Elsevier

The Journal of Emergency Medicine

Volume 17, Issue 4, July–August 1999, Pages 625-630
The Journal of Emergency Medicine

Original Contributions
Management of sickle cell pain crisis in the emergency department at teaching hospitals

Presented at the American College of Emergency Physicians Research Forum, Cincinnati, Ohio, February 1996.
https://doi.org/10.1016/S0736-4679(99)00050-5Get rights and content

Abstract

The purpose of this study is to determine the frequency and variety of strategies being used in the Emergency Department (ED) management of sickle cell pain crisis (SCPC). One thousand randomly selected academic emergency physicians received a multiple-choice survey; 549 (55%) completed the survey. Forty-five percent of respondents treat patients with SCPC every week or almost every shift. Twenty percent use protocols for management of SCPC. Respondents consider pain refractory to outpatient treatment if it is persistent after two (23%) or three (53%) doses of parenteral analgesic. Meperidine or morphine is the most common initial analgesic. In the routine management of uncomplicated SCPC, i.v. analgesics, i.v. hydration, oxygen therapy, and complete blood counts are often or always used by 67, 71, 66, and 82% of respondents, respectively. Some patterns in the diagnostic and therapeutic management of patients with SCPC in the ED are identified, but overall practice is highly variable. Some popular elements of care are divergent from those suggested by the scientific literature.

Introduction

The painful crises of sickle cell anemia are common (1). Because of the nature of the disease, and sometimes because of limited access to health care, patients with sickle cell pain crisis (SCPC) are often treated not by a hematologist in the office, but rather by the emergency physician in the Emergency Department (ED).

Each emergency physician’s management of SCPC has evolved as the product of personal experiences with this presentation, hypotheses concerning the pathophysiology of pain crisis, and input from the hematology and chronic pain management communities.

Reviews of the literature disagree on whether “traditional” ED management of SCPC includes hydration as a central element 2, 3, 4, whether oral or i.v. hydration is preferable 2, 3, 5, 6, whether antihistamine adjuvants should be used 2, 5, 7, whether supplemental oxygen should be given to all patients 2, 3, 4, 5, 6, 8, 9, and whether screening laboratory and x-rays studies are indicated in all patients 2, 3, 6, 10. Most reviews suggest that meperidine is the most common parenteral analgesic and that it is most commonly given intramuscularly (i.m.), but others suggest that other analgesics are also common and may be preferable 2, 3, 5, 7, 11, 12. There has been little critical scientific study of the components of ED management of SCPC, and the literature that does exist suggests large variability in the current practice.

The purpose of this study is to determine the frequency and variety of various strategies being used in the ED management of sickle cell pain crises. By identifying the prevailing methods of management, we hope to facilitate communication among emergency physicians regarding the sometimes controversial care of these patients.

Section snippets

Materials and methods

The Institutional Review Board of the Medical College of Pennsylvania approved this study.

Results

The survey was returned by 527 (52.7%) of the sample. Another 22 respondents ultimately completed the survey by telephone interview, for a total response rate of 55%. Respondents most frequently worked in university hospitals (46%) and community teaching hospitals (36%), with the remainder working mostly in other types of teaching hospitals including children’s, county, or military hospitals. Ninety-one percent were board certified in emergency medicine. Forty-five percent of respondents

Discussion

Sickle cell pain crisis is a common presentation in academic emergency departments. The results of this survey identify patterns in the use of several proposed elements of care. Emergency physicians (and other physicians who care for patients with SCPC) can evaluate their own management strategies against these results.

These data also suggest considerable variability in the management of SCPC in academic EDs. The variability in therapy is illustrated by the use of i.m. pain medicines in the

References (18)

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