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

40 mins
60 mins
90 mins
120 mins
150 mins
180 mins
Consider Stroke Protocol
  • Severe or atypical headache
  • Altered mental status
  • Focal neurologic findings
  • New seizure
Consult Hematology, Neurology
Contact T7 Attending/APP for Medication Orders
  • Offer IN fentanyl immediately
  • Order pain medications
  • IV access if moderate/severe pain
    • CBC, differential
    • Reticulocyte count
  • History and Physical Exam
  • Child Life, Acupuncture Consult
  • Consider ThermaCare Wrap
  • Admit to central monitoring system
Initial Bundle
Morphine 0.1 mg/kg or
hydromorphone 0.01 mg/kg + IV ketorolac

Consider IN fentanyl
Ibuprofen + morphine IR or oxycodone

Reassess pain 20-30 min
Reassess 60 mins
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 50% initial dose if no significant improvement
Reassessing Pain
  • Reported pain remains the gold standard for pain assessment
  • Wake the child to reassess pain
  • Pain Scales Job Aid
Determine disposition, Hematology Consult
Persistent, significant pain
Child comfortable
Persistent pain
PO Opioid
Oxycodone or morphine IR
IV Opioid #4
  • Repeat morphine 0.1 mg/kg or hydromorphone 0.01 mg/kg
  • Start q2 hr scheduled opioid
  • Schedule ketorolac q6 hrs
  • Hourly pain assessment
  • Continue non-pharmacologic interventions
Reassess 1 hr
Child comfortable
Discharge criteria
  • Children with pain relief:
    • After 1-3 doses of
      IV analgesia
    • Continues at least 60 mins after PO analgesia
  • Absence of other complications of sickle cell disease
  • Morphine IR or oxycodone 3 day supply
  • Ibuprofen/acetaminophen for 5-7 days
  • Advise child/family timing of the next dose
  • Continue non-pharmacologic interventions
Posted: July 2010
Revised: August 2023
Editors: Clinical Pathways Team