ED Pathway for Evaluation/Treatment of Children
with Sickle Cell Disease and Pain
40 minutes
60 minutes
90 minutes
120 minutes
150 minutes
  • Severe or atypical HA
  • Altered mental status
  • Focal neurologic findings
  • New seizure
MD/CRNP/RN Team Assessment
  • Order pain medications or
  • Push provider button if no FLOC
  • Offer, discuss IN Fentanyl
  • Call Child Life
  • IV access
    • CBC with differential
    • Reticulocyte count
    • History and Physical
    • Other diagnostic tests
    • Consider Thermacare Wrap
Management Algorithm for Moderate/Severe Pain
Initial Bundle
(IV Morphine OR Hydromorphone) + IV Ketorolac
  • Ketorolac may be given within 1 hour of last PO NSAID dose as escalation of therapy if no hx of renal insufficiency
  • If patient has significant dehydration/volume depletion, speak with Attending about NS bolus prior to administration
  • It can be given w/o HCG results unless the patient is in the 3rd trimester of pregnancy, Class D
  • Reassess pain 20-30 min
IV Opioid #2
Give 50% initial dose if no significant improvement
  • Reassess pain 20-30 min
IV Opioid #3
Give 25% initial dose
Reassess 20-30 minutes and DETERMINE DISPOSITION
Persistent Significant Pain
Patient Comfortable
IV Opioid #4
  • Give 25% Initial Dose
  • Enter MRFT order
  • Hematology consult
  • Persistent Pain
PO Opioid
Oxycodone
  • Reassess 1 hour
  • Continue hourly reassessment
  • Pain medication q 2-4 hrs as needed
Patient Remains Comfortable
  • Discharge Criteria
  • Patients with pain relief:
    • After 1 – 3 doses of IV analgesia
    • Continues at least 60 minutes after PO analgesia
  • Absence of other complications of sickle cell disease
HACU Admission Criteria Inpatient Admission Criteria
  • ≥ 3 months of age
    • Non-toxic
    • Uncomplicated VOC
    • Requires multiple IV opioids
  • < 3 months of age
    • Focal neurologic findings
    • Acute chest syndrome
    • Splenic sequestration
    • Reticulocyte count < 1 % (unless Hgb > 10 g/dL)
    • Severe anemia (Hgb < 5 g/dL)
Posted: July, 2010
Revised: October 2011, October 2014, October 2015, May 2017
Authors: A. Ellison, MD, Lisa Payne, RN, C. Norris, MD, K. Smith-Whitley, MD, C. Jacobstein, MD, J. Lavelle, MD