AdultPediatric
Cannot miss / life threats
Cannot miss / life threats
Differential diagnosis — checklist
0/17
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
MSK / mechanical0/4
Cannot-miss neuro0/5
Infectious0/3
Vascular0/2
Visceral0/3
Initial ED workup
Bedside0/5
- Vitals (fever, hypotension, tachycardia)
- Bedside aortic US in any patient >50 with new back pain
- Focused neuro exam: motor, sensory, reflexes, gait
- Saddle sensation, rectal tone, post-void bladder US (PVR)
- Palpate midline for focal tenderness; inspect for vesicles, surgical scars, IVDU stigmata
Labs0/6
- CBC, BMP
- ESR + CRP if infection / abscess / malignancy concern (ESR >50 high-risk)
- Blood cultures × 2 if febrile or epidural abscess suspected
- UA + culture (pyelo, stone)
- Coagulation panel + type & screen if AAA, dissection, or anticoagulated with deficit
- Lipase if visceral cause considered
Imaging0/5
- Bedside aortic US — first move in patient >50
- MRI whole spine (with & without contrast) — emergent for cauda equina, epidural abscess, cord compression, hematoma
- CT spine (without contrast) if MRI unavailable/contraindicated, or for fracture / instability
- CT angiography for AAA / dissection
- Lumbar XR for compression fracture or spondylolisthesis (limited utility otherwise)
Initial management0/5
- Multimodal analgesia: acetaminophen 1 g + NSAID (ketorolac 15 mg IV / ibuprofen 600 mg PO); opioid sparingly for severe pain
- Short course muscle relaxant (cyclobenzaprine 5 mg TID) — caution in elderly
- Heat, early mobilization; avoid bed rest
- Treat the cause: antibiotics for infection, dexamethasone for cord compression, reverse anticoagulation for hematoma, BP/HR control for dissection
- PT referral and primary care follow-up; return precautions for new neuro deficit, fever, retention, or saddle anesthesia
ED next steps
ED next steps
- Vitals + screen for sepsis, AAA, neuro deficit, retention.
- If any red flag → labs (CBC, ESR/CRP, BMP, coags, blood cx), bedside aortic US, MRI/CT as indicated.
- Cauda equina, cord compression, epidural abscess/hematoma → emergent MRI (with & without contrast) + neurosurgery consult; dexamethasone 10 mg IV for malignancy.
- Suspected AAA / dissection → 2 large-bore IVs, type & cross, BP/HR control, immediate vascular/CT surgery consult.
- No red flags → multimodal analgesia (acetaminophen + NSAID), reassurance, early mobilization, PT referral, PCP follow-up in 1–2 weeks.
- Return precautions: fever, new weakness, urinary retention, saddle anesthesia, worsening pain.
Pearls / pitfalls
Pearls
- RED FLAGS — image and admit: age <18 or >50 (new), trauma, fever, IVDU, immunocompromise, weight loss, cancer hx, anticoagulation, progressive neuro deficit, saddle anesthesia, bowel/bladder dysfunction, pain at rest or worse at night, recent spine procedure.
- Always check post-void residual + rectal tone in any back pain with neuro symptoms — cauda equina is a clock.
- ESR/CRP is a powerful screen for spinal infection; normal values make abscess very unlikely.
- First-time 'back pain' in patient >50 → bedside aortic US before sending to PT.
- Give dexamethasone IMMEDIATELY for suspected malignant cord compression — do not wait for MRI (with & without contrast).
- Imaging is NOT indicated for acute non-specific low back pain without red flags — leads to unnecessary procedures.