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Case Presentation & Conclusion

Case Presentation

In the middle of a busy evening shift, you encounter a 25-year-old man with a chief complaint of sickle cell crisis. He states that he has had an upper respiratory infection for about a week, followed by progressive pain to his lower back and legs. At home, he has been taking 4-mg tablets of hydromorphone every 3 hours, which reduces his pain score from a 10 to a 9. His vital signs are as follows: heart rate of 77, blood pressure of 115/70 mm Hg, respiratory rate of 14 breaths per minute, and temperature of 36.9°C (98.4°F). He does not appear to be uncomfortable and is sitting in bed using a cellular phone. The nurse has placed a peripheral IV, delivering a 1-L bolus of NS. You get the CBC results, and his hemoglobin is 10.2 mg/dL. You ask yourself several questions:


• Can this patient be having a crisis without a drop in hemoglobin?
• Is there a blood test I can do to confirm that he is truly having a crisis?
• Is the patient addicted to opiates or drug-seeking?
• What fluids should I administer?
• What kind of opiates should I administer?
• Should I administer supplemental oxygen?                                                                                         • Should I give him IV ketorolac? Are there any other medications that might help?

You are surprised that despite many years of practice you are not sure of the answers and wonder why that is.

Case Conclusion

You returned to the bedside of the young man with SCD who presented with the complaint of sickle cell crisis. After reviewing the literature, you now have answers to the clinical questions that were raised:


Can this patient be having a crisis without a drop in hemoglobin? Yes. Painful crises are not associated with drops in hemoglobin; furthermore, high hemoglobin (10 mg/dL is very high for individuals with SCD) is associated with increased viscosity, which may predispose to pain.
Is there a blood test I can do to confirm that he is truly having a crisis? No. Performing a peripheral smear to look for sickled cells will not yield any information about whether the patient is in crisis, nor will any other readily available laboratory test. The patient had normal vital signs and looked comfortable, which initially made you skeptical about his 10/10 pain, but you realized that vital sign abnormalities are uncommon with VOC. The patient told you he has regular follow-up in a hematology clinic and access to dilaudid prescriptions through his hematologist. He assured you that he would not come to the ED unless the pain was intractable.
Is the patient addicted to opiates or drug-seeking? It is unlikely, but you realized that the ED is not the time or the place to evaluate for addiction. You treated the patient’s pain aggressively and relayed any concerns to the hematologist who will be following the patient.• What fluids should I administer? You instructed the nurse to stop the 1-L bolus of NS, and start an infusion of D5 ½ NS at the maintenance
rate.
What kind of opiates should I give this patient? You administered 2 doses of 2-mg IV hydromorphone 15 minutes apart, and the patient reported his pain score was down to 6/10. You started the patient on a hydromorphone PCA with a basal rate of 0.1 mg/hr and demand doses of 0.2 mg every 8 minutes.
Should I administer supplemental oxygen? No. The patient is not hypoxic, so you stopped all supplemental oxygen.
Should I give him IV ketorolac? Are there any other medications that might help? No. The patient’s creatinine level came back at 0.9. Because patients with SCD have supranormal proximal tubule function, you know that his renal function may be significantly decreased even though his creatinine is normal. You elected not to give NSAIDs. You gave the patient acetaminophen, diphenhydramine, and an incentive spirometer. You decided not to give magnesium or ketamine.

After 3 hours in the ED, you reassessed the patient. His pain was well controlled, but he did not think he would be able to go home. You contacted the inpatient service and admitted him to the hospital. Five days later, he was transitioned to oral analgesics and discharged from the hospital.

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Last Modified: 07/23/2017
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