Trick of the Trade: Dix-Hallpike maneuver variation

Hallpike-dix maneuver

The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).

  • Place the gurney’s head of the bed down flat.
  • Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney.
  • Rotate patient’s head 45 degrees.
  • Help the patient lie down backwards quickly.
  • The patient’s head should be hanging off of the gurney edge in about 20 degrees extension.
  • Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.

I find 2 things challenging in this maneuver.

  • The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
  • In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.

Trick of the Trade: A modified Dix-Hallpike maneuver

Place blankets or a pillow under the shoulders for the Dix-Hallpike maneuver.

Hallpike-dix maneuver pillow blanket


The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.

By |2020-01-07T23:52:15-08:00Aug 30, 2011|ENT, Neurology, Tricks of the Trade|

Paucis Verbis: Spinal epidural abscess

Spinal epidural abscess anatomy illustrationOne of the most challenging diagnoses to make is that of a spinal epidural abscess (SEA), especially if you work in an Emergency Department which cares for many IV drug users and HIV patients. There’s never before been a published diagnostic guideline or algorithm which helps you with risk-stratification.

In the Journal of Neurosurgical Spine, a diagnostic guideline was prospectively evaluated on a small population (n=31) as compared to historical controls (n=55). They found that an ESR test had a sensitivity of 100% if a patient had at least 1 risk factor for SEA. A CRP test was much less helpful.

Not a practical algorithm

Unfortunately, they didn’t study the utilization rate of the MRI scanner with this guideline. Are they getting better results (fewer diagnostic delays and fewer cases of patients later in their clinical course) because they are just MRI-scanning more people? Almost everyone in my ED with back pain would fall into the Urgent/Emergent MRI box…  I’m not a fan of this algorithm.

Regardless, this algorithm may help you in shaping your diagnostic decision and medical decision making documentation.

PV Card: Spinal Epidural Abscess

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.


  1. Davis D, Salazar A, Chan T, Vilke G. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6):765-770. [PubMed]
By |2021-10-12T16:17:13-07:00Aug 5, 2011|ALiEM Cards, Infectious Disease, Neurology|

Trick of the Trade: Corneal reflex test

CornealreflexThe corneal reflex test (blink test) examines the reflex pathway involving cranial nerves V and VII. Classically the provider lightly touches a wisp of cotton on the patient’s cornea. This foreign body sensation should cause the patient to reflexively blink.

This maneuver always makes me a little worried about causing a corneal abrasion, especially if you are examining a very somnolent patient. You are wondering — Is there no blinking because you’re not touching the cornea hard enough? You apply harder pressure but still no blink. You repeat the test and now the patient finally blinks. That’s 3 times you’ve just scraped against the cornea.

What’s an alternative approach?


By |2016-11-11T18:58:00-08:00Apr 20, 2011|Neurology, Tricks of the Trade|

Paucis Verbis card: Generalized Convulsive Status Epilepticus

StatusEpilepticusHow do you manage patients who present in status epilepticus, knowing that “time is CNS function”? The longer patients remain seizing, the greater their morbidity and mortality.

Did you know that one study showed that 48% of their patients who presented in generalized convulsive status epilepticus (GCSE) had subtle persistent GCSE on EEG, despite no clinical evidence of overt seizure activity? That’s scary.

Do you send off a serum tricyclic toxicology screen for all your patients with GCSE? Because of the prevalence of TCA overdoses locally, our Neurology consultants definitely order it. We are picking up a surprising number of positive tricyclic tox screens.

PV Card: Status Epilepticus

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.


  1. Shearer P, Riviello J. Generalized convulsive status epilepticus in adults and children: treatment guidelines and protocols. Emerg Med Clin North Am. 2011;29(1):51-64. [PubMed]
By |2021-10-17T09:07:41-07:00Jan 21, 2011|ALiEM Cards, Neurology|

Paucis Verbis card: Workup for first-time seizure

StatusEpilepticusHow do you workup adult patients who present with a new-onset seizure and now neurologically back to normal?

There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches.

For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes:

  • Glucose and electrolytes
  • Urine pregnancy test, if appropriate
  • +/- Urine toxicology screen
  • Head CT (noncontrast)

Otherwise, the more complex cases require a more extensive workup, which may include a lumbar puncture in the setting of a fever, severe headache, immunocompromised status, or persistent altered mental status.


Be sure you obtain a head CT for patients who you think are presenting with a simple new-onset, alcohol-withdrawal seizure. One study showed that 6.2% of these patients actually have a significant lesion on CT (eg. bleed, mass).

PV Card: Workup for First Time Seizure

Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.


  1. ACEP C, Clinical P. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2004;43(5):605-625. [PubMed]
  2. Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure. Emerg Med Clin North Am. 2011;29(1):41-49. [PubMed]
By |2021-10-17T09:10:01-07:00Jan 14, 2011|ALiEM Cards, Neurology|
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