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Aim:
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:
Acute lower back pain – non traumatic Back pain radiating into buttock or leg
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):
Hypotension Suspected Acute Coronary Syndrome Decreased neurological sensation
Fever Suspected Aortic Aneurysm Incontinence with no history
History of trauma Decreased limb strength Bilateral sciatica
Primary Survey:
Airway: patency Breathing: resp rate, accessory muscle use, air entry, SpO2.
Circulation: perfusion, BP, heart rate, temperature 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.
Airway – at risk Breathing – respiratory distress Circulation – shock / altered perfusion
Partial / full obstruction RR < 5 or >30 /min HR < 40bpm or > 140bpm
SpO2 < 90% BP < 90mmHg or > 200 mmHg
Disability – decreased conscious level Exposure Postural drop > 20mmHg
GCS ≤ 14 or any fall in GCS by 2 Temperature < 35.5°C or > 38.5°C Capillary return > 2 sec
points BGL < 3mmol/L or > 20mmol/L
History:
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:
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 Cervical or thoracic pain Fever or chills
Any change to patient’s neurovascular status Signs of traumatic injury Unexplained weight loss
Bilateral sciatica Bladder dysfunction History of malignancy
Investigations / Diagnostics:
Bedside Investigations: Laboratory / Radiology:
BGL: If < 3mmol/L or > 20mmol/L notify SMO Pathology: Not generally indicated unless infection or malignancy
suspected - refer to local STOP
ECG: [as indicated] look for Arrhythmia , AMI Urine ßHCG if suspected pregnancy
Urinalysis / MSU: if urinary symptoms present Group and Hold (if bleeding suspected)
Postural Blood Pressure (3mins >20mmHg) Blood Cultures (if Temp≥38.5 or ≤35°C)
Radiology: Not generally indicated - refer to SMO.
Resuscitation / Stabilisation: Symptomatic Treatment:
Oxygen therapy & cardiac monitor [as indicated] Antiemetic: as per district standing order
IV cannulation [if IV analgesia required] Analgesia: as per district standing order
Acute Lower Back Pain (non-traumatic) – Adult Emergency Nurse Protocol Page 1
Adult Emergency Nurse Protocol 20XX
ACUTE LOWER BACK PAIN
Non Traumatic
1. 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-PACE-
MgtOfTheDeterioratingAdultMaternityInpatient.pdf
2. 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
3. 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
4. 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.
5. Best Practice BMJ Assessment of Back Pain. Available Online http://bestpractice.bmj.com.acs.hcn.com.au/best-
practice/monograph/189/overview/summary.html
6. 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.iasp-pain.org/AM/Template.cfm?
Section=Fact_Sheets3&Template=/CM/ContentDisplay.cfm&ContentID=12978
7. 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:
Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Acute Lower Back Pain (non-traumatic) – Adult Emergency Nurse Protocol Page 2