Decision algorithm for management of oral anticoagulation (OAC) therapy for patients who present to the emergency department (ED) with recent-onset atrial fibrillation (AF) requiring rate control or cardioversion (CV) in the ED.Immediate OAC= a dose of OAC should be given just before cardioversion; either a novel direct oral anticoagulant (NOAC) or a dose of heparin or low molecular weight heparin with bridging to warfarin if a NOAC is contraindicated. ASA, acetylsalicylic acid; CAD, coronary artery disease; CHADS2,Congestive Heart Failure,Hypertension,Age,Diabetes,Stroke/Transient Ischemic Attack; TIA, transient ischemic attack.

Risk factorScoreScoreAdjusted stroke rate (%/yr)

Congestive HF/LV dysfunction (LVEF 75222.2

Diabetes mellitus133.2

Stroke / TIA / thromboembolism244.0

Vascular disease (prior MI, peripheral artery dx, aortic plaque)156.7

Age 65-74169.8

Sex Category (ie. female)179.6

86.7

915.2

NB: major risk factors = Age >75 Stroke / TIA / thromboembolismClinically relevant non-major risk factors:

Family medicine FM41 low back painDifferential Diagnosis of Acute Low Back PainDIAGNOSISKEY CLINICAL CLUES

Intrinsic spine

Compression fractureHistory of trauma (unless osteoporotic), point tenderness at spine level, pain worsens with flexion, and while pulling up from a supine to sitting position and from a sitting to standing position

Herniated nucleus pulposusLeg pain > back pain and worsens when sitting; pain from L1-L3 nerve roots radiates to hip and/or anterior thigh, pain from L4-S1 nerve roots radiates to below the knee

Lumbar strain/sprainDiffuse back pain with or without buttock pain, pain worsens with movement and improves with rest

Spinal stenosisLeg pain > back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)

SpondylolisthesisLeg pain > back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral or bilateral

SpondylolysisCan cause back pain in adolescents, although it is unclear whether it causes back pain in adults; pain worsens with spine extension and activity

Spondylosis (degenerative disk or facet joint arthropathy)Similar to lumbar strain; disk pain often worsens with flexion activity or sitting, facet pain often worsens with extension activity, standing, or walking

Systemic

Connective tissue diseaseMultiple joint arthralgias, fever, weight loss, fatigue, spinous process tenderness, other joint tenderness

Inflammatory spondyloarthropathyIntermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis to lumbar flexion

MalignancyPain worsens in prone position, spinous process tenderness, recent weight loss, fatigue

Vertebral diskitis/ osteomyelitisConstant pain, spinous process tenderness, often no fever, normal complete blood count, elevated erythrocyte sedimentation rate and/ or C-reactive protein level

Referred

Abdominal aortic aneurysmAbdominal discomfort, pulsatile abdominal mass

Gastrointestinal conditions: pancreatitis, peptic ulcer disease, cholecystitisAbdominal discomfort, nausea\vomiting, symptoms often associated with eating

Herpes zosterUnilateral dermatomal pain, often allodynia, vesicular rash

Pelvic conditions: endometriosis, pelvic inflammatory disease, prostatitisDiscomfort in lower abdomen, pelvis, or hip

Retroperitoneal conditions: renal colic, pyelonephritisCostovertebral angle pain, abnormal urinalysis results, possible fever

Red Flags for Serious Etiologies of Acute Low Back PainPOSSIBLE ETIOLOGYHISTORY FINDINGSPHYSICAL EXAMINATION FINDINGS

CancerStrong: Cancer metastatic to bone Intermediate: Unexplained weight lossWeak: Vertebral tenderness, limited spine range of motion

Weak: Cancer, pain increased or unrelieved by rest

Cauda equina syndromeStrong: Bladder or bowel incontinence, urinary retention, progressive motor or sensory lossStrong: Major motor weakness or sensory deficit, loss of anal sphincter tone, saddle anesthesia

Weak: Limited spine range of motion

FractureStrong: Significant trauma related to age*Weak: Vertebral tenderness, limited spine range of motion

Intermediate: Prolonged use of steroids

Weak: Age older than 70 years, history of osteoporosis

InfectionStrong: Severe pain and lumbar spine surgery within the past yearStrong: Fever, urinary tract infection, wound in spine region

Intermediate: Intravenous drug use, immunosuppression, severe pain and distant lumbar spine surgeryWeak: Vertebral tenderness, limited spine range of motion

Weak: Pain increased or unrelieved by rest

note:Presence of one or two weak or intermediate red flags may warrant observation because few patients will be significantly harmed if diagnosis of a serious cause is delayed for four to six weeks. Presence of any strong red flag warrants more urgent workup and probable referral to a spine subspecialist.*Fall from a height or motor vehicle crash in a young patient, minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis.Information from references5,6, and8.

NB: they may co-exist

Nature of the pain aching throbbing pain = inflammation, e.g. sacroiliitis deep aching diffuse pain = referred pain, e.g. dysmenorrhoea superficial steady diffuse pain = local pain, e.g. muscular strain boring deep pain = bone disease, e.g. neoplasia, Paget's disease intense sharp or stabbing (superimposed on a dull ache) = radicular pain, e.g. sciatica

Summary of diagnostic guidelines for spinal pain Continuous pain (day and night) = neoplasia, especially malignancy or infection. The big primary malignancy is multiple myeloma. The big 3 metastases are from lung, breast and prostate. The other 3 metastases are from thyroid, kidney/adrenal and melanoma. Pain with standing/walking (relief with sitting) = spondylolisthesis. Pain (and stiffness) at rest, relief with activity = inflammation. In a young person with inflammation think of ankylosing spondylitis or Reiter's disease. Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis. Pain provoked by activity, relief with rest = mechanical dysfunction. Pain in bed at early morning = inflammation, depression or malignancy/infection. Pain in periphery of limb = discogenic radicular or vascular claudication or spinal canal stenosis claudication. Pain in calf (ascending) with walking = vascular claudication. Pain in buttock (descending) with walking = neurogenic claudication. (radiculopathy) One disc lesion = one nerve root (exception is L5-S1 disc). One nerve root = one disc (usually). Two or more nerve rootsconsider neoplasm. The rule of thumb for the lumbar nerve root lesions is L3 from L2-L3 disc, L4 from L3-L4, L5 from L4-L5 and S1 from L5-S1. A large disc protrusion can cause bladder symptoms, either incontinence or retention. Back pain that is related to posture, aggravated by movement and sitting, and relieved by lying down is due to vertebral dysfunction, especially a disc disruption. NB: plain X-rays may be normal in disc prolapse, esp in younger patients A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.

Practice tips Back pain that is related to posture, aggravated by movement and sitting, and relieved by lying down is due to vertebral dysfunction, especially a disc disruption. The pain from most disc lesions is generally relieved by rest. Plain X-rays are of limited use, especially in younger patients, and may appear normal in disc prolapse. Remember the possibility of depression as a cause of back pain; if suspected, consider a trial of antidepressants. If back pain persists, possibly worse during bed rest at night, consider malignant disease, depressive illness or other systemic diseases. Pain that is worse on standing and walking, but relieved by sitting, is probably caused by spondylolisthesis. If pain and stiffness is present on waking and lasts longer than 30 minutes upon activity, consider inflammation. Avoid using strong analgesics (especially opioids) in any chronic non-malignant pain state. Bilateral back pain is more typical of systemic diseases, while unilateral pain typifies mechanical causes. Back pain at rest and morning stiffness in a young person demand careful investigation: consider inflammation such as ankylosing spondylitis and Reiter's disease. A disc lesion of L5-S1 can involve both L5 and S1 roots. However, combined L5 and S1 root lesions should still be regarded with suspicion, e.g. consider malignancy. A large central disc protrusion can cause bladder symptoms, either incontinence or retention. Low back pain of very sudden onset with localised spasm and protective lateral deviation may indicate a facet joint syndrome. Disc herniation: The T12-L1 and L1-L2 discs are the groin pain discs. The L4-L5 disc is the back pain disc. (most common discs in disc herniation) The L5-S1 disc is the leg pain disc. Severe limitation of SLR straight leg raise (especially to < 30) indicates lumbar disc prolapse. A preventive program for dysfunctional back pain based on back care awareness and exercises is mandatory advice. Remember that most back problems resolve within a few weeks, so avoid overtreatment.

Signs of nerve root involvement at different spinal levels (Table 12.14)LevelReduced muscle powerReduced sensationReduced or absent reflexOther

L3 or L4quadricepsanterior and lateral aspects of thighknee jerk

L5dorsiflexion of big toe and ankleparticularly dorsum of foot

S1plantar flexion of ankleparticularly lateral aspect of footankle jerk

cauda equinaprogressive foot or leg weakness, often bilateral'saddle' areadecreased anal sphincter tone; distended bladder