duration, and height of fever, and the presence of associated symptoms such as cough, respiratory distress, and abdominal pain Elicit immunization status and compliance with prophylactic antibiotics Without a clear source of infection, laboratory assessment should include a CBC with a reticulocyte count, blood culture, and a type and screen Other evaluations may include a chest x-ray, urinalysis with culture, or cerebrospinal fluid analysis as clinically indicated A type and cross should be sent if history suggests splenic sequestration, acute chest syndrome, or significant neurologic symptoms Administer antibiotics promptly, prior to knowledge of laboratory results Typically, administer ceftriaxone (50 mg/kg up to 2,000 mg) for broad-spectrum antibiotic coverage lasting 24 hours while cultures are pending; outpatient management is appropriate in stable patients in whom there are no early concerns for developing complications and who have reliable caretakers with the means to return if necessary Acute Chest Syndrome Initial Assessment Acute chest syndrome is a life-threatening complication of sickle cell disease indicative of pneumonia, pulmonary infarction, or both Lifetime risk of acute chest syndrome is 48% and causes 25% of sickle cell disease–related deaths The patient usually presents with fever, tachypnea, chest pain, rales, and hypoxia In a dehydrated patient, the initial physical examination findings may be minimal Management/Diagnostic Testing Any sickle cell patient who presents with chest pain requires immediate assessment, monitoring, and treatment including IV access, fluids, oxygen administration, and laboratory testing including CBC with reticulocyte count, type and screen, blood culture, and chest x-ray (see Table 93.6 ) Any acute infiltrate should be concerning for acute chest syndrome and the patient should be treated with antibiotics including a thirdgeneration cephalosporin such as ceftriaxone and atypical coverage with a macrolide Add vancomycin in the severely ill patient All patients with suspected acute chest syndrome require admission for further management Closely monitor patients with chest pain without radiographic findings or hypoxia and encourage incentive spirometry, as splinting puts them at risk for the development of acute chest syndrome which may not be present on presentation Consider simple transfusion in the presence of severe anemia (hemoglobin