APPROACH TO LOW BACK PAIN: Dr. M.

Sahitya Niranjali
HISTORY: DIFFERENTIAL DIAGNOSIS:
-Provocative factors
Structural Mechanical / non-specific
-Quality of pain
Arthritis
-Radiation Prolapsed intervertebral disc
-Severity & Systemic Symptoms Annular tear of intervertebral disc
-Timing Spondylolysis / Spondylolisthesis
Spinal Stenosis
RED FLAGS: Neoplasm Primary or Secondary including
-Bowel/ Bladder dysfunction Multiple Myeloma
-Anaesthesia (Saddle) Referred pain Major viscera
-Constitutional symptoms (night pain, to spine Retroperitoneal structures
Aorta
weight loss, fever/chills)
Hip
-Chronic disease – H/O cancer, steroid
Infection Discitis
use, HIV infection
Osteomyelitis
-Paraesthesia Paraspinal abscess
-Age >55 years Inflammator Spondyloarthropathies
-IVDU/ Infection y Sacroiliitis /Sacroiliac dysfunction
-Neurological deficits Metabolic Osteoporotic vertebral collapse
Paget’s disease
Osteomalacea
EXAMINATION: Hyperparathyroidism
-Monitor vitals
-Inspect skin for infection/trauma MANAGEMENT:
-Abd examination & Pulse deficits (AAA) -MSK Back pain: Analgesia
-Cardiac examination (Murmurs) -Cauda Equina Syndrome: IV Dexamethasone,
-Neurological examination including reflexes Immediate specialist referral
& Dermatomes -Aortic Dissection: IV Labetalol to control HR &
-Anal tone BP, Immediate specialist referral
-Straight leg raise test -Ruptured AAA: Blood resuscitation, Immediate
INVESTIGATIONS: Specialist referral
-CBC, CRP (suspected infection) -Epidural abscess or vertebral osteomyelitis:
-Blood grouping & Typing (Ruptured AAA) Broad Spectrum Antibiotics
-Bedside USG – R/O AAA, Bladder distension
-CT Abd (Aortic Dissection) DRAIN:
INTERCOSTAL Dr. M. Sahitya Niranjali
-Urgent MRI (Cauda equina syndrome)

Reference: RCEM Learning, Rosen’s Emergency Medicine 10th edition

 INDICATIONS:
- Spontaneous & traumatic pneumothorax
- Haemothorax
- Empyema
- Patients with penetrating chest trauma undergoing positive pressure
ventilation or long-distance transport
CONTRAINDICATIONS:
Absolute: None
Relative: Presence of multiple pleural adhesions & emphysematous blebs
Coagulopathy
PATIENT POSITION: ENTRY SITE: Triangle of safety
Semi-erect with ipsilateral am abducted

EQUIPMENT:

PROCEDURE: INFORMED CONSENT

 Position the patient, prepare the skin & administer the local anaesthetic. Use a
scalpel with No.10 blade to make a transverse 3 to 5cm incision through the
skin & subcutaneous tissue, over the rib.

Use a large Kelly clamp to push & spread the deeper tissues, & bluntly dissect a
track over the rib, while avoiding the vessels on the inferior surface of the rib. Firm
resistance will be felt when the parietal pleura is met. Close the clamp & push it
forward to penetrate the pleura.

With only the clamp tips in the pleural cavity, spread the clamps to make an
adequate hole in the pleura & then withdraw it.

Before removing the clamp, slide a finger over it & into the pleural cavity so that
the dissected tract is not lost. Leave the finger in the pleural space & pass the tube
alongside the finger during insertion.

Alternatively, if a finger is not used as a tube guide, hold the tube in a large curved
clamp. & pass it into the pleural cavity.

Direct the tube posteriorly, medially & superiorly until the last hole of the tube is
clearly intrathoracic or resistance is felt. Attach the tube to the previously
assembled water seal or suction system. Ask the patient to cough, & observe
bubbles in the water seal chamber to assess patency of the system.

To secure the tube, first close the skin incision with a “stay” suture near the tube.
Tie the knot securely & leave the suture ends long for wrapping around & tying the
tube. Wrap the suture tightly at least twice around the tube, enough to indent the
tube slightly & tie securely.

After suturing the tube, place an occlusive dressing of petrolatum-impregnated

COMPLICATIONS:
Y- shaped gauze.
 - Infection
- Laceration of intercostal vessel
- Pulmonary injury
- Intraabdominal or solid organ tube placement
- Failure of re-expansion of pneumothorax
- Re-expansion pulmonary edema

Reference: Robert’s and Hedges Clinical Procedures 7th edition

 PULMONARY EMBOLISM: Dr. M. Sahitya Niranjali

MODIFIED WELLS SCORE

INVESTIGATIONS:
CRITERIA POINTS
- FBC, U&E,
CLINICAL FEATURES: LFT, Coagulation
Clinical signs/ symptoms of DVT 3
- D-dimer
- Dyspnoea
- ABG
- Pleuritic chest pain PE is most likely diagnosis 3
- Cardiac
- Signs of DVTbiomarkers –
Tachycardia (HR>100 bpm) 1.5
- CoughTroponin I, NT-proBNP
- Chest X-Ray  1. Hamptom
- Haemoptysis Immobilization/ 1.5
- Feverhump: wedge opacity in the Surgery in previous 4 weeks
setting of
- Syncope
pulmonary Prior DVT/ PE 1.5
infarct.
Haemoptysis 1
2.
Westermark sign: Prominent Active malignancy 1
pulmonary artery with 0-4 Points  PE Unlikely
>4  PE Likely
decreased peripheral vasculature.
- ECG  1. Sinus Tachycardia. 3. S1Q3T3
2. New RBBB. 4. Right axis deviation
- ECHO  1. RA/RV dilatation
2. Dilated IVC
- Venous Doppler
- CTPA (Definitive confirmation of PE)
- V/Q scan (done if there is contraindication to CTPA such as renal impairment
or contrast allergy)

MANAGEMENT:
- Oxygen
- Fluid resuscitation in <BP: 0.9% NaCl 500ml over 15-30mins (Monitor
closely for signs of heart failure.
- Start inotropes if SBP remains <90 mmHg.
- UNFRACTIONATED HEPARIN: Start UFH in haemodynamically
unstable patients prior to thrombolysis, or while awaiting reports.
Initial bolus: 80 units/kg
Initial infusion rate: 18 units/kg/hr
 Repeat APTT after 4-6 hours.
- THROMBOLYSIS: INFORMED CONSENT. Used in submassive PE.
Absolute Contraindications: Relative Contraindications:

-Prior intracranial haemorrhage -Age >75 years

-Known structural intracranial
cerebrovascular disease (AV malformations)
-Known malignant intracranial problem
-Ischaemic stroke within 3 months
-Suspected aortic dissection
-Active bleeding or bleeding diathesis
-Recent surgery encroaching on the spinal
canal or brain
-Recent significant closed-head or facial
trauma with radiologic evidence of bony
fracture or brain injury.
-Current use of anticoagulation
-Pregnancy
-Non compressible vascular punctures
-Traumatic or prolonged CPR (>10mins)
-Recent Internal bleeding (within 2 to 4
weeks)
-H/O chronic, severe and poorly controlled
hypertension
-Severe uncontrolled HTN on presentation
(SBP >180 mmHg or DBP >110 mmHg)
-Dementia
-Major surgery within 3 weeks

Continue UFH anticoagulation for several hours after the end of thrombolysis
before switching to oral anticoagulation.
PROCEDURAL SEDATION:

INDICATION:
- Joint
Reference: British reduction
Medical Journal, British Thoracic Society, NICE Guidelines, American College of Cardiology
RCEM Learning,
- Fracture European Society of Cardiology
manipulation
- Electrical cardioversion
- Suturing
- Incision and drainage
- Painless diagnostic studies (eg. CT scan)
 - Paraphimosis reduction
- Burn debridement
- Paediatric foreign body removal

CONTRAINDICATION:
- ASA >2
- Appropriate medical personal/ equipment not available
- High risk of aspiration. Eg: Alcohol intoxication
- Head injury with LOC, decreased conscious level

PRE-SEDATION ASSESSMENT:
AMERICAN SOCIETY OF ANAESTHESIOLOGISTS CLASSIFICATION:
ASA I Healthy patient without systemic disease
ASA II Patient with mild systemic disease
ASA III Patient with severe systemic disease
ASA IV Patient with severe systemic disease posing a threat to life
ASA V Moribund patient who cannot survive without surgery

HISTORY:
- History of events and current condition
- Past medical & surgical history
- Previous anaesthetic/ sedation history/ complications
- Current medications & Allergies
- Fasting status – 2 hours for clear fluids & 6 hours for solid food
AIRWAY ASSESSMENT  LEMON Airway assessment method

EQUIPMENT:
- High flow oxygen source & Suction
- Airway management equipment
- Vitals Monitoring equipment, ECG & defibrillator
- Reversal agents
- Resuscitation drugs
- Adequate staff
INFORMED CONSENT
MEDICATIONS:
DRUG ROUTE DOSE ONSET DURATION ADVERSE CAUTION
EFFECTS
MIDAZOLAM IV 0.05 30-60s 30mins Respiratory No analgesic
Anxiolysis, to 0.1 depression, properties,
Sedation, mg/kg Hypotension Elderly people,
Amnesia concurrent
opioid use
PROPOFOL IV 1-2 <1 min 10 mins Loss of airway No analgesic
Sedation mg/kg reflexes, properties, No
Amnesia Respiratory antagonist,
depression Elderly people,
Concurrent
opioid use,
Cardiovascular
disease.
KETAMINE IV 1-2 1-2 15-30 mins Laryngospasm, Active
Dissociative mg/kg mins Increased salivary respiratory tract
anaesthetic, & respiratory infections,
anxiolysis, secretions, Raised Glaucoma,
amnesia, HR/ BP/ ICP Hyperthyroidism
analgesia, airway
reflexes
maintained
NITROUS Inhaled Titrate 30 sec 1 min Vomiting, Pneumothorax,
OXIDE to Hypoxia Bowel
Sedative, effect obstruction,
Analgesic Middle ear or
sinus disease,
head injuries
DISCHARGE – STEWARD RECOVERY SCORE:
 DISCHARGE INSTRUCTIONS:
- Not to drive/ operate heavy machinery for 12 hours.
- To eat light diet for the next 12 hours.
- To avoid alcohol. To take only prescribed medications as needed.
- To not make any important decisions or sign important documents for next
12 hours.
- To report to ED if breathing difficulty or persistent vomiting.
- To have a person to look after the patient for the next 12 hours.
ADVANCED TRAUMA LIFE SUPPORT:
c - Catastrophic haemorrhage control
A – Airway
Reference: protection
Clinical Procedures & Cervical Spine
– Roberts Protection
and Hedges – 7th edition
B – Breathing & Ventilation
Tintinalli’s Emergency Medicine 7th edition
C – Circulation
Rosen’s 10with
th
haemorrhage control
edition
D – Neurologic status
E – Completely undress but prevent hypothermia
PRIMARY SURVEY
 AIRWAY
ASSESSMENT

Talk to the patient

Patient converses Patient cannot

normally converse

Airway patent
Airway compromised

LOOK- increased work of breathing

LISTEN- Snoring, Gurgling, Noisy breathing
FEEL

Airway Adjuncts
NPA/ OPA
Oxygen

Cervical Spine Protection: C-COLLAR. Triple Immobilization:

Definitive Airway: Continued Initial Measures:
Intubate & ventilate Respiratory Clear airway
Distress Jaw Thrust/ Chin lift
 BREATHING
ASSESSMENT

Inspection
Palpation
Percussion
Auscultation

Pneumothorax Flail Chest/ Haemothorax

Pulmonary contusion

1.Needle Thoracostomy Chest Drain

(Tension Pneumothorax)

2.Three sided occlusive

dressing (Open
Pneumothorax)

3.Chest Drain

CIRCULATION
Normovolaemic Hypovolaemic

-Establish 2 large IV cannula

-Control External haemorrhage
-Continuous monitoring
-Blood transfusion
-Fluid Resuscitation
-Place NG/Foley’s

AVPU SCORING / GLASGOW COMA SCALE

Temperature
Blood Glucose Monitoring

EXPOSURE
GCS < or equal to 8  Definitive Airway
Undress completely
Quick head to toe examination

Procced to Secondary Survey begins

SECONDARY SURVEY only when;
-Primary Survey in completed
-Patient is demonstrating
normalization of vital signs
after resuscitation.
-Complete neurological
examination
 Log Roll & Examine Back
Check peripheral pulses

INVESTIGATIONS:
- CBC, U&E, LFT, COAGULATION PROFILE, BLOOD GROUPING &
TYPING, SEROLOGY
- eFAST
- CXR
- CERIVAL IMAGING (Based on Canadian C-Spine)
- PELVIS X-RAY
- Any suspected long bone fracture X-Ray
- BRAIN IMAGING (if indicated)
MANAGEMENT:
- A Oxygen  Airway Adjuncts  Definitive Airway
- B Manage chest trauma accordingly
- C In Hypotension  IV Fluid Resuscitation (RL is preferred) +/- Blood
Transfusion
- D In Seizure  Antiepileptics
In Hypothermia  Warm IV Fluids, Warm blankets
- E NG Tube/ Foley’s catheter – Monitor output
Analgesia +/- Antiemetics
Antibiotics
TT +/- TT Immunoglobulin

SPEAK TO FAMILY
MLC
REFER TO SPECIALIST

Reference: Advanced Trauma Life Support 10th edition