II. Indications
III. Approach: Step 1 - Nystagmus
- Absent
- Go to Step 4 - Assess Walking
- Spontaneous Vertigo
- Go to Step 2 - Assess Nystagmus Direction
- Positional Vertigo (typically BPPV)
- Confirm that patient is able to stand or walk without assistance (if not, go to Step 5)
- Test Specifically for BPPV findings
- McClure-Pagnini Test or Supine roll test (tests in horizontal plane for lateral canal)
- Dix-Hallpike Maneuver (tests in sagittal and Coronal Plane for posterior canal)
- Author's bedside strategy for BPPV testing (not part of official STANDING algorithm)
- Epley Maneuver (test right and left sides, treat for posterior canal BPPV, up to 90% of cases)
- Other maneuvers if Epley Maneuver is not effective
- Barrel Roll Maneuver (test and treat lateral canal BPPV, 5-10% of cases)
- Deep Head Hanging Maneuver (test and treat anterior canal BPPV, uncommon to rare)
IV. Approach: Step 2 - Nystagmus Direction
- Multidirectional or Vertical
- Go to Step 5 - Evaluate for Central Vertigo
- Unidirectional Vertigo (left or right)
- Go to Step 3 - Perform Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
V. Approach: Step 3 - Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
- Positive Test or Abnormal Test
- ABSENT corrective saccades
- Go to Step 5 - Evaluate for Central Vertigo
- Negative Test or Normal Test
- PRESENT quick corrective saccade movements to catch-up (HiNTs-Peripheral)
- Typically consistent with Vestibular Neuronitis
- Confirm that patient is able to stand or walk without assistance (if not, go to Step 5)
VI. Approach: Step 4 - Stand or Walking without assistance
VII. Approach: Step 5 - Central Vertigo Evaluation
- See Vertigo due to Central Causes
- See Acute Vestibular Syndrome
- Head Imaging for CVA
VIII. Resources
- Standing Algorithm and Triage Application (Italian Journal of Emergency Medicine)
IX. References
- Vanni (2014) Acta Otorhinolaryngol Ital 34(6):419-26 +PMID: 25762835