A 5-year-old boy is brought to the emergency department with severe leg pain that started 6 hours earlier. His mother says that their heating system broke last night so she "tried to keep him warm with lots of blankets." The patient was given ibuprofen and oxycodone at home without relief of pain. He played outside with his brother yesterday but did not experience any trauma or injury. He has not had fever, cough, vomiting, or rash. Medical history includes mild persistent asthma and sickle cell disease, and he has been hospitalized once for a vaso-occlusive pain episode. Temperature is 37.2 C (99 F) , blood pressure is 100/62 mm Hg, pulse is 150/min, and respirations are 20/min. Physical examination shows a young child lying in bed in significant discomfort, crying and holding his left leg. Mucous membranes are moist and capillary refill is <2 seconds. The lungs are clear to auscultation, and the abdomen is soft, nontender, and nondistended without organomegaly. The left anterior calf is markedly tender to palpation but does not have erythema, warmth, or swelling. A peripheral intravenous line is inserted, and a complete blood count is drawn.
What is the best next step in management of this patient?

Question

A 5-year-old boy is brought to the emergency department with severe leg pain that started 6 hours earlier.  His mother says that their heating system broke last night so she "tried to keep him warm with lots of blankets."  The patient was given ibuprofen and oxycodone at home without relief of pain.  He played outside with his brother yesterday but did not experience any trauma or injury.  He has not had fever, cough, vomiting, or rash.  Medical history includes mild persistent asthma and sickle cell disease, and he has been hospitalized once for a vaso-occlusive pain episode.  Temperature is 37.2 C (99 F), blood pressure is 100/62 mm Hg, pulse is 150/min, and respirations are 20/min.  Physical examination shows a young child lying in bed in significant discomfort, crying and holding his left leg.  Mucous membranes are moist and capillary refill is <2 seconds.  The lungs are clear to auscultation, and the abdomen is soft, nontender, and nondistended without organomegaly.  The left anterior calf is markedly tender to palpation but does not have erythema, warmth, or swelling.  A peripheral intravenous line is inserted, and a complete blood count is drawn. 
What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf7f_d95e_8f63_0b44de50d2b6_MD0005_00 The most common manifestation of sickle cell disease (SCD) is a vaso-occlusive episode (VOE). VOEs are acute episodes of minor to severe pain that typically affect the back, chest, abdomen, or extremities. Triggers can include dehydration, infection, stress, weather changes, or menstruation. Treatment often requires hospitalization and consists of prompt administration of oral or intravenous pain medication and gentle rehydration. Outpatient therapy typically includes nonsteroidal anti-inflammatory drugs and acetaminophen for mild pain and oral opiate medications (eg, oxycodone) for moderate pain. Intravenous opiates (eg, morphine) are the first-line treatment in the emergency department and should be given within 30 minutes of arrival. Rehydration is also a key component of VOE management, as dehydration is known to cause sickling and worsen VOEs. Intravenous fluids are indicated for hypovolemic or hypotensive patients as initial fluid resuscitation. This patient's blood pressure is normal for age, and pain medications should therefore be given first. (Choice A) Patients with SCD are at increased risk for bacteremia, specifically from encapsulated organisms due to functional asplenia. All patients with SCD with fever should have a blood culture drawn and be started on antibiotics. Because this patient is afebrile, a blood culture is not indicated. (Choice C) Codeine is contraindicated in children age <12 due to unpredictable metabolism resulting in increased conversion to active opioid metabolites, resulting in life-threatening respiratory depression. (Choice D) This patient did not improve on oral opiate therapy at home, and therapy should be escalated. Intravenous opiates are preferred for hospitalized patients or those in the emergency department with significant pain. (Choice E) The most likely cause of pain in this patient is a VOE, which is a clinical diagnosis and does not require imaging. Fracture or osteomyelitis is unlikely in the absence of trauma or fever. Educational objective: Patients with sickle cell disease who have a severe vaso-occlusive episode and are hemodynamically stable should be treated promptly with intravenous opioids. References: Evidence-based management of sickle cell disease in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/22164362) Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. (http://www.ncbi.nlm.nih.gov/pubmed/25203083)

A 5-Year-Old Boy Is Brought to the Emergency Department with Severe