Emergency Department Clinical Pathway for the Evaluation/Treatment
of Children with Sickle Cell Disease and Pain

Goals and Metrics
40 minutes
60 minutes
90 minutes
120 minutes
180 minutes
Sickle Cell Disease Patient with Pain
Consider Stroke Protocol:
  • Severe or atypical HA
  • Altered mental status
  • Focal neurologic findings
  • New seizure
Consult Hematology, Neurology
Triage
MD/CRNP/RN Team Assessment
  • Order pain medications or
  • Push provider button if no Frontline Ordering Clinician
  • Offer, discuss IN fentanyl
  • Call Child Life
  • IV access if moderate/severe pain
  • CBC, differential, reticulocyte count
  • History and Physical
  • Other diagnostic tests
  • Consider ThermaCare® Wrap
Management of Moderate/Severe Pain
Management of Mild Pain
Initial Bundle
(IV Morphine OR Hydromorphone) + IV Ketorolac
Ibuprofen + Morphine IR or Oxycodone
Reassess pain 20-30 min
Reassess 60 minutes
Reassess pain 20-30 min
IV Opioid #2
Give 50% initial dose if no significant improvement
Persistent
Pain
Patient
Comfortable
Follow Moderate/Severe Pain
IV Opioid #3
Give 25% initial dose if no significant improvement
Reassess 60 minutes and DETERMINE DISPOSITION
Hematology Consult
Persistent Significant Pain
Patient Comfortable
Admit
Persistent Pain
PO Opioid
Oxycodone or Morphine IR
IV Opioid #4
  • Morphine 0.1 mg/kg
  • Hydromorphone 0.01 mg/kg
  • Start q 2-3 hr scheduled opioid
  • Ketorolac q 6 hrs
  • Continue hourly reassessment
Reassess 1 hour
Patient Comfortable
Discharge Criteria
Discharge
  • 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
  • Morphine IR or Oxycodone
    • 3-day supply
  • Advise patient/family time next doses due
Pain Medication Dosing
  • Ketorolac may be given 1 hour after last PO NSAID dose as escalation of therapy if no history 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.
Posted: July, 2010
Revised: October 2011, October 2014, October 2015, May 2017, January 2020, March 2020, November 2020
Authors: J. Umana MD; A. Ellison, MD; J. Fuchs RN; M. Wengler CRNP; H. Huang Pharm D; C. Norris, MD; K. Smith-Whitley, MD; C. Jacobstein, MD; J. Lavelle, MD