Abstract：
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks\' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term (\"what the average physician would do in similar circumstances\") or in the common parlance sense (\"the standard action typically used by physicians in routine practice\").
摘要：
学术急诊医学学会的《急诊科合理和适当护理指南》（GRACE-3）是针对急诊科（ED）中急性头晕和眩晕的成年患者的主题。一个多学科指南小组应用了建议评估的分级，发展,和评估（GRADE）方法，用于评估持续时间少于2周的急性头晕成年ED患者的五个问题的证据确定性和建议强度。预期人群是向ED呈现急性头晕或眩晕的成年人。小组根据头晕的时间和触发因素得出了15项基于证据的建议，但认识到存在替代诊断方法，如STANDING方案和眼球震颤检查结合步态不稳定或存在血管危险因素。作为总体建议，（1）急诊临床医生应接受急性前庭综合征（AVS；HINTS）患者床旁体检技术和良性阵发性位置性眩晕（BPPV；Dix-Hallpike试验和Epley动作）的诊断和治疗方法的培训。为了帮助区分AVS患者的中枢和外周原因，我们建议：（2）在眼球震颤患者中使用HINTS（用于受过使用培训的临床医生），(3)使用手指摩擦进一步帮助排除眼球震颤患者的中风，(4)无眼球震颤患者使用步态不稳定的严重程度,（5）不要使用脑计算机断层扫描（CT），（6）如果有接受过HINTS培训的临床医生，请勿使用常规磁共振成像（MRI）作为一线测试，和（7）在中央或模棱两可的HINTS检查患者中使用MRI作为确认测试。在自发性发作性前庭综合征患者中：（8）寻找脑缺血的症状或体征，（9）不要使用CT，和（10）如果有短暂性脑缺血发作的关注，使用CT血管造影或MRI血管造影。在患有触发（位置）发作性前庭综合征的患者中，（11）使用Dix-Hallpike试验诊断后管BPPV（pc-BPPV），（12）不要使用CT，（13）不要常规使用MRI，除非存在非典型的临床特征。在诊断为前庭神经炎的患者中，（14）考虑短期类固醇作为治疗选择。在诊断为pc-BPPV的患者中，(15)用Epley手法治疗。很明显，截至2023年，在没有经过特殊培训的急诊临床医生的常规实践中，提示测试不准确，部分是由于在错误的患者中使用，部分是由于其解释问题。大多数急诊医生没有接受使用HINTS的培训。因此，这不是护理标准，该术语的法律意义（“普通医生在类似情况下会做什么”）或通用意义（“医生在常规实践中通常使用的标准行为”）。
