR = 3.06; 95% CI 1.52–6.17; P = 0.002)’. The caveat appended is that ‘this result, though interesting, has to be taken in context with our small sample size’. Indeed, stepwise regression is well known for the potential to emphasise a spurious association between variables, and low sample sizes reduce the likelihood that a ‘statistically significant’ result reflects a true effect. This is likely in this case, where a single piece of evidence for benefit seems to be contradicted by all the other evidence provided. The authors conclude that DL should evolve to VL, claiming that C-MAC VL allows the flexibility to perform both DL and VL without having to remove the scope to transition between the two, and requires no change in laryngoscopic technique when first using it (indeed, in this
study, 89% of intubators used it in exactly this manner). However, the overall success rate was no better and the complication rates higher in both standard and difficult patient groups – hardly evidence to back their claim. An alternate conclusion from this study might have been that whereas VL can improve the glottic view in patients with difficult airways, it had no better ultimate success rate than DL and came at a cost of higher complications (predominantly oxygen desaturation) in patients with both standard and difficult airways. This is hardly an endorsement for choosing VL over DL, at least in the two institutions that the study was conducted in.
Competing interests None declared.
Reference 1. Vassiliadis J, Tzannes A, Hitos K, Brimble J, Fogg T. Comparison of the C-MAC video laryngoscope with direct Macintosh laryngoscopy in the emergency department. Emerg. Med. Australas. 2015; 27: 119–25.
Gary TALL NSW Ambulance, Central Coast Local Health District, Charmhaven, New South Wales, Australia doi: 10.1111/1742-6723.12421
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2015) 27, 378–379
LETTERS TO THE EDITOR
Continuing lack of the diagnosis of benign paroxysmal positional vertigo in a tertiary care emergency department Dear Editor, Benign paroxysmal positional vertigo (BPPV) is a debilitating medical condition seen frequently in EDs and family medicine clinics.1 The patient commonly complains of short experience of ‘room spinning’ associated with certain activities, such as looking up and bending down. The underlying cause is believed to be the existence of ‘calcium carbonate’ crystals in the posterior, horizontal and anterior semicircular canals. BPPV can be diagnosed by a simple bedside Dix-Hallpike and log roll tests. Epley manoeuvre is one commonly used manoeuvre for treating posterior and anterior canal BPPV. Other head rotation manoeuvres commonly used for the treatment of horizontal canal includes the Gufoni, Vannuchi–Asprella and barbecue roll methods.2 The American Academy of Otolaryngology–Head and Neck Surgery does not advocate routine use of medications and radiological imaging as part of of BPPV management.3 The purpose of the present study was to see the current process for the diagnosis of BPPV in patients with dizziness and vertigo symptoms presenting to a tertiary care ED and whether this complied with the recommendations. This was a retrospective study of all patients with a discharge diagnosis of peripheral vertigo for a 6 month period, from July to December 2012. The electronic records of over 12 000 patients with a presenting complaint of dizziness were searched. Our ED is a high-volume department where over 500 000 new patients are seen per annum. The In-
stitutional Review Board (IRB) of Hamad Medical Corporation approved the study in March 2014 as a low-risk project. Out of 12 000 patients with presenting complaints of dizziness and vertigo, only 2727 were included in the study. The mean age of the study population was 41.52 ± 14.09 years with a median of 40 years. There were 1554 (57%) men and 1173 (43%) women. There were 521 (19.1%) offered brain CT. The ALOS in the ED was 3 h (range 45 min to 7 h). No patient (0%) was offered Dix–Hallpike test for the diagnosis of BPPV. This study showed that despite guidelines recommending the use of bedside manoeuvres for the diagnosis and the treatment of BPPV, very few patients get recommended assessment and treatment. CT scan is usually requested when there is a suspicion of a central cause of vertigo. In most cases of peripheral vertigo, there is no recommendation for brain CT.4 In our study, 521 (19.1%) of the patients underwent CT scan of the brain. All 521 CT scans were reported as normal. In our study, no patient (0%) was offered Dix– Hallpike manoeuvre for the diagnosis of BPPV. These results are comparable with a study where 36.5% of the patients with a diagnosis of peripheral vertigo were offered brain CT and 0.2% (8/3522) visits with dizziness symptoms were offered Epley and other manoeuvres.4 The ALOS was 3 h in our ED for these patients with peripheral vertigo. This considerable delay was mainly because of waiting for investigations, such as blood tests and brain CT in
some patients. The limitations included the capture method and retrospective nature of this study. It is possible that bedside tests were performed but not documented. However, in other studies the medical records have shown the true reflection of actual clinical tests.5 BPPV is a common medical problem managed by emergency physicians. Most patients experience poor quality of life during the illness. More research is needed to promote awareness about the management of BPPV among emergency physicians. This will lead to a better prognosis for the patient and significant savings in the healthcare industry.
Competing interests None declared.
References 1. Von Brevern M, Lezius F, Tiel-Wilck K et al. Benign paroxysmal positional vertigo: current status of medical management. Otolaryngol. Head Neck Surg. 2004; 130: 381–2. 2. Asprella Libonati G, Gufoni M. Parossistica vertigo from CSL: maneuvers of barbecue and varying others. In: Nuti D, Pagnini P, Neighbors C, eds. Actions of XIX the Day of Clinical Nistagmografia. Milan: Formenti, 1999; 321–36. 3. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol. Head Neck Surg. 2008; 139 (5 Suppl 4): S47–81. 4. Kerber KA, Burke JF, Skolarus LE et al. Use of BPPV processes in emergency department dizziness presenta-
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
379
LETTERS TO THE EDITOR
tions: a population-based study. Otolaryngol. Head Neck Surg. 2013; 148: 425–30. 5. Stange KC, Zyzanski SJ, Smith TF et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison
with direct observation of patients visits. Med. Care 1998; 36: 851–67.
Khalid BASHIR,1,2 Abdul R ABID,3 Ahmed FELAYA,1 Maarij MASOOD,1 Hossam A AHMAD1 and Peter CAMERON1
1 Emergency Department, Hamad Medical Corporation, Doha, Qatar; 2 Emergency Department, Bronglais Hospital, Aberystwyth, UK; and 3 Cardiology, Hamad Medical Corporation, Doha, Qatar doi: 10.1111/1742-6723.12418
Re: Comparison of the C-MAC video laryngoscope with direct Macintosh laryngoscopy in the emergency department Dear Editor, I read with interest the article by Vassiliadis et al.1 published in the April 2015 issue of the Emergency Medicine Australasia. I find some difficulty linking this study’s results with the stated key findings and conclusion, which favour use of the C-MAC videolaryngoscope in most situations. The rates of ultimate success of intubation are similar: 94.9% for the C-MAC videolaryngoscope (henceforth known as ‘VL’) and 95.1% for Macintosh (henceforth known as ‘DL’). Interestingly, the solution for failure with one is generally to use the other. There is a failure to properly acknowledge the higher complication rates occurring under VL in this study. The overall complication rate with VL was 38.5%, compared with 32.7% with DL (table 4). There was a large difference in the complication rates even with first-pass success in patients with standard airways (Cormack and Lehane grades I and II), with 24.6% of VL patients experiencing a complication (mostly oxygen desaturation) compared with 4.5% in the DL group (table 3). First-pass success VL patients with difficult airways (Cormack and Lehane grades III and IV) also had a higher complication rate (34.6%) than the similar DL group (29.4%). No acknowledge-
ment or attempted explanation is attached to these findings. As first-pass success with laryngoscopy is mainly a surrogate marker for lower complication rates, the marginally better first-pass success with VL (85.0%) compared with DL (81.6%) becomes meaningless in this regard. The author’s conclusion of benefit thus seems to hang solely on ‘the chance of intubation success increased by more than threefold by using a C-MAC VL in the setting of a grade III/IV oral view (total of 109) over DL (OR = 3.06; 95% CI 1.52–6.17; P = 0.002)’. The caveat appended is that ‘this result, though interesting, has to be taken in context with our small sample size’. Indeed, stepwise regression is well known for the potential to emphasise a spurious association between variables, and low sample sizes reduce the likelihood that a ‘statistically significant’ result reflects a true effect. This is likely in this case, where a single piece of evidence for benefit seems to be contradicted by all the other evidence provided. The authors conclude that DL should evolve to VL, claiming that C-MAC VL allows the flexibility to perform both DL and VL without having to remove the scope to transition between the two, and requires no change in laryngoscopic technique when first using it (indeed, in this
study, 89% of intubators used it in exactly this manner). However, the overall success rate was no better and the complication rates higher in both standard and difficult patient groups – hardly evidence to back their claim. An alternate conclusion from this study might have been that whereas VL can improve the glottic view in patients with difficult airways, it had no better ultimate success rate than DL and came at a cost of higher complications (predominantly oxygen desaturation) in patients with both standard and difficult airways. This is hardly an endorsement for choosing VL over DL, at least in the two institutions that the study was conducted in.
Competing interests None declared.
Reference 1. Vassiliadis J, Tzannes A, Hitos K, Brimble J, Fogg T. Comparison of the C-MAC video laryngoscope with direct Macintosh laryngoscopy in the emergency department. Emerg. Med. Australas. 2015; 27: 119–25.
Gary TALL NSW Ambulance, Central Coast Local Health District, Charmhaven, New South Wales, Australia doi: 10.1111/1742-6723.12421
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
![[Management of benign paroxysmal positional vertigo in first care centers].](/assets/img/hold.png)
