Disposition

The disposition decision in dizziness is binary on paper — admit or discharge — but in practice has a useful middle option: observe and re-examine after the initial intensity settles. That re-examination often resolves an indeterminate first HINTS into a clear peripheral or central pattern.

The single most powerful admission trigger is any central feature on HINTS. Every other rule is a refinement of that one.

The HINTS-derived disposition rule is: any one of normal HIT, direction-changing nystagmus, or vertical skew in an AVS patient mandates admission to a stroke pathway, regardless of CT findings and even regardless of an initial negative DWI-MRI.1 Posterior-fossa stroke is dangerous and treatable; the cost of over-admission is much lower than the cost of a missed cerebellar infarct.

The discharge pathway has its own quality bar. A patient with PC-BPPV after a successful Epley should leave the ED with written post-Epley advice, return precautions, and a follow-up appointment — both because BPPV recurs in 15–30% at one year, and because successful repositioning is best confirmed by a re-test at one week. Repositioning + structured discharge planning is the highest-evidence episode of care the ED delivers for vertigo.3 Vestibular rehabilitation referral within 72 hours is the single most impactful outpatient intervention.2

Newman-Toker's epidemiological work shows that close to one in three of the posterior-circulation strokes that present to the ED with isolated dizziness are missed — and the system-level cost of those misses is measured in millions of dollars per case in litigation alone.4 The disposition rule is therefore deliberately asymmetric: false positives (admitting a vestibular neuritis) cost a bed; false negatives (discharging a stroke) cost a life and the clinician's career.

The observation pathway is undervalued. Many indeterminate HINTS resolve when the vomiting settles enough for the patient to fixate. A two-to-four-hour observation with antiemetic, IV fluids, and a re-examination produces a better-quality disposition than committing to admit or discharge on the noisy first exam.