Minor injuries: Clinical guidance and practice resources

Nonpharmacologic treatment, including superficial heat, massage, acupuncture or spinal manipulation, should be used initially for most patients with acute or subacute low back pain, as they will improve over time regardless of treatment.

When pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants should be used.

Nonpharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy or spinal manipulation, should be used initially for most patients who have chronic low back pain.

For patients who have chronic low back pain and do not respond to nonpharmacologic therapy, NSAIDs should be used. Tramadol or duloxetine should be considered for those patients who do not respond to or do not tolerate NSAIDs. Opioids should only be considered if other treatments are unsuccessful and when the potential benefits outweigh the risks for an individual patient.

Topical NSAIDs, with or without menthol gel, should be used as first line therapy for adults with acute pain from non-low back, musculoskeletal injuries.

Oral NSAIDs and acetaminophen may be considered as options for pharmacologic treatment for adults with acute pain from non-low back, musculoskeletal injuries. Non-pharmacologic options for patients include specific acupressure or transcutaneous electrical nerve stimulation (TENS).

Opioids, including tramadol, should not be used as first line treatments for adults with acute pain from non-low back musculoskeletal injuries. Severity of the injury, patient intolerance of other treatments and potential harms should be considered before initiating treatment with opioids.

Pharmacologic treatment with alendronate, risedronate, zoledronic acid or denosumab should be prescribed for women with osteoporosis to reduce the risk of hip and vertebral fractures.

Pharmacologic treatment should continue for five years, during which time bone density monitoring should not be done.

Menopausal estrogen therapy, menopausal estrogen plus progesterone or raloxifene should not be used in women with osteoporosis.

The decision to treat women 65 years or older who have osteopenia and are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, benefits and harms of treatment and costs of medications.

Treatment with bisphosphonates should be offered to men who have osteoporosis to reduce the risk of vertebral fractures.

Individuals with a nosebleed who require prompt management should receive treatment for active bleeding with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for five minutes or longer.

Individuals in whom bleeding precludes identification of a bleeding site despite nasal compression should receive treatment for active bleeding with nasal packing.

Individuals with a suspected bleeding disorder or for individuals who are using anticoagulation or antiplatelet medications should receive resorbable packing to manage the nosebleed. Education should be provided about the type of packing placed, timing of, and plan for, removal of packing (if not resorbable), post-procedure care and any signs or symptoms that would warrant prompt reassessment.

Anterior rhinoscopy should be performed to identify a source of bleeding after removal of any blood clot (if present) for individuals with nosebleeds.

Nasal endoscopy should be performed to identify the site of bleeding and guide further management for individuals with recurrent nasal bleeding, despite prior treatment with packing, cautery or with recurrent unilateral nasal bleeding.

Individuals with an identified site of bleeding should be treated with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery and moisturizing or lubricating agents.

Individuals with persistent or recurrent bleeding not controlled by packing or nasal cauterization should be evaluated for candidacy for surgical arterial ligation or endovascular embolization.

In the absence of life-threatening bleeding, first-line treatments should be used prior to transfusion, reversal of anticoagulation or withdrawal of anticoagulation/antiplatelet medications for patients using these medications.

Individuals with a history of recurrent bilateral nosebleeds or family history of nosebleeds should be assessed for presence of nasal telangiectasias and/or oral mucosal telangiectasias to diagnose hereditary hemorrhagic telangiectasia syndrome.

Individuals with nosebleeds and their caregivers should receive education about preventive measures for nosebleeds, home treatment for nosebleeds and indications to seek additional medical care.

Dysphonia (hoarseness) should be diagnosed in a patient with altered voice quality, pitch, loudness or vocal effort that impairs communication or reduces voice-related quality of life (QOL).

Patients with hoarseness should be assessed by history and/or physical examination for underlying cause and factors that may modify management. Factors that may indicate the need for expedited laryngeal evaluation include: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, presence of concomitant neck mass, respiratory distress or stridor, radiation treatment to the neck, a history of tobacco abuse and occupation as a singer or vocal performer.

The patient’s larynx should be visualized when dysphonia fails to resolve or improve within four weeks or if a serious underlying cause is suspected.

Computed tomography or magnetic resonance imaging should not be obtained in patients with a primary complaint of dysphonia prior to visualizing the larynx.

Anti-reflux medications or corticosteroids should not be prescribed for patients with isolated dysphonia without prior visualization of the larynx.

Antibiotics should not be routinely prescribed to treat dysphonia.

Following diagnostic laryngoscopy:

For patients seeking outpatient care following an incident that involved a plausible mechanism of TBI, qualified health care professionals should attempt to confirm or rule-out a diagnosis of traumatic brain injury based on the 2023 American Congress of Rehabilitation Medicine criteria (ACRM).

Patients should be (re)directed to an ED for urgent evaluation if they have any of the following: Declining or fluctuating level of consciousness; New onset of: pupil asymmetry, focal neurologic abnormality, seizures, repeated vomiting, or marked change in behavior; Severe or worsening headache; Racoon (panda) eyes, Battle’s sign, rhinorrhea/otorrhea, or other signs of undiagnosed skull fracture.

Health care professionals should not order a brain MRI or CT for every patient but may consider ordering a brain MRI or CT for those with atypical clinical features or symptom course.

Health professionals should screen all patients with TBI for social determinants of health (SDoH), including but not limited to food, housing, and transportation insecurity, transportation needs, financial difficulties, employment-related concerns, migration status, and interpersonal safety.

Health care professionals should:

Health care professionals may provide written and oral information to the patient (and their accompanying family/caregiver) at the initial visit, and ongoing education at subsequent visits.

Health care professionals may screen the following domains for factors that increase the risk of persisting symptoms:

Health care professionals should prioritize symptoms that:

Health care professionals should characterize the headache history and presentation(s) to determine if the patient has posttraumatic headache with features similar to migraine, tension-type, cervicogenic, and/or other headache types.

Qualified health care professionals should screen for new onset mental health conditions and worsening of pre-existing mental health conditions after TBI.

Referral to specialty care should be considered for patients who are at high risk for persisting symptoms, continue to have disabling symptoms beyond 30 days post-injury, and/or are not responding to first-line interventions in primary care.