Download Back Pain

Adult Emergency Nurse Protocol
20XX
ACUTE LOWER BACK PAIN
Non Traumatic
Aim:
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Early identification and treatment of acute lower back pain and escalation of care for patients at risk.
Early initiation of treatment / clinical care and symptom management within benchmark time.
Assessment Criteria: On assessment the patient should have one or more of the following signs / symptoms:
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 Back pain radiating into buttock or leg
Acute lower back pain – non traumatic
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):
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Hypotension
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Suspected Acute Coronary Syndrome
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Decreased neurological sensation
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Fever
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Suspected Aortic Aneurysm
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Incontinence with no history
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History of trauma
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Decreased limb strength
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Bilateral sciatica
Primary Survey:
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Airway: patency
Circulation: perfusion, BP, heart rate, temperature
Breathing: resp rate, accessory muscle use, air entry, SpO2.
Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags criteria 1.
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Airway – at risk
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Breathing – respiratory distress
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Circulation – shock / altered perfusion
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Partial / full obstruction
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RR < 5 or >30 /min
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HR < 40bpm or > 140bpm
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SpO2 < 90%
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BP < 90mmHg or > 200 mmHg
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Disability – decreased conscious level
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Exposure
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Postural drop > 20mmHg
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GCS ≤ 14 or any fall in GCS by 2
points
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Temperature < 35.5°C or > 38.5°C
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Capillary return > 2 sec
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BGL < 3mmol/L or > 20mmol/L
History:
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Presenting complaint
Allergies
Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non-prescription
meds, Any recent change to meds
Past medical past surgical history relevant – i.e. Osteoporosis, Immunosuppression
Last ate / drank & last menstrual period (LMP)
Events and environment leading to presentation i.e. trauma
Pain Assessment / Score: PQRST (Palliating/ provoking factors, Quality, Region/radiation, Severity, Time onset)
Associated signs / symptoms: limb weakness, urinary incontinence or retention, unexplained weight loss, fevers.
Systems Assessment:
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Inspection: appearance on back for bruising, abrasions, abnormalities; ability to ambulate and gait should be observed; spinal
range of motion; ability to straight leg raise.
Palpation: for boney / musculoskeletal tenderness;
Neurovascular & neurological assessments i.e. neurological deficits - weakness, spasticity, or hyper/hyporeflexia
Notify CNUM and SMO if any of the following red flags is identified from History or Systems Assessment.
 Unrelieved pain post analgesia
 Any change to patient’s neurovascular status
 Bilateral sciatica
 Cervical or thoracic pain
 Signs of traumatic injury
 Bladder dysfunction
 Fever or chills
 Unexplained weight loss
 History of malignancy
Investigations / Diagnostics:
Bedside Investigations:
Laboratory / Radiology:
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BGL: If < 3mmol/L or > 20mmol/L notify SMO 
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ECG: [as indicated] look for Arrhythmia , AMI 
Urinalysis / MSU: if urinary symptoms present
Postural Blood Pressure (3mins >20mmHg)
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Pathology: Not generally indicated unless infection or malignancy
suspected - refer to local STOP
Urine ßHCG if suspected pregnancy
Group and Hold (if bleeding suspected)
Blood Cultures (if Temp≥38.5 or ≤35°C)
Radiology: Not generally indicated - refer to SMO.
Resuscitation / Stabilisation:
Symptomatic Treatment:
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Oxygen therapy & cardiac monitor [as indicated]
IV cannulation [if IV analgesia required]
Hourly neurovascular observations
Antiemetic: as per district standing order
Analgesia: as per district standing order
Acute Lower Back Pain (non-traumatic) – Adult Emergency Nurse Protocol
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Adult Emergency Nurse Protocol
20XX
ACUTE LOWER BACK PAIN
Non Traumatic
Supportive Treatment:
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Nil By Mouth (NBM) if required
Monitor vital signs as clinically indicated
(BP, HR, T, RR,SpO2)
Monitor pain assessment / score
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Monitor neurovascular status [as clinically indicated]
Fluid Balance Chart (FBC)
Bladder scan if the patient doesn’t void urine within 2 hours to
exclude urinary retention
Practice Tips / Hints:
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Monitor the patient’s pain levels and regularly reassess after analgesia
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Provide the patient with an Acute Lower Back Pain patient factsheet [Emergency Care Institute]
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Complete a mobility assessment prior to patient discharge home
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A presumed diagnosis of cauda equina syndrome necessitates an urgent work-up.
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Bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the cauda
equina.
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A complete history and physical examination should identify impending neurological compromise and the need for emergent referral
to a spinal surgeon.
Further Reading / References:
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SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient
SESLHD/PR283. http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACEMgtOfTheDeterioratingAdultMaternityInpatient.pdf
Australian Acute Musculoskeletal Pain Guidelines Group (2004). Evidence-based Management of Acute Musculoskeletal Pain. A
guide for Clinicians. Retrieved on the 16/08/2013 from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp95.pdf
Emergency Care Institute (2012). Patient Factsheet Acute Lower Back Pain. Retrieved on the 22/07/2013 from:
http://www.ecinsw.com.au/sites/default/files/field/file/Acute%20Low%20Back%20Pain%20Patient%20Factsheet.pdf
Friedman, B. W., O’Mahony, S., Mulvey, L., Davitt, M., Choi, H., Xia, S., Esses, D., Bijur, P., & Gallagher, J. (2012). One-Week
qnd 3-Months Putcomes After an Emergency Department Visit for Undifferentiated Musculoskeletal Low Back Pain. Annals of
Emergency Medicine, 59(2), 128-133.
Best Practice BMJ Assessment of Back Pain. Available Online http://bestpractice.bmj.com.acs.hcn.com.au/bestpractice/monograph/189/overview/summary.html
International Association for the Study of Pain (2011). Principles of Emergency Department Pain Management for Patients with
Acute Painful Medical Conditions. Retrieved on the 12/07/2013 from: http://www.iasppain.org/AM/Template.cfm?Section=Fact_Sheets3&Template=/CM/ContentDisplay.cfm&ContentID=12978
Mosby’s Nursing Consult (2011). Chronic Pain. Retrieved on the 12/07/2013 from:
http://www.nursingconsult.com/nursing/evidence-based-nursing/monograph?monograph_id=189173&parentpage=search
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:
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Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
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Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date
Revision No.
Author and Approval
Acute Lower Back Pain (non-traumatic) – Adult Emergency Nurse Protocol
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