Dizziness is a common and often alarming symptom that prompts many visits to the Emergency Room (ER). This broad term encompasses several distinct sensations, including true vertigo (the feeling of spinning), lightheadedness or near-fainting, and disequilibrium (a sense of unsteadiness or imbalance). The primary function of the ER is not to find a definitive, long-term diagnosis but to rapidly stabilize the individual and rule out acute, life-threatening emergencies. These critical conditions include stroke, hemorrhage in the brain, or severe cardiac events that could compromise blood flow to the head. The ER’s systematic approach differentiates between benign issues and those requiring immediate, aggressive intervention.
The Initial ER Assessment: History and Vitals
The evaluation begins immediately at triage, where a nurse records the patient’s baseline vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation. This initial check-in is the first step in identifying instability, such as dangerously high or low blood pressure or an irregular heartbeat. The medical history is considered the most powerful diagnostic tool for dizziness, often revealing the cause before any tests are ordered.
The ER staff will ask specific, detailed questions to characterize the patient’s experience, focusing on “timing and triggers.” This includes the precise onset—whether the dizziness was sudden and continuous or started gradually—and its duration. Staff will also investigate triggers, such as whether the spinning sensation occurs only with specific head movements. The interview will cover associated symptoms, like a severe headache, chest pain, difficulty speaking, or weakness, which are considered red flags for neurological or cardiovascular emergencies. A full review of all current medications is also completed, as many drugs can cause dizziness as a side effect.
Diagnostic Procedures to Identify Life Threats
After the focused history, objective testing begins with a goal of excluding catastrophic events. Standard blood work often includes a complete blood count (CBC) to check for severe anemia or infection, a chemistry panel to assess electrolytes and hydration status, and a glucose test for hypoglycemia. An electrocardiogram (EKG) is routinely performed to look for heart rhythm disturbances (arrhythmias) or signs of a heart attack that could be causing lightheadedness due to poor blood circulation.
A thorough neurological and physical exam is performed. This often includes checking for orthostatic vital signs, where blood pressure and heart rate are measured while the patient is lying down, sitting, and standing. Significant drops indicate dehydration or an autonomic issue.
For patients experiencing acute, continuous vertigo, a specialized bedside evaluation called the HINTS exam may be performed. HINTS (Head Impulse, Nystagmus, Test of Skew) is a three-part eye and head movement test that is highly sensitive at differentiating a stroke (a central cause) from a less dangerous inner ear problem (a peripheral cause).
Imaging is not automatically ordered for all dizziness complaints. A computed tomography (CT) scan of the head is typically reserved for cases where there is a sudden, severe onset, trauma, or specific neurological deficits that suggest bleeding in the brain. However, a CT scan is not effective at ruling out the most common type of stroke that causes continuous vertigo, which occurs in the posterior circulation of the brain. If a central cause like a stroke is strongly suspected, magnetic resonance imaging (MRI) is the preferred method, though it is not always immediately available or required in the ER setting.
Immediate Treatment for Common Causes
Once life-threatening conditions have been ruled out, the ER team focuses on symptom relief for the most common, benign causes. For patients whose dizziness is due to volume depletion or orthostatic hypotension—a drop in blood pressure upon standing—intravenous (IV) fluids are frequently administered. Rehydrating the patient can quickly restore blood volume and stabilize blood pressure, often resolving the lightheadedness.
For the spinning sensation of vertigo, pharmacologic agents are used to dampen the inner ear signals or control severe nausea. Medications commonly administered include anti-nausea drugs, and sometimes antihistamines or benzodiazepines, which act as vestibular suppressants to calm the inner ear’s response.
For the common condition known as Benign Paroxysmal Positional Vertigo (BPPV), a specific, non-pharmacological treatment is often performed in the ER. This condition is caused by dislodged calcium crystals, or otoconia, moving into the ear’s semicircular canals.
The Epley maneuver, a series of precise head and body movements, is used to physically reposition these crystals back into the utricle. This particle repositioning procedure can provide immediate and often complete relief for the patient, confirming the benign nature of the problem and avoiding the need for further extensive testing.
Determining Next Steps: Admission or Discharge
The final step in the ER visit is determining the patient’s disposition: whether they need to be admitted to the hospital or can be safely discharged home. Admission is required if the workup reveals an acute, serious condition, such as a new stroke suggested by imaging, persistent instability in vital signs, or findings suggestive of a severe cardiac issue. Patients who cannot safely ambulate or have concerning neurological exam findings are also typically admitted for observation and further specialist consultation.
For the majority of patients, who are found to have a benign cause or a self-limiting issue, discharge is appropriate once symptoms have significantly improved or resolved and the life threats have been excluded. A safe discharge requires a clear follow-up plan with the patient’s primary care physician or an appropriate specialist, such as a neurologist or cardiologist, if the cause remains unclear but is deemed non-emergent. The ER physician will ensure the patient understands their diagnosis, any prescribed discharge medications, and specific instructions for when to return to the ER should new or worsening symptoms occur.