Difference between revisions of "Vaso-occlusive pain crisis"

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Revision as of 11:43, 9 September 2016

Background

Precipitating Factors

  • For vaso-occlusion:
    • Stress
    • Cold weather
    • Dehydration
    • Hypoxia
    • Infection
    • Acidosis
    • Alcohol intoxication
    • Pregnancy
    • Exertional stress

Clinical Features[1]

  • Pain
    • 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 hemoglobin drop

Differential Diagnosis

Sickle cell crisis

Evaluation

  • CBC
    • Assess for significant anemia
  • Chemistry / LFT / lipase
    • If abdominal pain, may be cholecystitis, mesenteric ischemia, or perforation
  • Retic count (if aplastic crisis considered - rare in adults)
    • Should be >0.5%
  • CXR
    • If cough, shortness of breath, or febrile
  • O2
    • If hypoxic; otherwise may inhibit erythopoesis
  • ECG
  • T&S/T&C
  • blood culture2
  • VBG
  • UA
  • Urine pregnancy
  • Head CT/MRI
    • If symptoms of stroke

Management

  • Analgesia
    • IV opiods prefered (Morphine or hydormorphone)
      • Avoid IM route (use SQ if necessary)
      • Avoid meperidine
      • Use PCA pump if available
      • Redose in 30min if inadequate
      • Normally admit if needs more than three doses
    • Use of concurrent acetaminophen encouraged, unless contraindicated
  • Hydration
    • Initial bolus should be 1/2NS with goal of increasing MCV of sickled cells[2][3]
    • 1.5 times maintenance with D5 1/2NS
    • Normal Saline boluses for hypovolemic shock
  • O2 is not useful in the nonhypoxic patient

Anemia

  • Transfusion
    • Indications:
      • Aplastic crisis
      • Sequestration crisis
      • hemoglobin <6 with inappropriately low retic count
      • hemoglobin <10 with acute crisis
    • Transfuse 10 mL/kg over 2hr period

Disposition

  • Consider admission to the hospital if:
    • Acute chest syndrome is suspected
    • Sepsis, osteomyelitis, or other serious infection is suspected
    • Priapism, aplastic crisis, hypoxia
    • WBC >30K
    • Platlet <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

External Links

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. Guy, R. Treatment of Sickle Cell Crisis with Hypotonic Saline Clinical Research 1971; 19: 420
  3. Pathogenesis and Treatment of Sickle Cell Disease H. Franklin Bunn, M.D. N Engl J Med 1997; 337:762-769