| Triage rapidly (<15 minutes) |
- The individual has likely been having pain at home that has exceeded what they can manage with oral opioids
- Follow individualized care plan if available
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| Assess pain clinically |
- Believe the individual's and/or family's self-report of pain
- Rapidly assess pain location(s), quality, duration, severity
- Assess potential comorbidities that cause pain (eg, avascular necrosis of a joint, compression fracture)
- Assess potential comorbidities that require other treatments (eg, stroke, infection, acute chest syndrome, splenic sequestration)
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| Initiate analgesia as soon as possible (<30 minutes) |
- Most individuals will require opioids
- Initial dose is based on intensity of pain and previous effective doses
- If initial dose is unknown, use one of the following:
- Intravenous morphine (0.1 to 0.15 mg/kg; maximum single dose 10 mg)
- Intravenous hydromorphone (0.02 to 0.05 mg/kg; maximum single dose 1.5 mg)
- Intranasal fentanyl (1.5 mcg/kg, give up to two doses, 5 to 10 minutes apart; maximum single dose 100 mcg)*
- Rapidly reassess for efficacy and repeat dose if needed at appropriate interval (20 minutes for morphine, 30 minutes for hydromorphone)
- Provide adjunctive therapies if appropriate (refer to the section below)
- Avoid ineffective therapies (refer to the section below)
- Admit to hospital if pain control is inadequate with three or more doses of an opioid analgesic (or two doses of intranasal fentanyl)
- Plan for around-the-clock analgesia with additional doses for breakthrough pain; do not rely exclusively on as-needed (PRN) dosing
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| Adjunctive therapies |
- Adjunctive therapies are used in addition to (not instead of) analgesia
- Ensure adequate hydration (encourage oral fluids, give intravenous fluids if hypovolemic)
- Enlist family and other psychosocial supports
- Use heat packs if helpful
- Possible use of ketamine
- Treat insomnia and other conditions that interfere with adequate sleep
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| Therapies to avoid or use sparingly |
- Never use placebo
- Avoid ice and cold compresses (may precipitate sickling)
- Avoid meperidine
- Avoid ketorolac in adults; if ketorolac is given, no more than one dose should be used
- Use anxiolytics only if indicated for anxiety, not for pain
- Use NSAIDs cautiously as they may cause renal failure or bleeding and may be ineffective in many cases
- Use oxygen only for hypoxia, not for routine pain
- Use transfusion only for indicated complications, not for uncomplicated vaso-occlusive pain
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