Sickle Cell Disease with Pain Clinical Pathway — Emergency Department

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

Goals and Metrics
Provider Resources
40 mins
 
 
60 mins
 
 
90 mins
 
 
120 mins
 
 
150 mins
 
 
180 mins
Child with Sickle Cell Disease and Pain
Consider Stroke Protocol
  • Severe or atypical headache
  • Altered mental status
  • Focal neurologic findings
  • New seizure
Consult Hematology, Neurology
 
 
ED Triage
 
 
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
 
 
Management of Moderate/Severe Pain
Management of Mild Pain
Initial Bundle
IV ketorolac and
Morphine 0.1 mg/kg or hydromorphone 0.01 mg/kg
  • Consider IN fentanyl
  • Ibuprofen and
  • 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
 
 
 
 
 
 
 
Persistent pain
Consider IV
pain medications
Child comfortable
 
 
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
 
 
 
 
Admit
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
 
 
Discharge
  • 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: November 2024
Editors: Clinical Pathways Team