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Emergency Department Evaluation

History
Obtaining a history on an individual with SCD can be divided into 2 parts: addressing the acute complaint
and characterization of the severity of the patient’s disease.

Table 3 lists the key components for evaluation of ED patients with SCD. The hematologist should be alerted to all ED visits, as follow-up has been associated with reduced bounce-back visits. The first step is to form an appropriate differential diagnosis. For example, pain is the most common complaint associated with ED visits for SCD, but VOC must be a diagnosis of exclusion; once other causes have been sufficiently ruled out, proceed with a pain evaluation. What follows is a discussion of the evaluation for a patient with the chief complaint of pain. Specific elements of the evaluation for other complaints (infection, neurologic complaints) are discussed in their component sections.

Historical Evaluation Of Pain
Key questions include the locations, severity, and duration of pain; the exact amount of oral opiates taken at home; and the effect these opiates had on the pain score. Any validated pain assessment tool is acceptable, and there is insufficient evidence to recommend any particular one. Well-validated pain assessment tools include the verbally administered 0-10 numerical rating scale,29 the 100-millimeter netvisual analog scale,29 and the Wong-Baker FACES™ Pain Rating Scale for children.30 Important elements of the history for complaints other than pain are discussed in the Special Circumstances: Other Complications of SCD section on page 9.

Opiate Addiction And Drug-Seeking Behavior In Sickle Cell Disease
Many emergency clinicians are concerned that their SCD patients are addicted to opiates or are seeking drugs. Furthermore, there is widespread belief that prescribing opiates in the ED will foster addiction and enable drug-seeking behavior.31 Qualitative32 and quantitative33 studies of opiate use in SCD patients indicate that rates of true addiction are low (below 5%). For the emergency clinician, the following
recommendations can be made: unless there is clear evidence that the patient does not actually have SCD, take the patient’s complaint seriously and use opiates aggressively. It is true that a small fraction of people with SCD exhibit drug-seeking behavior to feed addiction or divert drugs to supplement income. It is also true that an attempt by the emergency clinician to identify drug-seeking patients and deny them analgesia will inevitably result in denial of analgesia for patients who deserve pain relief and compassionate care. Patients in need of treatment for addiction or diversion should be identified at follow-up with hematology or primary care, not in the ED.

Physical Examination
The physical examination on an individual with SCD should focus on several areas. Examine the eyes and mucous membranes for jaundice, and if present, ask the patient if this is significantly changed from baseline. Auscultate for cardiac murmurs and focal pulmonary abnormalities. When examining the abdomen, pay close attention to the liver and spleen, as both can be a site of significant red cell sequestration. For each pain location, examine carefully for signs of infection (tenderness, erythema, fluctuance) as cellulitis, osteomyelitis, and abscess often masquerade as vaso-occlusive pain.

Use Of Vital Sign Abnormalities To Assess Pain Severity
Many emergency clinicians use the presence or absence of abnormal vital signs to help objectively quantify the severity of a patient’s pain. Few studies specifically address this question; however, vital sign data from interventional clinical trials are sufficient to recommend against this practice. In a recent randomized controlled trial of inhaled nitric oxide for VOC that included 150 subjects, mean blood pressure measurements were below 120/70 mm Hg.34 In another randomized controlled trial of ketoprofen for the management of VOC pain, only one of the patients in the trial presented with tachycardia.35 A single-center, retrospective review of 459 VOC episodes specifically looked at blood pressure during crisis and found zero episodes of hypertension associated with VOC.36 Thus, individuals with SCD will usually not exhibit vital sign abnormalities, and many will not manifest distress even when in excruciating pain.

 

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Last Modified: 07/23/2017
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