Disposition depends upon ED findings, observation, and response to initial therapy. The following is a list of guidelines to aid ED physicians in determining which children with SCD require hospitalization:
1. Temperature greater than or equal to 103°F/39°C, WBC counts greater than 30,000/mm3, or left shift and/or other hematologic parameters greatly altered from baseline values.
2. Any signs of respiratory distress, hypoxia, and/or lobar infiltrate on chest x-ray.
3. Any new CNS findings or presence of neurologic crisis.
4. Patients with splenic sequestration or aplastic crisis.
5. An acute abdomen.
6. Prolonged priapism.
7. Any type of vasooclusive crisis that does not respond to intravenous hydration and analgesia (usually after about 4 to 6 h of therapy).
8. Inability to maintain adequate oral hydration.
9. Patients in whom the diagnosis remains uncertain.
10. Follow-up (i.e., telephone contact, return visit, etc.) is uncertain or unlikely because of distance, inconvenience, or poor compliance.
If patients with vasoocclusive crisis are discharged home, they should be advised to maintain adequate oral hydration, take pain medication (a 2- to 3-day supply should be provided), and return immediately if fever over 100.4°F/38°C occurs, the pattern of pain worsens or changes, or vomiting begins. All patients treated and released from the ED should be reevaluated in 24 to 48 h by their private pediatrician/physician or hematologist (generally 24 h for children and 24 to 48 h for adults).
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