Category: Updates

Vertigo and the Sudbury Risk Score

Background

Vertigo can be difficult to diagnose correctly with BPPV being common and stroke / central vertigo much less common with intervention due to stroke even rarer. Confounding the prevalence issues are stroke mimics (benign etiology presenting as stroke) and chameleons (stroke presenting as benign etiology). The HINTs exam can be quite sensitive but can be difficult to perform correctly and is very user dependent. The neverending search for a better screening tool for further stroke evlauation lead the authors of the Sudbury Risk Score to near simultaneously publish their derivation and validation manuscripts.

Bottom line / Clinical Implications

The study authors tout the potential utility of the Sudbury Vertigo Risk, but do not suggest it is ready for clinical implementation. From the validation study manuscript:

If this score is prospectively validated in centers not included in the derivation cohort, the next step will be a consensus meeting. This meeting will need to include neurologists, radiologists, ED physicians, ENT surgeons, and patients. The goal would be to establish the most appropriate investigations and treatments at each serious outcome probability level.

It seems reasonable to incorporate this score in your thinking about your patient with vertigo, but there is no specific guidance that incorporates this score from hospital systems or EM clinical societies.

Limitations

  • Both validation and derivation studies were conducted at large urban tertiary centers in Canada. This may not generalize well to your small community hospital in another country.
  • There is no external validation — the validation study was a retrospective review of 6 years of patient information at the same institutions that performed the derivation. The authors mention this limitation.
  • This score remains operator dependent — accurate scoring depends on a focused neurological exam; motor, sensory, and cerebellar deficits must be actively sought, or risk will be underestimated.

Study Inclusion/Exclusion

  • Adults (≥18 yr) who present to an ED or urgent-care setting
  • Within 14 days of onset of acute vertigo, dizziness, or imbalance.
  • Patient is alert (GCS = 15)
  • Patient is hemodynamically stable (SBP ≥90 mmHg)
  • No recent head/neck trauma, syncope, or active cancer.

Risk Score Points Calculation

VariableDescriptionPoints
MalePatient’s sex is male+1
Age >65 yearsPatient is older than 65 years+1
DiabetesPatient has a diagnosis of diabetes+1
HypertensionPatient has a history of hypertension+3
Motor or sensory deficitPatient has either motor or sensory neurological deficits+5
Cerebellar deficitIncludes diplopia, dysarthria, dysphagia, dysmetria, or ataxia+6
BPPV diagnosis (protective)A clinical diagnosis of benign paroxysmal positional vertigo (BPPV) is present−5

Interpretation

Sudbury Vertigo Risk ScoreRisk of Serious DiagnosisClinical Implication
<50%Low risk – no further testing needed
5–8~2–4%Moderate risk – further investigation if unclear
>8Up to 41% or higherHigh risk – urgent evaluation and neuroimaging

References

  1. Kerber KA, Sangha N, Burke JF, Jancis MO, Baecker A, Shen E, Nguyen H, Monjazeb S, Manthena P, Park S, Sharp AL, Meurer WJ. Cumulative Incidence of Stroke Disability and Mortality Following Emergency Department Discharge for Dizziness: A Cohort Study. Ann Emerg Med. 2025 Nov 18:S0196-0644(25)01244-2.
  2. MDCalc Sudbury Vertigo Risk Calculator

Pebbles in our shoes

What is this?

An initiative to help decrease stress and frustration in the workplace. An anonymous survey designed for small and easy fixes that can be resolved in a timely manner depending on the type of submission. We hope it adds to the quality of life in the ED!

How do I submit a response?

pebbles qr code

Through this form or the QR code (to right), you can submit a quick 3 question survey which will go to ED leadership.

Where are the physical QR codes?  

QR codes are located in the ED nursing station, staff bathrooms and break room.

We will report back regularly with any positive changes we can address or make from this.

What are some examples of appropriate “pebbles” to submit:

  • Overhead light in bed 3 is broken
  • Missing bladder scanner
  • Otoscope in bed 2 is broken
  • Cart not stocked in room 4
  • Lattice charger missing in team B

Thanks:

Emily McCormack, RN and Gail Lavin-Murphy, PA-C

Fetal Remains

Public Health Law governing disposition of fetal remains has changed reccently. Families are no longer required to bury fetal remains over 20 weeks gestation. In general, GYN should be consulted, and the new consent form (see below) must be completed and scanned in to the EMR.

From the Desk of Michael Nimaroff, MD, MBA, Senior Vice President, OBGYN Service Line, Northwell Health

There are important changes to the NYS Public Health Law governing disposition of fetal remains. Previously, the families of products of conception delivered in our facilities outside of New York City were required to bury all products of conception for any remains over 20 weeks gestation. This requirement has been eliminated and now families are not required to bury fetal remains of any gestation. 

For all sites in New York State and outside the New York City limits, families must be given the option to opt-out of self-disposition of products of conception over 20 weeks gestation. Our Pathology departments will manage fetal remains less than 24 weeks gestational age/26 weeks since last menstrual period (LMP). Discussions are underway with funeral directors and county coroner leads for mechanisms to dispose of the remains above the gestational age limits noted above. As we move to comply with this change, for families who choose not bury the products of conception, the remains will be held in hospital morgues. (Pathology departments are aware of the change).

The change requires a revision to our current Disposition of Products of Conception consent.  As this revision moves through the formal approval process, we have been advised by the Office of Legal Affairs to implement the changes immediately and have attached the updated consent to replace the current disposal of fetal remains consent document.  Inclusion of the revised form is being expedited to Vital Docs, for the immediate timeframe please use the attached consent.

Management of fetal remains does not change for any of the Northwell facilities in New York City (Queens, Staten Island, Manhattan, Bronx or Brooklyn), although all sites will use the new form. 

Please note, that these changes do not apply to live births but only to pregnancy loss resulting from spontaneous miscarriage, stillbirth, or any termination of pregnancy. 

For more information on the Public Health Law governing this change: Sections 4160 – 4163 of the Public Health Law

Zio Patch at NWH ED

REMINDERS

1: Ziosuite can be accessed here.

2: Zio workflow and announcement

2: Please consult cardiology for appropriate patients

  •  Palpitations/syncope etc.. That are stable for discharge
  • Establish with the cardiologist that this is an appropriate patient for Zio patch
  • Communicate with Dan Matthews, referral coordinator via meditech or teams that Zio was placed

2:  Remind patient basics about this product

  •  Data is only available to the cardiologist after the device is sent back to the manufacturer and the cardiologist accesses the data
  • If the patient comes back to the ED the next day, we have NO way of knowing what their electrical rhythm was from the patch
  • Do not submerge your body in water (swimming/hot tub)
  • If the patient feels an event while wearing the patch, tap the button on the device…
  • Remind them about common cardiac return precautions

3:  Basics of the process (see process map and overview attached for more detail)

  •  ED provider consults cardiology and decides on Zio
  • Zio ordered by ED provider, ED provider gives basic education on product
  • ED PCT places patch
  • Referral coordinator registers patient into the Zio system (potentially next day if after hours/weekend placement)
  • Patient gets discharged and follows up with cardiology after 2 weeks (to allow time for the 14 day monitor and product to be sent back to Zio)

4. The ZIO patches are stored in Joe’s office, next to the prescription pads.

5. The tracking book for PCTs to record Zio Patch patient information will be stored next to the Rabies book.

6. If you order a Zio on someone, please send Evan an email to ensure the process is working as designed

Direct to CT Stroke Care

This is the process:

  1. EMS brings in potential stroke patient
  2. Charge Nurse assigns the team and pulls the provider for an evaluation
  3. EMS stops in front of the charge desk where the patient is evaluated by:
    • Registration
    • ED nurse
    • ED provider
      • Assess that patient is having stroke symptoms requiring stroke work up (brief neuro exam, NOT full NIHSS)
    • ED provider and RN go through check list to ensure
      • Vital signs stable for CT transport
      • Glucose safe for CT transport
      • Airway intact
  4. Patient goes to CT scan on EMS stretcher, transfers to NWH weighted stretcher, weight is checked outside of CT scan.  RN enters weight and allergies.
  5. RN calls charge NR or ED provider to advise that weight and allergies are entered
  6. ED provider enters the stroke orders (This means that after you evaluate a code stroke in the hallway, 2 or 3 minutes later, you’ll be notified to place the orders.  So please do not immediately get involved with a complex situation until you have entered the stroke orders)
  7. Patient returns to the assigned room and usual stroke care follows.

See overview of evaluation pathways in this swim lane diagram.