The HINTS Exam

HINTS Exam for Acute Vestibular Syndrome (AVS)

Kattah et a. Stroke. 2009 Nov;40(11):3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17

Determining if vertigo is from a peripheral or central cause can be perplexing.  You can use the HINTS exam to rule out a central cause of vertigo and avoid getting an MRI.

The HINTS exam

Head Impulse test, bidirectional Nystagmus, Test of Skew.

How to perform the exam?

Head Impulse test: vestibular-ocular motor test. Patient focuses on examiner.  Slowly displace head in either direction 20 degrees & rapidly rotate to midline.  Looking for any “slippage” off the visual target during rotation. No fixation saccade -> normal response -> in context of AVS, indicates problem due to stroke (vs. vestibular neuritis). Normal response = (+) sign

Nystagmus: Look for nystagmus on lateral gaze with patient focusing on object.   Nystagmus = (+) sign

Test of Skew: alternate covering each eye & look for re-fixation or movement of the eye in response -> skew deviation. Small horizontal re-fixations are normal.  Vertical re-fixations are abnormal. Skew deviation = (+) sign

Interpretation of HINTS exam: If any one of the following is positive, the test is positive (i.e. concerning for central etiology of vertigo).

The evidence -> 100% sensitivity and 96% specificity for central cause of AVS. More sensitive than early MRI for stroke.

Watch the Video Demonstration

HINTS Exam.pdf


Lateral canthotomy

Orbital compartment anatomylateral canthotomy

Procedure that releases lateral canthal tendons to allow orbit to expand anteriorly.  Used when there’s an increase in orbital pressure.  The orbit is not very expandable so an increase in pressure that exceeds perfusion pressure causes ischemia of the optic nerve and retina.

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CT Scan and Pediatric Head Trauma (PECARN)

Kuppermann et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70

Bottom Line

Pediatric patients presenting in the ED with head trauma can be identified as low risk by 6 prediction factors and managed safely without a Head CT:

Age<2 years & NONE of the following factors: AMS, palpable skull fracture, scalp hematoma (except frontal), hx of LOC ≥ 5s, severe MOI, or not acting normally per parent


Age≥2 years & NONE of the following factors: AMS, signs of basilar skull fracture, Hx of LOC, history of vomiting, severe MOI or severe headache

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Can I Rule Out SBP From Clinical Judgment?

Physician clinical impression does not rule out spontaneous bacterial peritonitis in patients undergoing emergency department paracentesis. Ann Emerg Med. 2008 Sep;52(3):268-73. doi:10.1016/j.annemergmed.2008.02.016. Epub 2008 Apr 23

Bottom Line

Clinician assessment and clinical characteristics are not sufficient to r/o or diagnose SBP.  Patients presenting to the ED presenting for paracentesis cannot be ruled out from SBP from clinical judgment (sensitivity 76.5%) or any clinical characteristsics.  Pts should get routine fluid analysis even when clinical suspicions are low.

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Eye complaints

One of my classmates did an EM rotation down in the South and shared this humorous and straightforward breakdown of eye complaints.  While there’s an overwhelming number of conditions that manifest in the eye, there are only two drop-what-you’re-doing “true emergencies” that I’ve learned while on my ophthalmology rotation.

1.  Retrobulbar hematoma

2.  Globe rupture

Next are a couple of the broad categories of eye complaints.  It’s not perfect by any means and obviously there’s more to it than this, but it’s a good starting point in generating a DDx.

Painful eye:

(Next step: Apply topical anesthetic)

Pain decreases –> Corneal abrasion, corneal ulcer, foreign body, conjunctivitis

Pain unaffected –> Iritis/uveitis, glaucoma

Can’t see:

No pain –> CRAO, CRVO, retinal detachment, CVA

Pain –> Glaucoma, globe rupture, orbital fx, brian hemorrhage, traumatic iritis

Looks funny:

Subconjunctival hemorrhage

RSI for dummies

The inspiration for this post comes from seeing a variety of intubation methods used during my EM rotations.  The first part is a basic explanation of intubating.  The part to follow explores changes that can be made depending on the circumstances.

Basically, rapid sequence intubation consists of three parts: pretreatment, induction and paralysis.  (The crashing patient who’s unconscious and apneic receives BVM and intubation w/out pretreatment, induction or paralysis)

Oversimplifying the process helps to keep things straight inside a beginner’s head, so we’ll start simple.  In reality, there’s the 9 P’s to think about (Plan, Preparation, Protect C spine, Positioning, Preoxygenation, Pretreatment, Paralysis/Induction, Placement w/ proof, and Postintubation care).  There will be many different changes in medications, equipment choices etc depending on the patient.  But, that all comes later.  For now, let’s start with an overview of the three parts of RSI: Pretreatment, induction and paralysis.

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Minor head trauma

27 y/o M calls you asking whether or not he should go to the ED to get a CT scan.  He just fell off his motorcycle on train tracks and hit his un-helmeted head.  He might have lost consciousness for a minute or so, but has since returned to his baseline.  Other than a small abrasion at the site of impact, he states everything is all right.

Which clinical decision rules do you use ?

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