Rosen & Barkin's 5-Minute Emergency Medicine Consult (91 page)

TREATMENT

• Immobilization is not generally recommended for nontraumatic pain.
  
• Rapid transport for vascular concerns
  

• NSAIDs:
  
  • Musculoligamentous pain
    
  • Renal colic
    
  • Similar benefits as APAP but less optimal side-effect profile
    
• APAP: Considered 1st-line therapy for mild-to-moderate pain
  
  • Moderate but conflicting evidence for benefit of NSAID and acetaminophen combination over each individually in postoperative pain
    
  • APAP and NSAIDs not effective for sciatica pain
    
• Muscle relaxants:
  
  • Cyclobenzaprine, methocarbamol, carisoprodol, or tizanidine
    
  • Benefits must be balanced by side effects, mostly sedation, dizziness, and dry mouth
    
• Benzodiazepines:
  
  • No clear difference from skeletal muscle relaxants
    
  • Likely higher risk profile for addiction
    
• Narcotics:
  
  • A reasonable (3–5 days) course may be given for severe pain not relieved by anti-inflammatory or APAP. Effective for neuropathic pain
    
  • Risk benefit profile should be considered and discussed with patient
    
• Corticosteroids:
  
  • No benefit in radicular or nonradicular back pain
    
• Spinal manipulation:
  
  • A short course (<2 wk) may be helpful in acute LBP without sciatica
    
• Physical therapy/exercise:
  
  • No clear consensus for indications
    
  • May be helpful in symptomatic relief, preventing further episodes and teaching patients
    
• Acupuncture:
  
  • Controversial, probable benefit for chronic musculoskeletal pain
    
  • No clear benefit over other modalities
    
  • Trigger point therapy with minimal to no evidence of benefit for chronic LBP not studied for acute
    
• Massage:
  
  • May be beneficial when combined with exercises and education
    
• Heat/cold therapy:
  
  • Limited evidence to support that heat wrap therapy may help reduce pain and disability for patients with back pain <3 mo. Improved as adjunct to exercise.
    
• Bed rest:
  
  • Unhelpful to speed recovery and may impede improvement. If patient requires bed rest acutely or is symptomatically improved, 1 or 2 days may be recommended.
    
• Back exercises:
  
  • Unlikely to be useful in acute phase; may assist with prevention of future episodes
    
• Expected recovery to pain-free state:
  
  • Conflicting data, mostly in non-ED setting
    
  • ∼33% within 1 wk
    
  • ∼90% within 6–8 wk
    
  • Low SES, female sex, baseline disability and chronic LBP significant for worse functional outcome at 1 and 3 wk
    
  • Newer ED data suggests functional limitation in 50% of patients with pain at 3 mo.
    
• Recurrence is common: ∼40%
  

• Acetaminophen: 500 mg (peds: 10–15 mg/kg, do not exceed 5 doses/24h) PO q4–6h, do not exceed 4 g/24h
  
• Hydrocodone/acetaminophen: 5/500 mg PO q4–6h
  
• Ibuprofen: 600–800 mg PO q6–8h (peds: 10 mg/kg q6h)
  
• Naproxen: 250–500 mg PO q12h
  
• Oxycodone/acetaminophen: 5/500 mg PO q4–6h
  

• Cyclobenzaprine: 5–10 mg PO TID. Caution patient regarding drowsiness.
  
• Methocarbamol: 500–1,500 PO q6h. Caution patient regarding drowsiness.
  
• Valium: 5–10 mg PO q8h
  
• You may combine 1st- and 2nd-line therapies but side-effect profile will increase
  

FOLLOW-UP

• Severe pain with inability to ambulate
  
• Pain unresponsive to ED management
  
• Progressive neurologic deficits
  
• Signs of cauda equina syndrome
  
• Infectious, vascular, or neoplastic etiologies
  

Uncomplicated presentation with ability to control pain and ambulate

• Maintain a high suspicion for serious disease including vascular etiology, neoplasm, or infection.
  
• Have a low threshold for imaging or diagnostic testing.
  
• Follow up patients on NSAIDS or opioids more carefully for complications or adverse events related to therapy.
  

• Back pain is unusual in the pediatric patient; a high suspicion for an infectious etiology must be maintained.
  
• For musculoligamentous pain, a single trial found that Ibuprofen provides good pain control with a low side-effect profile.
  

Limited evidence suggests that strengthening and pelvic tilt exercises combined with routine prenatal care may have benefit in treating back pain; unclear if they prevent pain

Urgent neurosurgical or orthopedic consultation for definite diagnosis or high suspicion for abscess or lesion (disc, neoplasm, or other) with rapidly progressive objective neurologic findings

• Uncomplicated back pain: PCP in 1–2 wk
  
• New sciatica without neurologic findings: PCP or specialist in 7–10 days
  
• Complicated with sensory findings only or minimal motor symptoms: 24–48 hr
  
• Marked or rapidly progressive motor symptoms, or bowel/bladder findings warrant specialist consultation in the ED or transfer if unavailable.
  

• Consider MRI for history of IVDA to rule out epidural abscess or if concerns of nonbony spinal metastases.
  
• Elderly with minimal trauma may sustain fractures.
  
• Consider vascular etiology in elderly patients with 1st-time presentation of back pain.
  
• Advise patients that this is often a prolonged course and they should not expect rapid resolution.
  
• Opioids should be limited to a short course from the ED.
  

• Cantrill SV, Brown MD, Carlisle RJ, et al. American College of Emergency Physicians Opioid Guideline Writing Panel. Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department.
  Ann Emerg Med.
  2012;60(4):499–525.
  
• Davies RA, Maher CG, Hancock MJ. A systematic review of paracetamol for non-specific low back pain.
  Eur Spine J
  . 2008;17:1423–1430.
  
• Friedman BW, O’Mahony S, Mulvey L, et al. One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain.
  Ann Emerg Med.
  2012;59(2):128–133.
  
• Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain.
  Spine
  . 2008;33(16):1766–1774.
  
• Waterman BR, Belmont PJ Jr, Schoenfeld AJ. Low back pain in the United States: Incidence and risk factors for presentation in the emergency setting.
  Spine J.
  2012;12(1):63–70.
  

CODES

• 724.2 Lumbago
  
• 724.3 Sciatica
  
• 724.5 Backache, unspecified
  

BASICS

• A tracheal infection potentially causing acute airway obstruction. Also known as bacterial croup and laryngotracheobronchitis. Exudative tracheitis can refer to a less severe form of disease
  
• Usually secondary bacterial infection of trachea, complicating antecedent viral infection, or less commonly, instrumentation
  
• Fatal in 0–20%
  
• Tracheal membrane formation, purulent discharge, subglottic edema, erosions, with normal epiglottis
  
• Classically presents with prodrome similar to croup followed by rapid deterioration and loss of airway patency
  
• Mean age 5 yr; rarely occurs in adults
  
• More common in children than epiglottitis, presumably due to success of
  Haemophilus influenzae
  immunization
  
• More frequent August–December
  

• Staphylococcus aureus
  (with occ. methicillin-resistant
  S. aureus
  [MRSA])
  
• Moraxella catarrhalis
  
• Streptococcus pneumoniae
  
• Group A streptococcal species
  
• Pseudomonas aeruginosa
  
• H. influenzae type B
  
• Escherichia coli
  
• Anaerobes
  
• Klebsiella pneumoniae
  
• Nocardia
  
• Associated with influenza A (including H1N1) and B, parainfluenza, adenovirus, and RSV viral infections
  
• Aspergillus
  , HSV in immunocompromised hosts (HIV)