Reviewed by Dr. Sabrina Berdouk
On a busy ED shift, “dizziness” is the chief complaint that can feel both benign and terrifying at the same time.
Most of these patients will have BPPV or vestibular neuritis. However, a small but critical minority will have a posterior circulation stroke—and these are the ones we absolutely cannot miss.
This is where the STANDING algorithm shines. It is a simple, structured, four-step bedside exam built around physiology that helps you separate peripheral vs. central causes in real-time.
In this post, we cover:
- The Physiology: Why vertigo is so dangerous to misjudge.
- The Algorithm: STANDING, step-by-step.
- The Toolkit: What you actually need at the bedside.
- The Pitfalls: Common mistakes that lead to missed strokes.
1. Why You Should Care (The Data)
The Problem:
- Dizziness/vertigo accounts for ~5% of ED visits.
- Posterior circulation strokes are frequently misdiagnosed, with missed stroke rates in dizzy patients reported between 20–35% (especially cerebellar infarcts).
- CT Heads are essentially useless early on. In acute vestibular syndrome (AVS), a CT is notoriously insensitive. You cannot rule out a stroke with a normal CT.
The Solution:
- Bedside exams like HINTS (in expert hands) and STANDING (in trained ED clinicians) reach sensitivities >90% for central causes in AVS, with a negative predictive value (NPV) of ≈99%.
- STANDING specifically adds a gait component, making it more robust for the generalist than HINTS alone.
2. The STANDING Algorithm in One Line
SponTAneous Nystagmus – Direction – Impulse – staNdinG
It boils down to 4 Clinical Steps:
- S: Is there spontaneous or positional nystagmus?
- D: What is the direction? (Peripheral vs. Central pattern)
- I: Head Impulse Test (HIT).
- G: Can the patient stand and walk? (Gait)
The Goal: Under the hood, STANDING sorts out BPPV vs. AVS, and within AVS, it separates Peripheral vs. Central.
3. “Step 0”: The Pre-Requisite
CRITICAL: Do not apply STANDING to every dizzy patient. It is designed for Acute Vestibular Syndrome (AVS).
The AVS Patient looks like this:
- ✅ Acute onset vertigo/dizziness.
- ✅ Continuous (hours–days, not seconds).
- ✅ Nystagmus is usually present.
- ✅ Nausea/vomiting and head-movement intolerance.
🛑 STOP: Do NOT use STANDING if:
- The patient has brief, episodic attacks (<1 min) triggered by movement → Think BPPV.
- The patient has vague lightheadedness/presyncope → Think Cardiac/Systemic.
- There are clear focal neuro deficits (aphasia, hemiparesis) → This is a Stroke Code.
- The vertigo has completely resolved.
4. The Bedside Toolkit
The Rules of Engagement:
- No Meds First: Do not give meclizine, benzos, or Zofran before the exam. These suppress nystagmus and alter gait, destroying your diagnostic accuracy. Treat the exam as a “lab test”—don’t contaminate the sample.
- Equipment: A bed, a penlight, and a spotter for the gait test. (Frenzel goggles are a bonus but not mandatory).
5. STANDING: Step-by-Step
STEP 1 – S: Spontaneous vs. Positional
Action: Patient supine, head neutral. Look for nystagmus at rest (spontaneous). If none, check for nystagmus triggered by head movement (positional).
- Positional, brief, fatigable nystagmus: Likely BPPV.
- Persistent spontaneous nystagmus: This is AVS. –> Proceed to Step 2.
- No nystagmus: Go to Step 4 (Gait) and broaden differential (migraine, cardiac, mimic).
STEP 2 – D: Direction of Nystagmus
Classify the nystagmus you found in Step 1.
| Peripheral Pattern (Reassuring) | Central Pattern (Red Flag) |
| Unidirectional: Fast phase beats the same way regardless of where they look. | Direction-Changing: Fast phase beats Right when looking Right, Left when looking Left. |
| Horizontal or Horizontal-Torsional. | Pure Vertical (Upbeat/Downbeat) or Pure Torsional. |
| Suppresses with visual fixation. | Does not suppress (or worsens) with fixation. |
- Decision: If Central Pattern → STOP. Assume Stroke. If Peripheral Pattern → Proceed to Step 3.
STEP 3 – I: Head Impulse Test (HIT)
Perform this ONLY if you have spontaneous, unidirectional nystagmus.
Action: Ask patient to fixate on your nose. Rapidly rotate head (10–20°) to the side. Watch the eyes.
- Abnormal (Positive) HIT: Eyes travel with the head, then make a corrective saccade back to your nose.
- Interpretation: The VOR is broken. This suggests a Peripheral lesion (Neuritis).
- Normal (Negative) HIT: Eyes stay locked on your nose. No saccade.
- Interpretation: The VOR is intact. In a patient with continuous vertigo, this is Central (Stroke) until proven otherwise.
Mnemonic: In AVS, a “broken” reflex (Abnormal HIT) is “good” (Peripheral). A “working” reflex (Normal HIT) is “bad” (Central).
STEP 4 – G: Standing and Gait
Action: Have the patient sit up, stand (with feet apart), and walk if safe.
- Peripheral: Unsteady, veers to one side, but can maintain posture and walk with help.
- Central: Truncal ataxia. Cannot stand without assistance. Falls backward or feels “pushed” to the floor.
6. Synthesis: Putting it Together at 3 A.M.
Scenario A: The Peripheral Picture (Likely Neuritis)
- S: Spontaneous Nystagmus present.
- D: Unidirectional (e.g., always beats left).
- I: HIT is Abnormal (corrective saccade when head turned right).
- G: Can walk (unsteady but independent).
- Action: Symptomatic management, discharge planning/ENT follow-up.
Scenario B: The Central Picture (Likely Stroke)
- S: Spontaneous Nystagmus present.
- D: Direction-changing OR Pure Vertical.
- I: HIT is Normal (no saccades).
- G: Severe ataxia (cannot stand).
- Action: Stroke Protocol + MRI.
7. Documentation Templates (Copy/Paste)
Option 1: Peripheral / Neuritis Note
“Acute continuous vertigo. No focal neuro deficits.
STANDING Exam:
S: Spontaneous unidirectional horizontal nystagmus present.
D: Nystagmus beats left in all gaze directions. Adheres to Alexander’s Law.
I: Head Impulse Test Abnormal (positive) with corrective saccades on rotation to the right.
G: Patient unsteady but able to stand and walk independently; no severe truncal ataxia.
Impression: Findings consistent with peripheral etiology (vestibular neuritis). Stroke risk discussed; strict return precautions given.”
Option 2: Central / Stroke Concern Note
“Acute continuous vertigo with vomiting.
STANDING Exam:
S: Spontaneous nystagmus present.
D: Nystagmus is direction-changing (gaze-evoked) / Pure Vertical.
I: Head Impulse Test Normal (negative); VOR intact bilaterally.
G: Patient has severe truncal ataxia; unable to stand without assistance.
Impression: Exam findings concerning for central etiology (posterior circulation stroke). MRI Brain ordered; Neurology consulted.”
8. The “Don’t Get Burned” Pitfalls
- Wrong Patient: Using STANDING on a patient with episodic vertigo. If they tell you “it only spins for 30 seconds when I roll over,” do a Dix-Hallpike, not a HIT.
- The Meds Trap: Giving 4mg of Zofran and 5mg of Valium before you look at the eyes. You have now masked the nystagmus.
- Sloppy HIT: If you move the head too slowly, the patient will use smooth pursuit to track you. The movement must be rapid and unpredictable.
- Ignoring the Legs: A patient who cannot stand needs an MRI, even if their eyes look “okay.” Truncal ataxia is a massive red flag.
- The “Normal CT” Trap: Do not let a normal non-contrast CT reassure you in a dizzy patient. The exam beats the scan.
The Takeaway
If you walk into the room and remember nothing else, remember this:
In continuous vertigo, Unidirectional Nystagmus + Abnormal HIT + Can Walk = Peripheral.
Anything else is Central until proven otherwise.
