Are emergency physicians and paramedics providing canalith repositioning manoeuvre for benign paroxysmal positional vertigo?

Dear Editor, Benign paroxysmal positional vertigo (BPPV) is an extremely common problem seen in EDs that can be managed effectively by ED clinicians. BPPV sufferers usually complain of brief short episodes of ‘spinning’ associated with certain types of head movement, such as looking up and bending down. BPPV can be a recurrent and disabling problem in 56% of patients. Posterior canal BPPV is the most common type and rarely BPPV is caused by the horizontal and anterior canals. Vertigo can rarely be caused by a central pathology in the brain (brainstem, cerebellum) or a peripheral cause in the inner ear. Up to 54% of patients with dizziness presenting to family physicians suffer from peripheral vertigo. BPPV can be effectively managed by one of many canalith repositioning manoeuvres (CRM), such as Epley or others. There is anecdotal evidence that most clinicians do not provide CRM for BPPV patients. We conducted a crosssectional questionnaire survey in 2014 (Table 1). This survey was done to determine the current practice of management of BPPV among emergency physicians and paramedics working at Hamad Medical Corporation. The outcome of this study will help us in designing training interventions for improving the knowledge and practice regarding management of BPPV. Between May and July 2014, an anonymous cross-sectional survey was conducted among ED physicians and paramedics in Doha, the state of Qatar. Our ED sees over half a million new patients every year, and the physicians are from over 30 different countries with varying levels of training. Most physicians and patients are expats. The response rate was 90% (81/ 90). Only 11% of emergency physicians and 0% paramedics would diagnose and treat BPPV with physical manoeuvres. There were three main reasons described for not offering CRM. Seventy-six per cent of participants stated that they never learned the manoeuvre, 14% stated that they do not have time to offer the manoeuvre, whereas 10% believed that medications should be tried first. In our study, the most common reason (76%) stated for not offering the manoeuvre was lack of training. Unfamiliarity with the technique, concerns about cerebellar stroke and not considering the diagnosis of BPPV are other possible reasons for not offering CRM. In one population-based study of management of dizziness in the ED, only 136 (3.9%) patients had DHT and seven out of 3522 (0.2%) patients were offered CRM. These results are comparable with our study where only 11% of clinicians stated that they would offer CRM to patients with BPPV. Most ED physicians and EMS staff do not have enough time available to effectively manage patients with BPPV. However, if CRM is offered to these patients, it will not only improve symptoms but will also reduce the burden on emergency services because of their re-attendance. Medications are commonly given to vertigo sufferers to improve the spinning sensation and to control nausea and vomiting, but there is no evidence to suggest that these medications provide better treatment than CRM. The American Academy of Neurology and Head and Neck Surgery does not recommend routine use of medications for BPPV. BPPV is a common condition and can be effectively managed at the bedside. Training should be offered to all clinicians so that this can be diagnosed and treated early to prevent recurrence and anxiety for the patients.