Improper Performance of HINTS Exam in Emergency Physicians Is Driven by Incorrect Use of Nystagmus
Kara Nolan, Nathan Murray, Ethan Lambert, Wenshan Liu, Murtaza Akhter
American Journal of Emergency Medicine, April 28, 2025
✅ Clinical Takeaway:
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HINTS = Only valid when continuous vertigo + spontaneous nystagmus are present
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Do not perform HINTS in patients without nystagmus
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Focused education on patient selection for HINTS is urgently needed.
📌 Conclusion:
The majority of emergency physicians misuse the HINTS exam, often applying it to patients lacking nystagmus, a core requirement for valid interpretation. This misuse undermines its diagnostic utility and points to a critical educational gap in vestibular assessment.
🧪 Methods:
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Design: Retrospective chart review (1-year period)
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Setting: Public hospital ED with emergency medicine residency
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Chart inclusion criteria: Contained keywords “hints,” “skew,” or “impulse”
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Classification: HINTS exams categorized as:
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Appropriate
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Inappropriate
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Either way
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Inappropriate uses further analyzed for presence of dizziness and absence of nystagmus
📊 Key Results:
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146 charts analyzed (after excluding 29 irrelevant cases)
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71.2% (95% CI: 63.5–78.1%) of HINTS exams were performed inappropriately
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Main reason: HINTS was conducted on patients without nystagmus
Nolan, K., Murray, N., Lambert, E., Liu, W. and Akhter, M., 2025. Improper performance of HINTS exam in emergency physicians is driven by incorrect use of nystagmus. The American Journal of Emergency Medicine.