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Pain Crisis

Pediatric Emergency Department Management of Moderate to Severe Pain in Children with Sickle Cell Disease

  1. History:
    1. Nature, location, duration, and severity of pain
    2. Character of pain similar to previous sickle pain
    3. Analgesics already used for this episode
    4. Associated symptoms- especially fever or evidence of dehydration
    5. Consider etiologies other than sickling
    6. Previous experience with analgesics (efficacy and side effects). What does patient / family feel best alleviates pain?
  2. Physical Examination: (complete with emphasis on)
    1. Vital signs
    2. Hydration status
    3. Degree of pallor
    4. Evidence of infection
    5. Cardiopulmonary status
    6. Spleen size (compare with baseline exam)
    7. Penis (priapism)
    8. Neurological
  3. Laboratory Evaluation:
    1. CBC, diff, platelets, and reticulocyte count (compare with patient's baseline values)
    2. Blood culture if febrile (T > 38.5°C)
    3. Type and cross match if extreme pallor, respiratory or neurological symptoms, or acute splenic enlargement present.
    4. CXR and pulse ox if:
      1. Chest pain
      2. Cough
      3. Tachypnea
      4. Respiratory symptoms
    5. Consider abdominal ultrasound and liver function tests for RUQ, epigastric pain (R/O cholelithiasis/cholecystitis)
  4. Treatment:
    1. Intravenous Fluids
      1. D5 ½ NS at 1.5 times maintenance
      2. If acute chest syndrome, D5 ½ NS at ¾ maintenance
    2. Medications
      1. NSAIDs:
        1. Ketorolac (Toradol) 0.5 mg/kg (30 mg maximum dose) IV OR
        2. Ibuprofen 10 mg / kg PO (800 mg maximum dose)
      2. Antipruritic
        1. Diphenhydramine 1 mg/kg with max dose of 50 mg PO prn itching
      3. Opioids:
        1. < 50 kg
          1. Morphine 0.1-0.15mg/kg IV OR
          2. Hydromorphone (Dilaudid) 0.015-0.02 mg/kg IV.
        2. > 50 kg
          1. Morphine 5-10 mg IV OR
          2. Hydromorphone (Dilaudid) 1.5 mg IV.
    3. Titrate Opioid for 2 hours
      1. Titrate with ¼ to ½ of the initial opioid dose q 30 minutes until patient experiences relief or is sedated (Opioid sedation scale >=3, see below)
      2. Reassess pain and degree of relief q 15-30 min. Adequate pain control is defined as a 50-60% reduction in the pain score (see Wong-Baker Faces Pain Rating Scale below).
  5. Disposition:
    1. Treat patient as outlined above for 2 hours.
      1. If pain is controlled, give dose of the patient's prescribed oral opioid analgesic(s).
        1. If pain relief is maintained for1 hour following oral analgesic, discharge home with appropriate prescriptions and follow-up per Hematologist on-call
      2. If pain is not controlled, start scheduled opioid, notify Hematologist on-call and admit to hospital
        1. Schedule Opioid q 1-2 hours.
          1. Calculate scheduled dose as in Section 4.b.iii above
          2. Give "rescue doses" at ¼ to ½ scheduled dose at 30 minute intervals between scheduled doses.
          3. Adjust scheduled dose as needed to achieve pain control

        2. Start PCA pump (consult Hematologist on call).
    2. Sickle Cell Pain Threshold Chart
      Sickle Cell Pain Threshold Chart
       Opioid Sedation Scale
      S =Sleep, easy to arouse
      1 =Awake and alert
      2 =Slightly drowsy, easily aroused
      3 =Frequently drowsy, arousable, drifts off to sleep during conversation
      4 =Somnolent, minimal or no response to physical stimulation
      McCaffery M, Pasero C: Pain: Clinical manual, p. 267. © 1999, Mosby, Inc.

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