Vaso-occlusive pain crisis: Difference between revisions
No edit summary
Line 1: Line 1:
==Background==
==Background==
*Common complication of [[sickle cell anemia]], constituting 79-91% of ED visits<ref>Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47</ref>
*Sickled red blood cells obstruct vasculature, causing ischemic injury and pain
===Precipitating Factors===
===Precipitating Factors===
*Stress
*Stress
*Cold weather
*Cold weather
*Dehydration
*[[Dehydration]]
*Hypoxia
*[[Hypoxia]]
*Infection
*[[Infection]]
*Acidosis
*[[Acidosis]]
*Alcohol intoxication
*[[Alcohol intoxication]]
*Pregnancy
*[[Pregnancy]]
*Exertional stress
*Exertional stress


==Clinical Features<ref>Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47</ref>==
==Clinical Features<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
*Pain
**Most common manifestation of SCA (79-91% of ED visits)
**Lower [[back pain|back]], long bones most commonly affected
**Lower back, long bones most commonly affected


==Differential Diagnosis==
==Differential Diagnosis==
Line 22: Line 24:
*CBC
*CBC
**Because anemia can precipitate a crisis, must check for acute hemoglobin drop
**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)
*Retic count (if aplastic crisis considered - rare in adults)
**Should be >0.5%
**Should be >0.5%
*T&S/T&C
*Consider:
*Urine pregnancy
**Chemistry / [[LFTs]] / lipase
*[[CXR]]
***If abdominal pain, may be cholecystitis, mesenteric ischemia, or perforation
**If cough, shortness of breath, or febrile
**T&S/T&C
**Urine pregnancy
**[[CXR]]
***If cough, shortness of breath, or febrile


==Management==
==Management==
Line 48: Line 51:
*O2 if [[hypoxia]]; otherwise may inhibit erythropoiesis
*O2 if [[hypoxia]]; otherwise may inhibit erythropoiesis


===Anemia===
===[[Anemia]]===
*Transfusion [[PRBCs]] 10 mL/kg over 2hr period
*Transfusion [[PRBCs]] 10 mL/kg over 2hr period
*Indications:
*Indications:
**[[Aplastic crisis]]
**[[Aplastic crisis]]
**Sequestration crisis
**[[splenic sequestration|Sequestration crisis]]
**hemoglobin <6 with inappropriately low retic count
**hemoglobin <6 with inappropriately low retic count


Line 60: Line 63:
*[[Sepsis]], [[osteomyelitis]], or other serious infection is suspected
*[[Sepsis]], [[osteomyelitis]], or other serious infection is suspected
*[[Priapism]], [[aplastic crisis]], [[hypoxia]], splenic sequestration
*[[Priapism]], [[aplastic crisis]], [[hypoxia]], splenic sequestration
*WBC >30K
*[[leukocytosis|WBC >30K]]
*Platlet <100K
*[[thrombocytopenia|Platelet <100K]]
*Pain is not under control after 3 rounds of analgesics in ED
*Pain is not under control after 3 rounds of analgesics in ED
*<1yr old
*<1yr old

Revision as of 19:11, 1 October 2019

Background

  • Common complication of sickle cell anemia, constituting 79-91% of ED visits[1]
  • Sickled red blood cells obstruct vasculature, causing ischemic injury and pain

Precipitating Factors

Clinical Features[2]

  • Pain
    • Lower back, long bones most commonly affected

Differential Diagnosis

Sickle cell crisis

Evaluation

  • CBC
    • Because anemia can precipitate a crisis, must check for acute hemoglobin drop
  • Retic count (if aplastic crisis considered - rare in adults)
    • Should be >0.5%
  • Consider:
    • Chemistry / LFTs / lipase
      • If abdominal pain, may be cholecystitis, mesenteric ischemia, or perforation
    • T&S/T&C
    • Urine pregnancy
    • CXR
      • If cough, shortness of breath, or febrile

Management

  • 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. [5] [6] [7]
      • There are no randomized controlled trials that have assessed the safety and efficacy of different routes, types or quantities of fluid.[8]
  • O2 if hypoxia; otherwise may inhibit erythropoiesis

Anemia

Disposition

Consider admission

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

  1. ↑ Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47
  2. ↑ Lovett P. et al. Sickle cell disease in the emergency department. Emerg Med Clin North Am. 2014 Aug;32(3):629-47
  3. ↑ *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
  4. ↑ *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
  5. ↑ Glassberg, J., Evidence-based management of sickle cell disease in the emergency department.Emerg Med Pract, 2011. 13(8): p. 1-20
  6. ↑ 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)
  7. ↑ 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.
  8. ↑ 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
Retrieved from "https://www.wikem.org/w/index.php?title=Vaso-occlusive_pain_crisis&oldid=231383"