Adult Emergency Nurse Protocol 20XX

ACUTE LOWER BACK PAIN

Non Traumatic

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

 Hourly neurovascular observations

Supportive Treatment:
 Nil By Mouth (NBM) if required
 Monitor vital signs as clinically indicated
(BP, HR, T, RR,SpO2)
 Monitor pain assessment / score
 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:

 Monitor the patient’s pain levels and regularly reassess after analgesia
 Provide the patient with an Acute Lower Back Pain patient factsheet [Emergency Care Institute]
 Complete a mobility assessment prior to patient discharge home
 A presumed diagnosis of cauda equina syndrome necessitates an urgent work-up.
 Bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the cauda
equina.
 A complete history and physical examination should identify impending neurological compromise and the need for emergent referral
to a spinal surgeon.
Further Reading / References:

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.

Revision & Approval History

Date Revision No. Author and Approval

Acute Lower Back Pain (non-traumatic) – Adult Emergency Nurse Protocol Page 2