ED Pathway for Evaluation/Treatment of Children
with Sickle Cell Disease and Pain
Goals and Metrics
40 minutes
60 minutes
90 minutes
120 minutes
150 minutes
Pain Medication Dosing
Management Algorithm
for Mild Pain
Emergency Department Technician
Sickle Cell Disease Patient with Pain
  • Severe or atypical HA
  • Altered mental status
  • Focal neurologic findings
  • New seizure
Triage
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