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
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