Immediate Questions

A. How does patient characterize the pain? Is it acute? If recurrent, how frequent are the acute painful episodes? How many times has patient sought medical attention for pain in the past year? How often has patient required hospitalization for painful episodes? Have painful episodes been managed with oral or parental therapies? What has been the typical frequency and duration of painful episodes?

B. Is this episode similar to previous episodes? If a patient describes the pain as being different, it should raise suspicion of a different etiology of the pain. Most patients with chronic pain, such as that caused by sickle cell crisis or disease, are able to recognize their typical painful episode.

C. What medication, if any, has been tried? Is patient taking pain medication(s) at home (prescription or over-the-counter)? What dose and for how long? Is pain medication effective? What medications have worked in the past? This information gives clinician a starting point for ascertaining how well the pain is typically controlled and which analgesics to start with in current treatment. Chronic or recurrent opioid therapy leads to opioid tolerance, requiring usually higher doses to attain pain relief.

D. Pain Assessment

1. Can patient identify characteristics of the pain (stabbing, shooting, throbbing, aching, burning)? Determine the intensity of each site of pain using an appropriate validated pain scale; self-report is preferred. Behavioral-observational pain scales are used for preverbal or neurologically impaired children.

2. When did this painful crisis begin? Can patient identify any aggravating or alleviating factors? Has pain limited patient's ability to function (sleep, eat, go to school)?

Breakthrough painful episodes in children with sickle cell disease are treated as acute pain. Because of the recurring and life-long nature of this pain, however, principles of chronic pain management are also necessary, such as behavioral-cognitive, psychological, and physical modalities.

E. Are there any precipitating factors? Fever, dehydration, hypoxemia, stress, and fatigue are common precipitating factors of pain in patients with sickle cell disease.

III. Differential Diagnosis. There is a broad differential diagnosis of pain in children. For example, sources of pain in patients with sickle cell disease include vasoocclusion caused by the sickling process, osteomyelitis, avascular necrosis, trauma, tumor, and somatization disorder. This chapter is not intended to provide a review of the medical management of sickle cell disease, but rather a focused discussion of acute pain management. See Table I-17 for definitions of terms relating to pain and dependency.

IV. Database

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