Vaso-occlusive pain crisis: Difference between revisions
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***[[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> | ***[[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> | ***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 [[ | *O2 if [[hypoxia]]; otherwise may inhibit erythropoiesis | ||
===Anemia=== | ===Anemia=== |
Revision as of 04:03, 24 September 2019
Background
Precipitating Factors
- 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
Differential Diagnosis
Sickle cell crisis
- Vaso-occlusive pain crisis
- Bony infarction
- Dactylitis
- Avascular necrosis of femoral head
- Acute chest syndrome
- Asthma
- Pulmonary hypertension
- Gallbladder disease
- Acute hepatic sequestration
- Infection
- Parvovirus B19
- Splenic sequestration
- CVA
- Cerebral aneurysm and ICH
- Priapism
- Papillary necrosis
Evaluation
- CBC
- Because anemia can precipitate a crisis, must check for acute hemoglobin drop
- 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%
- T&S/T&C
- Urine pregnancy
- CXR
- If cough, shortness of breath, or febrile
Management
- 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[2]
- Ketamine (IN 1mg/kg 1ml per nostril or IV 0.3mg/kg)[3]
- Nonpharmacologic measures (e.g. heating packs, distraction)
- IV opioids (morphine or hydromorphone)
- 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. [4] [5] [6]
- There are no randomized controlled trials that have assessed the safety and efficacy of different routes, types or quantities of fluid.[7]
- Controversial
- O2 if hypoxia; otherwise may inhibit erythropoiesis
Anemia
- Transfusion PRBCs 10 mL/kg over 2hr period
- Indications:
- Aplastic crisis
- Sequestration crisis
- hemoglobin <6 with inappropriately low retic count
Disposition
Consider admission
- Acute chest syndrome is suspected
- Sepsis, osteomyelitis, or other serious infection is suspected
- Priapism, aplastic crisis, hypoxia, splenic sequestration
- WBC >30K
- Platlet <100K
- Pain is not under control after 3 rounds of analgesics in ED
- <1yr old
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
External Links
References
- ↑ Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47
- ↑ *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
- ↑ *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
- ↑ Glassberg, J., Evidence-based management of sickle cell disease in the emergency department.Emerg Med Pract, 2011. 13(8): p. 1-20
- ↑ 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)
- ↑ 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.
- ↑ 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