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Vertigo - Supine roll

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Indications

Vertigo or dizziness lasting less than two minutes initiated by head movements (e.g. turning while standing)

and

No nystagmus (prior to assessment)

and

No upwards rotatory nystagmus on Dix-Hallpike testing

Contraindications (absolute in bold)

Cervical spine pathology (known or suspected)

Vascular insufficiency (carotid or vertebrobasilar)

Limited mobility

Alternatives

None

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vertigo

Vomiting

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

Bed with access on both sides

Positioning

Supine in bed without a pillow

Medication

Medications are not useful for the brief episodes of vertigo associated with BPPV

Consider ondansetron 4 mg sublingual or IV, if unable to tolerate positional testing

Sequence (performing a supine roll)

Explain the test to patient, warning it may cause brief vertigo and nausea

Instruct patient to try and keep their eyes open

Turn the patients head 90 degrees to the left, observe for nystagmus, and return to the midline

Turn the patients head 90 degrees to the right, observe for nystagmus, and return to the midline

Sequence (Interpreting a positive result)

Direction changing horizontal nystagmus indicates a positive result

Fast beat pointing towards the ground on both sides = geotropic horizontal canal BPPV

Fast beat pointing away from the ground on both sides = apogeotropic horizontal canal BPPV

The direction of nystagmus in the more affected ear points to the ear with horizontal canal BPPV

Post-procedure care

By test results:

Positive test (horizontal nystagmus suggestive of horizontal canal BPPV)

Treat with Gufoni manoeuvre then wait 15 minutes

Reperform the supine roll and discharge home if no further provoked nystagmus

If repeat supine roll test is positive, then repeat the Gufoni manoeuvre

If unable to resolve vertigo, discuss with specialist for follow-up (neurology, ENT or vestibular physiotherapy)

Negative test

Reperform the Dix-Hallpike and supine roll tests with a more experience provider

Consider alternative diagnoses and discuss with specialist for review (neurology, ENT or vestibular physiotherapy)

Tips

History alone is insufficient to diagnose BPPV accurately, a positive test is required

The supine roll test is considered the gold standard for diagnosing horizontal canal BPPV

The supine roll test is only performed on patients without spontaneous nystagmus

Discussion

BPPV is caused by calcium carbonate otoliths in the semi-circular canals of the inner ear. The posterior (70%) and the lateral canals (25%) are most affected by this pathology.

The Dix-Hallpike test diagnoses BPPV caused by posterior canal otoliths. Typically, after a 5-20 seconds latency, vertical upwards and rotatory nystagmus will be seen which resolves within one minute. The otoliths in the posterior canal BPPV can be repositioned by the Epley manoeuvre, which is effective with one application in 80%.

If no nystagmus or horizontal nystagmus is seen on Dix-Hallpike testing, we perform a supine roll test looking for horizontal canal BPPV. Typically, after a 5-20 seconds latency, horizontal nystagmus will be seen on testing both sides which resolves within one minute. The nystagmus will either beat towards the ground on both sides, termed geotropic nystagmus, or away from the ground, which is termed apogeotropic. The otolith in the lateral canal can be repositioned by the Gufoni manoeuvre (the Epley manoeuvre will not cure these patients).

The supine roll test and Gufoni manoeuvre may be unknown to many emergency physicians. Practice of these techniques will expand the range of BPPV you can cure in the emergency department.

Patterns of movement-initiated vertigo we cannot diagnosis as posterior or horizontal canal BPPV, or which do not resolve with the Epley or other manoeuvres, require specialist review (ENT, neurology or vestibular physiotherapy) or follow-up to exclude rarer central causes.

Peer review

This guideline has been reviewed and approved by the following:

Emergency Care Institute

Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Produced with and reviewed by Dr Peter Johns, Assistant Professor, Department of emergency medicine, University of Ottawa.

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Kerber KA, Forman J, Damschroder L, et al. Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract. 2017;7(3):214-224. doi:10.1212/CPJ.0000000000000366

NSW Agency for Clinical Innovation. Benign paroxysmal positional vertigo. Sydney: ACI; 2017 Nov. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/274062/benign-paroxysmal-positional-vertigo-patient-factsheet.pdf

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