Sickle cell crisis: Difference between revisions
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==Background==
==Background==
===Precipitating Factors ===
[[File:Sickle cell 01.jpg|thumb|(A) normal red blood cells flowing freely through a blood vessel. (B) abnormal, sickled red blood cells sticking at the branching point in a blood vessel. Cross-section shows long polymerized sickle haemoglobin (HbS) strands stretching and distorting the cell.]]
#For vaso-occlusion:
##Stress
##Cold weather
##Dehydration
##Hypoxia
##Infection
##Acidosis
##Alcohol intoxication
##Pregnancy
##Exertional stress
#For aplastic crisis:
##Parvovirus B19 infection
##Folic acid deficiency
#For acute chest syndrome:
##Fat embolus
##Infection
##Pain crisis
##Asthma


== Work-Up ==
===Precipitating Factors===
#CBC
*For [[vaso-occlusive crisis]]:
##Assess for significant anemia
**Stress
#Chemistry / LFT / lipase
**Cold weather
##If abd pain, may be cholecystitis, mesenteric ischemia, or perforation
**[[Dehydration]]
#Retic count (if aplastic crisis considered - rare in adults)
**[[Hypoxia]]
##Should be >0.5%
**[[Infection]]
#CXR
**[[Acidosis]]
##If cough, SOB, or febrile
**[[Alcohol intoxication]]
#O2
**[[Pregnancy]]
##If hypoxic; otherwise may inhibit erythopoesis
**Exertional stress
#ECG
*For [[aplastic crisis]]:
#T&S/T&C
**[[Parvovirus B19]] infection
#BCx2
**[[Folate deficiency]]
#VBG
#UA
#Urine pregnancy
#Head CT/MRI
##If symptoms of stroke


==Clinical Manifestations==
==Clinical Features==
=== Vaso-Occlusive Crisis ===
===Vaso-Occlusive Crisis<ref>Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47</ref>===
#Pain
''See [[Vaso-occlusive pain crisis]]
##Most common manifestation of SCA (79-91% of ED visits)
##Lower back, long bones most commonly affected
##Because anemia can precipitate a crisis, must check for acute Hb drop
#Bony infarction
##More debilitating and refractory pain than past episodes
##Localized bone tenderness, elevated WBC
###Fat embolism can be complication
#Dactylitis
##Tender, swollen hands/feet
##May have low-grade fever
##Occurs in <2yr old, extremely rare >5yr old
#Avascular necrosis of femoral head
##Occurs in 30% of patients by age 30yr
##Pts p/w afebrile, inguinal pain with weight-bearing


=== Respiratory Distress and Chest Pain ===
===[[Avascular necrosis|Bony infarction]]===
#[[Acute Chest Syndrome]]
*More debilitating and refractory pain than past episodes
#PNA
*Localized bone tenderness, [[leukocytosis|elevated WBC]]
##Caused by chlamydia, mycoplasma, viral, strep pneumo, staph, H. Flu
**[[Fat embolism]] can be complication
##Only need blood cx in pts ill enough to require ventilator
#Asthma
##Common in pts with SCD
##Increases likelihood of chest syndrome by 4-6x
#Pulmonary Hypertension
##Develops in 15-35% of children with SCD
###Chest pain, DOE, hypoxia, right-sided heart failure, syncope, PE


=== Abdominal Pain ===
===[[Dactylitis]]===
*Differential Diagnosis
*Tender, swollen hands/feet
**Pain crisis
*May have low-grade [[fever]]
***3rd most common site of pain crisis
*Occurs in <2yr old, extremely rare >5yr old
***Sudden onset of poorly localized abdominal pain
*Radiographs will show soft tissue swelling in the acute phase. Recurrent episodes can lead to a mottled appearance of hand and feet small bones on radiography. <ref>George, A., DeBaun, M., & DeBaun, M. (2021, April 28). Acute and chronic bone complications of sickle cell disease. Retrieved April 20, 2022, from https://www.uptodate.com/contents/acute-and-chronic-bone-complications-of-sickle-cell-disease?search=sickle%20cell%20disease%20children&topicRef=110699&source=see_link</ref>
****May have tenderness, guarding; should not have rigidity/rebound
**Gallbladder disease (stones) is common; may occur as early as 2-4yr old
***RUQ pain, jaundice, anorexia, tender hepatomegaly, fever
***Bilirubin level higher than usual (>4mg/dL)
**Acute hepatic sequestration
***Labs are variable
***US or CT shows diffuse hepatomegaly


=== Infection ===
===[[Avascular necrosis]] of femoral head===
<ref>George, A., DeBaun, M., & DeBaun, M. (2021, April 28). Acute and chronic bone complications of sickle cell disease. Retrieved April 20, 2022, from https://www.uptodate.com/contents/acute-and-chronic-bone-complications-of-sickle-cell-disease?search=sickle%20cell%20disease%20children&topicRef=110699&source=see_link</ref>
*Due to occlusion of blood vessel lumens, which causes microfractures, leading to collapse of cancellous bone and the articular surface
*Occurs in 30% of patients by age 30yr, prevalence increases with age
*Patients present with afebrile, inguinal pain with weight-bearing but can be asymptomatic
**Decreased ROM and pain with ambulation or passive ROM
*Other common sites of involvement are the humeral head and the area above the knee
 
===[[Respiratory distress]] and [[chest pain]]===
*[[Acute Chest Syndrome]]
*[[Pneumonia]]
**Caused by [[chlamydia]], [[mycoplasma]], [[viruses|viral]], [[strep pneumo]], [[staph]], [[H. flu]]
**Only need blood culture in patients ill enough to require ventilator
*[[Asthma]]
**Common in patients with SCD
**Increases likelihood of acute chest syndrome by 4-6x
*[[Pulmonary Hypertension]]
**Develops in 15-35% of children with SCD
***[[Chest pain]], [[dyspnea|DOE]], [[hypoxia]], right-sided [[heart failure]], [[syncope]], [[PE]]
 
===[[Abdominal pain]]===
*[[vaso-occlusive crisis|Pain crisis]]
**3rd most common site of pain crisis
**Sudden onset of poorly localized abdominal pain
***May have tenderness, guarding; should not have rigidity/rebound
*[[Gallbladder disease]] (stones) is common; may occur as early as 2-4yr old
**[[RUQ pain]], [[jaundice]]/bilirubin higher than baseline, anorexia, tender hepatomegaly, fever
*Acute hepatic or [[splenic sequestration]]
**Labs are variable
**[[ultrasound: Abdomen|US]] or CT shows diffuse hepatomegaly or splenomegaly
*Bacterial [[gastroenteritis]]
**Increased risk for [[salmonella]]
**Consider treatment with [[ciprofloxacin]] and [[Bactrim]] in ill-appearing
 
===[[Infection]]===
*Across all ages, infection is leading cause of death
*Across all ages, infection is leading cause of death
**Increased prevalence of meningitis, PNA, arthritis, osteo
**Increased prevalence of [[meningitis]], [[pneumonia]], [[septic arthritis]], [[osteomyelitis]]
**[[Asplenic|No spleen]] means more susceptible to encapsulated organisms
*Children aged 6mo to 3yr at greatest risk for sepsis
*Children aged 6mo to 3yr at greatest risk for sepsis
*Parvovirus B19
*[[Parvovirus B19]]
**Can cause several different syndromes:
**Can cause several different syndromes:
***1. Erythema infectiosum ("slapped cheeks" rash)
***Erythema infectiosum ("slapped cheeks" rash)
***2. Gloves and socks syndrome
***Gloves and socks syndrome
****Well-demarcated, painful, erythema of hands and feet
****Well-demarcated, painful, erythema of hands and feet
*****Evolves nto petechiae, purpura, vesicles, skin sloughing
*****Evolves into petechiae, purpura, vesicles, skin sloughing
***3. Arthropathy - symmetric or asymmetric, knees and ankles
***[[arthralgia|Arthropathy]] - symmetric or asymmetric, knees and ankles
***4. Aplastic crisis
***[[Aplastic crisis]]
****Reticulocyte count drops 5d post-exposure, followed by Hb drop
****Reticulocyte count drops 5d post-exposure, followed by hemoglobin drop
****Can cause serious anemia which lasts for 2wk
****Can cause serious anemia which lasts for 2wk


=== Musculoskeletal Infection ===
===Musculoskeletal infection===
*Pts w/ SCD have increased rates of bone and joint infection
*Patients with SCD have increased rates of [[osteomyelitis|bone]] and [[septic arthritis|joint infection]]
**Difficult to distinguish from bony infarcts
**Difficult to distinguish from bony infarcts
***High fever is more typical of infection
***High [[fever]] is more typical of infection
***Limited range of motion is much more typical of infection
***Limited range of motion is much more typical of infection
***Left shift is unique to infection
***Left shift is unique to infection
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***May require bone scan or MRI to definitely distinguish infection from infarct
***May require bone scan or MRI to definitely distinguish infection from infarct


=== Splenic Sequestration ===
===[[Splenic sequestration]]===
*Major cause of mortality in <5yr old
*Major cause of mortality in <5yr old
*Labs: Hb drop, no change in bili, normal to incr retic count
*Labs: hemoglobin drop, no change in bili, normal to increased retic count
**2 types: major and minor
**2 types: major and minor
***Major
***Major
****Rapid drop of hb (>3pt)
****Rapid drop of hb (>3pt)
****Pallor, LUQ pain, splenomegaly
****Pallor, [[LUQ pain]], splenomegaly
****Can progress w/in hours to AMS, hypotension, CV collapse
****Can progress within hours to [[altered mental status]], [[hypotension]], [[pediatric shock|cardiovascular collapse]]
***Minor
***Minor
****More insidious, smaller drop in Hb
****More insidious, smaller drop in hemoglobin


=== Neurologic Disease ===
===Neurologic disease===
*CVA is 250x more common in children with SCD
*[[CVA]] is 250x more common in children with SCD
**10% of children suffer clinically overt stroke
**10% of children suffer clinically overt stroke
**20% found to have silent CVA on imaging
**20% found to have silent CVA on imaging
*Increased rate of cerebral aneurysm and ICH
*Increased rate of cerebral aneurysm and [[ICH]]


=== GU ===
===GU===
*Priapism
*[[Priapism]]
**Occurs in 25% by age 20
**Occurs in 25% by age 20
*Papillary necrosis
*Papillary necrosis
**Hematuria w/o casts or pyuria
**[[Hematuria]] without casts or pyuria
 
==Differential Diagnosis==
{{Sickle cell DDX}}
 
==Evaluation==
[[File:Sickle Cell.png|thumb|Algorithm for the Evaluation and Management of Sickle Cell Crises]]
===Work-up===
''Based on clinical presentation, but may include:''
*CBC (assess for significant anemia)
*Reticulocyte count (<0.5% suggests aplastic crisis - rare in adults), calculating reticulocyte index
**Laboratory value is a percentage, and absolute count corrects for level of anemia
**Absolute retic count = % retics x (pt Hct / normal Hct)
**Retic index = absolute retic count / maturation factor<ref>Poorana PP and Subhashree AR. Role of Absolute Reticulocyte Count in Evaluation of Pancytopenia-A Hospital Based Study. J Clin Diagn Res. 2014 Aug; 8(8): FC01–FC03.</ref>
***≥35%, maturation factor 1.0
***25 to <35%, maturation factor 1.5
***20 to <25%, maturation factor 2.0
***<20%, maturation factor 2.5
**Reticulocyte index ≥2 means adequate response
**Reticulocyte index <2 suggests hypoproliferation
*Metabolic panel, lipase (if abdominal pain)
*[[CXR]] (if cough, shortness of breath, or fever)
*[[ECG]]
*[[VBG]]
*[[Urinalysis]]
*Pregnancy test
*[[CT brain]] (if symptoms of CVA)
**Note that if patient is anemic, CT non-contrast is unreliable in ruling out hemorrhagic stroke, [[subarachnoid hemorrhage]]<ref>Lyon M et al. Approach to the diagnosis and treatment of acute subarachnoid hemorrhage in a patient with sickle cell disease. Am J Emerg Med. 2015 Mar;33(3):481.e3-4.</ref>
**Will need CTA, MRI, and/or MRA
 
===Evaluation===
*Generally a clinical diagnosis
*Certain syndromes require imaging/labs for confirmation (see below)


== Treatment ==
==Management==
=== Anemia ===
*Only use supplemental [[oxygen]] for patients who are hypoxic (<92%)
*Transfusion
*Reserve [[IVF]] bolus for patients who are hypovolemic
**Over hydration may cause atelectasis which may precipitate [[Acute Chest Syndrome]] and hyperCl acidosis which could lead to further sickling \
**Make sure to use hypotonic fluids: 1/2NS, D5-1/2NS
 
===[[Anemia]]===
*[[Packed red blood cells]] (transfuse 10 mL/kg over 2hr period)
**Indications:
**Indications:
***Aplastic crisis
***[[Aplastic crisis]]
***Sequestration crisis
***[[splenic sequestration|Sequestration crisis]]
***Hb <6 w/ inappropriately low retic count
***Hemoglobin <6 with inappropriately low retic count
***Hb <10 w/ acute crisis
***Hemoglobin <10 with acute crisis (e.g. symptomatic dizziness, [[SOB]], [[chest pain]])
**Transfuse 10 mL/kg over 2hr period
 
===[[Vaso-occlusive pain crisis]]===
*[[Analgesia]]
**IV [[opioids]] ([[morphine]] or [[hydromorphone]])
***Redose in 30min if inadequate
**Non-opioid analgesia
***[[NSAIDs]] (e.g. [[ketorolac]] 15mg q6h)
***[[Acetaminophen]]
***IV/IM [[haloperidol]] or [[droperidol]] 5-10mg<ref>*Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics</ref>
***[[Ketamine]] (IN 1mg/kg 1ml per nostril or IV 0.3mg/kg)<ref>*Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics</ref>
**Nonpharmacologic measures (e.g. heating packs, distraction)
*Hydration
**Controversial
***Dehydration promotes sickling
***[[IVF]] bolus may lead to atelectasis, pulmonary edema, and acute chest syndrome. Hyperchloremic metabolic acidosis due to normal saline may further precipitate sickling. <ref> Glassberg, J., Evidence-based management of sickle cell disease in the emergency department.Emerg Med Pract, 2011. 13(8): p. 1-20</ref> <ref> Carden, M.A., et al., Variations in pediatric emergency medicine physician practices for intravenous fluid management in children with sickle cell disease and vaso-occlusive pain: A single institution experience.Pediatr Blood Cancer, 2018. 65(1) </ref> <ref> Carden, M.A., et al., Normal Saline Bolus Use in Pediatric Emergency Departments is Associated with Worse Pain Control in Children with Sickle Cell Anemia and Vaso-occlusive Pain.Am J Hematol, 2019. </ref>
***There are no randomized controlled trials that have assessed the safety and efficacy of different routes, types or quantities of fluid.<ref>Okomo U, Meremikwu MM. Fluid replacement therapy for acute episodes of pain in people with sickle cell disease. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD005406. DOI: 10.1002/14651858.CD005406.pub4</ref>
*O2 if [[hypoxia]]; otherwise may inhibit erythropoiesis
 
===[[Acute Chest Syndrome]]===
*[[O2]]; titrate to pulse oximetry >92%
*Incentive Spirometer
*Hydration: [[oral rehydration therapy|Oral hydration]] preferred, [[IV hydration]] with hypotonic fluid if patient unable to tolerate PO
*[[Analgesia]]: pulmonary toilet is important but avoid excessive sedation
*[[Bronchodilators]]
*[[Antibiotics]]: 3rd generation [[cephalosporin]] + [[macrolide]]
*[[Transfusion]] (leucocyte depleted); consider [[pRBCs|transfusion]] to goal of hemoglobin 11 / hematocrit 30 for:
**O2 Sat <92% on room air
**hematocrit 10-20% below patient's usual hematocrit or dropping hematocrit
*[[Exchange transfusion]]; consider for:
**Progression of acute chest syndrome despite simple transfusion
**Severe [[hypoxemia]]
**Multi-lobar disease
**Previous history of severe acute chest syndrome or cardiopulmonary disease
 
===[[Priapism]]===
*[[IVF|Hydration]]
*[[pRBCs|Transfusion]] and/or [[exchange transfusion]]
*Urology consult
*If persists for >4-6hr:
**Aspiration of corpora
**Irrigate and infuse 1:1,000,000 epinephrine solution


=== Vaso-Occlusive Pain Crisis ===
===Neurologic disease===
#Analgesia
*[[tPA]] is ''not'' recommended
##IV opiods prefered (Morphine or hydormorphone)
*[[Exchange transfusion]] urgently (within 8 hours) to decrease hemoglobinS below 30%
###Avoid IM route (use SQ if necessary)
*[[IVF|Hydration]]
###Avoid meperidine
###Use PCA pump if available
###Redose in 30min if inadequate
###Normally admit if needs more than three doses
#Gentle hydration
##1.5 times maintenance w/ D5 1/2NS
##Only use NS boluses for acute dehydration or hypovolemic shock
#O2 is not useful in the nonhypoxic patient


=== Acute Chest Syndrome ===
===[[Splenic sequestration]]===
*See [[Acute Chest Syndrome]]
*[[Volume resuscitation]]
*Simple [[pRBCs|transfusion]] vs [[exchange transfusion]]


=== Priapism ===
===[[Fever]]===
#Hydration
*Any fever of ≥38.5C requires empiric [[antibiotics]] (regardless of well appearance or any localized infection found)
#Transfsuion and/or exchange transfusion
*[[Ceftriaxone]] 50mg/kg (maximum single dose 2g)
#Urology consult
#If persists for >4-6hr:
##Aspiration of corpora
##Irrigate and infuse 1:1,000,000 epi solution


=== Neurologic Disease ===
==Disposition==
#t-PA is not recommended
===Consider admission to the hospital===
#Urgent exchange transfusion to decrease HbS below 30%
*[[Fever]]
*[[Acute chest syndrome]] is suspected
*[[Sepsis]], [[osteomyelitis]], or other serious infection is suspected
*[[Priapism]], [[aplastic crisis]], [[hypoxia]]
*[[leukocytosis|WBC >30K]]
*[[thrombocytopenia|Platelet <100K]]
*Pain is not under control after 2-3 rounds of analgesics in ED
*<1yr old


===Splenic Sequestration===
===Consider discharge===
#Volume resuscitation
*Pain is under control and patient can take oral fluids and medications
#Simple transfusion vs exchange transfusion
*Ensure appropriate oral analgesics are available
*Provide home care instructions
*Ensure resource for follow-up


== Disposition ==
==See Also==
#Consider admission to the hospital if:
*[[Acute Chest Syndrome]]
##Acute chest syndrome is suspected
*[[Aplastic crisis]]
##Sepsis, osteomyelitis, or other serious infection is suspected
##Priapism, aplastic crisis, hypoxia
##WBC >30K
##Plt <100K
##Pain is not under control after 2-3 rounds of analgesics in ED
##<1yr old
#Consider discharge if:
##Pain is under control and patient can take oral fluids and medications
##Ensure appropriate oral analgesics are available
##Provide home care instructions
##Ensure resource for follow-up


== See Also ==
==References==
[[Acute Chest Syndrome]]
<references/>


== Source ==
*Tintinalli
*NIH & Heart, Lung and Blood Institute Guideline
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Latest revision as of 11:03, 23 April 2022

Background

(A) normal red blood cells flowing freely through a blood vessel. (B) abnormal, sickled red blood cells sticking at the branching point in a blood vessel. Cross-section shows long polymerized sickle haemoglobin (HbS) strands stretching and distorting the cell.

Precipitating Factors

Clinical Features

Vaso-Occlusive Crisis[1]

See Vaso-occlusive pain crisis

Bony infarction

  • More debilitating and refractory pain than past episodes
  • Localized bone tenderness, elevated WBC

Dactylitis

  • Tender, swollen hands/feet
  • May have low-grade fever
  • Occurs in <2yr old, extremely rare >5yr old
  • Radiographs will show soft tissue swelling in the acute phase. Recurrent episodes can lead to a mottled appearance of hand and feet small bones on radiography. [2]

Avascular necrosis of femoral head

[3]

  • Due to occlusion of blood vessel lumens, which causes microfractures, leading to collapse of cancellous bone and the articular surface
  • Occurs in 30% of patients by age 30yr, prevalence increases with age
  • Patients present with afebrile, inguinal pain with weight-bearing but can be asymptomatic
    • Decreased ROM and pain with ambulation or passive ROM
  • Other common sites of involvement are the humeral head and the area above the knee

Respiratory distress and chest pain

Abdominal pain

Infection

  • Across all ages, infection is leading cause of death
  • Children aged 6mo to 3yr at greatest risk for sepsis
  • Parvovirus B19
    • Can cause several different syndromes:
      • Erythema infectiosum ("slapped cheeks" rash)
      • Gloves and socks syndrome
        • Well-demarcated, painful, erythema of hands and feet
          • Evolves into petechiae, purpura, vesicles, skin sloughing
      • Arthropathy - symmetric or asymmetric, knees and ankles
      • Aplastic crisis
        • Reticulocyte count drops 5d post-exposure, followed by hemoglobin drop
        • Can cause serious anemia which lasts for 2wk

Musculoskeletal infection

  • Patients with SCD have increased rates of bone and joint infection
    • Difficult to distinguish from bony infarcts
      • High fever is more typical of infection
      • Limited range of motion is much more typical of infection
      • Left shift is unique to infection
      • ESR is unreliable
      • May require bone scan or MRI to definitely distinguish infection from infarct

Splenic sequestration

  • Major cause of mortality in <5yr old
  • Labs: hemoglobin drop, no change in bili, normal to increased retic count

Neurologic disease

  • CVA is 250x more common in children with SCD
    • 10% of children suffer clinically overt stroke
    • 20% found to have silent CVA on imaging
  • Increased rate of cerebral aneurysm and ICH

GU

  • Priapism
    • Occurs in 25% by age 20
  • Papillary necrosis

Differential Diagnosis

Sickle cell crisis

Evaluation

Algorithm for the Evaluation and Management of Sickle Cell Crises

Work-up

Based on clinical presentation, but may include:

  • CBC (assess for significant anemia)
  • Reticulocyte count (<0.5% suggests aplastic crisis - rare in adults), calculating reticulocyte index
    • Laboratory value is a percentage, and absolute count corrects for level of anemia
    • Absolute retic count = % retics x (pt Hct / normal Hct)
    • Retic index = absolute retic count / maturation factor[4]
      • ≥35%, maturation factor 1.0
      • 25 to <35%, maturation factor 1.5
      • 20 to <25%, maturation factor 2.0
      • <20%, maturation factor 2.5
    • Reticulocyte index ≥2 means adequate response
    • Reticulocyte index <2 suggests hypoproliferation
  • Metabolic panel, lipase (if abdominal pain)
  • CXR (if cough, shortness of breath, or fever)
  • ECG
  • VBG
  • Urinalysis
  • Pregnancy test
  • CT brain (if symptoms of CVA)
    • Note that if patient is anemic, CT non-contrast is unreliable in ruling out hemorrhagic stroke, subarachnoid hemorrhage[5]
    • Will need CTA, MRI, and/or MRA

Evaluation

  • Generally a clinical diagnosis
  • Certain syndromes require imaging/labs for confirmation (see below)

Management

  • Only use supplemental oxygen for patients who are hypoxic (<92%)
  • Reserve IVF bolus for patients who are hypovolemic
    • Over hydration may cause atelectasis which may precipitate Acute Chest Syndrome and hyperCl acidosis which could lead to further sickling \
    • Make sure to use hypotonic fluids: 1/2NS, D5-1/2NS

Anemia

Vaso-occlusive pain crisis

  • Analgesia
  • Hydration
    • Controversial
      • Dehydration promotes sickling
      • IVF bolus may lead to atelectasis, pulmonary edema, and acute chest syndrome. Hyperchloremic metabolic acidosis due to normal saline may further precipitate sickling. [8] [9] [10]
      • There are no randomized controlled trials that have assessed the safety and efficacy of different routes, types or quantities of fluid.[11]
  • O2 if hypoxia; otherwise may inhibit erythropoiesis

Acute Chest Syndrome

  • O2; titrate to pulse oximetry >92%
  • Incentive Spirometer
  • Hydration: Oral hydration preferred, IV hydration with hypotonic fluid if patient unable to tolerate PO
  • Analgesia: pulmonary toilet is important but avoid excessive sedation
  • Bronchodilators
  • Antibiotics: 3rd generation cephalosporin + macrolide
  • Transfusion (leucocyte depleted); consider transfusion to goal of hemoglobin 11 / hematocrit 30 for:
    • O2 Sat <92% on room air
    • hematocrit 10-20% below patient's usual hematocrit or dropping hematocrit
  • Exchange transfusion; consider for:
    • Progression of acute chest syndrome despite simple transfusion
    • Severe hypoxemia
    • Multi-lobar disease
    • Previous history of severe acute chest syndrome or cardiopulmonary disease

Priapism

Neurologic disease

Splenic sequestration

Fever

  • Any fever of ≥38.5C requires empiric antibiotics (regardless of well appearance or any localized infection found)
  • Ceftriaxone 50mg/kg (maximum single dose 2g)

Disposition

Consider admission to the hospital

Consider discharge

  • Pain is under control and patient can take oral fluids and medications
  • Ensure appropriate oral analgesics are available
  • Provide home care instructions
  • Ensure resource for follow-up

See Also

References

  1. ↑ Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47
  2. ↑ George, A., DeBaun, M., & DeBaun, M. (2021, April 28). Acute and chronic bone complications of sickle cell disease. Retrieved April 20, 2022, from https://www.uptodate.com/contents/acute-and-chronic-bone-complications-of-sickle-cell-disease?search=sickle%20cell%20disease%20children&topicRef=110699&source=see_link
  3. ↑ George, A., DeBaun, M., & DeBaun, M. (2021, April 28). Acute and chronic bone complications of sickle cell disease. Retrieved April 20, 2022, from https://www.uptodate.com/contents/acute-and-chronic-bone-complications-of-sickle-cell-disease?search=sickle%20cell%20disease%20children&topicRef=110699&source=see_link
  4. ↑ Poorana PP and Subhashree AR. Role of Absolute Reticulocyte Count in Evaluation of Pancytopenia-A Hospital Based Study. J Clin Diagn Res. 2014 Aug; 8(8): FC01–FC03.
  5. ↑ Lyon M et al. Approach to the diagnosis and treatment of acute subarachnoid hemorrhage in a patient with sickle cell disease. Am J Emerg Med. 2015 Mar;33(3):481.e3-4.
  6. ↑ *Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics
  7. ↑ *Lyness, D., & Motov, S. (2016, July 7). CERTA Opioid Alternatives and Analgesics. Retrieved July 25, 2016, from http://www.propofology.com/infographs/certa-opioid-alternatives-as-analgesics
  8. ↑ Glassberg, J., Evidence-based management of sickle cell disease in the emergency department.Emerg Med Pract, 2011. 13(8): p. 1-20
  9. ↑ Carden, M.A., et al., Variations in pediatric emergency medicine physician practices for intravenous fluid management in children with sickle cell disease and vaso-occlusive pain: A single institution experience.Pediatr Blood Cancer, 2018. 65(1)
  10. ↑ Carden, M.A., et al., Normal Saline Bolus Use in Pediatric Emergency Departments is Associated with Worse Pain Control in Children with Sickle Cell Anemia and Vaso-occlusive Pain.Am J Hematol, 2019.
  11. ↑ Okomo U, Meremikwu MM. Fluid replacement therapy for acute episodes of pain in people with sickle cell disease. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD005406. DOI: 10.1002/14651858.CD005406.pub4
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