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

40 minutes
60 minutes
90 minutes
120 minutes
180 minutes
Consider Stroke Protocol:
  • Severe or atypical HA
  • Altered mental status
  • Focal neurologic findings
  • New seizure
Consult Hematology, Neurology
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
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
  • 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
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