Emergency Department Clinical Pathway for the Evaluation/Treatment
of Children with Sickle Cell Disease and Pain
- Related Pathways
- Sickle Cell Disease with Fever
- Stroke, Suspected
- Vascular Access, ED
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
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
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 IVpain 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
- After 1-3 doses of
- 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
Evidence
- RN Learning Module
- American Society of Hematology 2020 Guidelines for Sickle Cell Disease: Management of Acute and Chronic Pain
CHOP Programs
Educational Media