Ketorolac for pain management

LanceCorpsman

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Although in the protocols for Oregon permit the usage of ketorolac, it isn't included in my EMS standing orders for the county (includes 7 agencies). Do other EMS agencies use Ketorolac? If you guys do you us, how effective is it? And what are the general pain management protocols of NSAIDs vs opioids?

I think its a no brainer to use a potent NSAID for trauma since we obviously have a opioid epidemic in this country.
 

NomadicMedic

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We use it for "moderate" pain. Kidney stones, headache, back pain. Anecdotaly, it seems to work well. 30mg IV / 60mg IM for adults. It's in our pain management protocol as a paramedic discretion.
 

E tank

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Age, renal function and hydration status are considerations. I'll refer you to the package insert. Along the lines of what GMCmedic is onto, the idea of an opioid epidemic, is in reality "prescription opioid epidemic", definitely not parenteral narcotics that we give for acute pain. I'm kind of "meh" for pre-hospital Toradol. I'm sure it has its place somewhere though. Not sure where.
 

MonkeyArrow

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If they need pain management, your first thought shouldn't be opioid epidemic.
It certainly should be a thought. There was a study in NEJM [http://www.nejm.org/doi/full/10.1056/NEJMsa1610524#t=abstract] a few months back that showed ED prescription patterns have a very significant effect on long term opioid use. Between low intensity and high intensity providers (prescribing opioids to percentage of all patients seen-between 7 and 24%), there was a 1.30 adjusted odds ratio of patients still using opioids 6 months out from the encounter when treated by a high intensity provider than when treated by a low intensity provider. The dose one would give on the ambulance is not going to cause addiction, but you have to be cognizant of the role you play in the system and the larger problem at hand.
 

Summit

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Ketorolac has some rough side effects for an NSAID. I really don't think that it works any better than other NSAIDs and I have seen zero evidence for the superiority of Ketorolac... except that Ketorolac is available IV/IM.

IME, if someone has pain at a level warranting opiates, then an NSAID is pissing in the wind unless you are using it as an opiate adjunct! (Exceptions: migraines and a few other etiologies). Tramadol has more punch than Toradol IME.

But say you have a candidate for Toradol... I'm now thinking about renal function, platelets, current anticoagulant meds, and other things like trauma/swelling/bleeding. I'm a huge fan of IV APAP over Ketorolac in appropriate patients because the side effect profile is so much milder. For PO, Meloxicam or Diclofenac over Ketorolac for duration and somewhat reduced side effect profiles (for extended use).
 

Tigger

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Ketorolac has some rough side effects for an NSAID. I really don't think that it works any better than other NSAIDs and I have seen zero evidence for the superiority of Ketorolac... except that Ketorolac is available IV/IM.

IME, if someone has pain at a level warranting opiates, then an NSAID is pissing in the wind unless you are using it as an opiate adjunct! (Exceptions: migraines and a few other etiologies). Tramadol has more punch than Toradol IME.

But say you have a candidate for Toradol... I'm now thinking about renal function, platelets, current anticoagulant meds, and other things like trauma/swelling/bleeding. I'm a huge fan of IV APAP over Ketorolac in appropriate patients because the side effect profile is so much milder. For PO, Meloxicam or Diclofenac over Ketorolac for duration and somewhat reduced side effect profiles (for extended use).
It sounds like IV APAP might be coming down in price. Some services in Massachusetts are starting to carry it.
 

Carlos Danger

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The potentially serious risks (GI bleeding, thrombosis, worsening of renal impairment) of ketorolac are real, but have probably been exaggerated, and can be easily managed by simply using conservative criteria for who gets it. Don't give it to people with a recent MI or stroke or TBI, people with a history of renal problems, gastric ulcers or other bleeding problems, and don't give it to people who are volume depleted, and it is just as safe as any other drug. Basically anyone healthy should be able to get it without any worry at all.

Unfortunately, I think the effectiveness has probably been somewhat exaggerated, too. It don't doubt that it works OK for mild-moderate pain in some people, but anything more than that and it simply isn't potent enough, though it should reduce opioid requirements at least, not that I would worry about that too much in the prehospital realm.

The problem is that acute pain is multi-factorial and highly subjective and often has an emotional component. Generally speaking, I think Americans who are in enough pain to seek analgesia from EMS or the ED are very often not satisfied with anything less than a very significant change in the way they feel. Opioids provide that via their GABA agonism in addition to their direct analgesic effects.

I'd probably like to have ketorolac in my prehospital drug box, and I'd probably use it occasionally if I did. But if I didn't have it, I don't think I'd miss it much.
 

RocketMedic

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Basically what Remi said. I carry it, I use it, it seems to work decently well.
 

StCEMT

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It would be nice as an alternative for the mild pain cases. Opening a narc box adds a lot of steps to my drop off, having something that wasn't so time intensive and still appropriate for the given pain level would be really nice.
 

Tigger

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It would be nice as an alternative for the mild pain cases. Opening a narc box adds a lot of steps to my drop off, having something that wasn't so time intensive and still appropriate for the given pain level would be really nice.
I hear this a lot. It baffles me that systems can make giving narcotics such a pain. I am sure you do not do this, but there are providers out there that don't (according to social media) give their meds because it's too much of a pain.
 

StCEMT

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I hear this a lot. It baffles me that systems can make giving narcotics such a pain. I am sure you do not do this, but there are providers out there that don't (according to social media) give their meds because it's too much of a pain.
I don't withhold due to paperwork, but it is a hard judgement call sometimes on if they are meeting that threshold in my head. Scraped knees just aren't gonna get it, that definitely isn't worth the paperwork. However to never do it except if the leg is backwards I disagree with. I miss just leaving a call number in the narc box. Now it's a doc signature on my computer, a pharm tech signature that they are accounted for on my computer, a doc signature on paper, demographics land medical record numbers on the paper, the pharmacy folder, and then drug box numbers. Not terrible, but definitely burns 10ish minutes getting it all done.
 

Summit

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I hear this a lot. It baffles me that systems can make giving narcotics such a pain. I am sure you do not do this, but there are providers out there that don't (according to social media) give their meds because it's too much of a pain.

Perverse disincentive
 

Brandon O

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Not to be Boring Brandon, but I feel obliged to point out that IV ketorolac is not all that much better than oral NSAIDs (like the ibuprofen in your cabinet), and IV acetaminophen is not better than oral acetaminophen.

They're just available for those who can't take pills. Which I bet most of your patients can.
 

DrParasite

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Not to be Boring Brandon, but I feel obliged to point out that IV ketorolac is not all that much better than oral NSAIDs (like the ibuprofen in your cabinet), and IV acetaminophen is not better than oral acetaminophen.

They're just available for those who can't take pills. Which I bet most of your patients can.
Speaking from personal experience with my first interaction with kindey stones over the weekend, IV ketorolac is awesome. IV Dilauded was great too. IV Zofran was also my friend, because I couldn't keep anything down for almost 20 hours until it passed.
 

Carlos Danger

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Not to be Boring Brandon, but I feel obliged to point out that IV ketorolac is not all that much better than oral NSAIDs (like the ibuprofen in your cabinet), and IV acetaminophen is not better than oral acetaminophen.

They're just available for those who can't take pills. Which I bet most of your patients can.

Weren't most of those studies done on surgical patients though? I find it hard to believe that in the non-perioperative setting, whether you are using these meds as an opioid adjunct in severe pain or alone for mild-moderate pain, the much faster onset time of the IV route doesn't improve satisfaction to a greater degree than the 30-minutes-at-least that it takes any PO med to start working. For that to be the case you'd basically have to claim that the IV med doesn't provide as much analgesia as the PO version.

Anecdotally, in my experience a gram of Ofirmev given upon emergence from anesthesia seems to work much better than the same dose given PO pre-op. For whatever that's worth. Also, not that it really applies to the EMS setting, but one interesting thing about acetaminophen is that with the IV form you can actually achieve serum levels that have been shown to have anti-hyperalgesic effects, but those serum levels cannot be safely reached with the PO form.
 

VentMonkey

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I have never carried any form of Toradol, but it was given to me IM when I slipped my disc, and had a severe case of drop foot. While I was certainly at the “surgical option only” point, it did absolutely nothing for me except burn my arm.
 

Akulahawk

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From my own experiences in the ED, I have found Toradol to work remarkably well at one thing: reducing pain from kidney stones. Outside of that, it doesn't seem to work any better at reducing pain than any of the non-narc PO meds.
 

Brandon O

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Weren't most of those studies done on surgical patients though? I find it hard to believe that in the non-perioperative setting, whether you are using these meds as an opioid adjunct in severe pain or alone for mild-moderate pain, the much faster onset time of the IV route doesn't improve satisfaction to a greater degree than the 30-minutes-at-least that it takes any PO med to start working. For that to be the case you'd basically have to claim that the IV med doesn't provide as much analgesia as the PO version.

Anecdotally, in my experience a gram of Ofirmev given upon emergence from anesthesia seems to work much better than the same dose given PO pre-op. For whatever that's worth. Also, not that it really applies to the EMS setting, but one interesting thing about acetaminophen is that with the IV form you can actually achieve serum levels that have been shown to have anti-hyperalgesic effects, but those serum levels cannot be safely reached with the PO form.

No expert in this area. I certainly do think that there is probably a faster onset of analgesia with IV forms, and this can be relevant/useful. Especially, of course, in those who can't take PO. The immediate post-surgical period being both, that is where I have seen the best utility for a dose of IV acetaminophen.

But after that initial period, pain often persists -- at least in my world -- and I usually plan to treat it with a regularly scheduled dose, and in that case I have a hard time imagining the route matters.

Curious about your remarks on treating hyperalgesia with acetaminophen. References?
 

VentMonkey

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From my own experiences in the ED, I have found Toradol to work remarkably well at one thing: reducing pain from kidney stones. Outside of that, it doesn't seem to work any better at reducing pain than any of the non-narc PO meds.
Interesting, I wonder why that’s so. My wife said that the Dilaudid was what worked wonders for her when she passed a stone.

I know when they gave me Toradol I was hoping more of the anti-inflammatory properties would set in, no such luck though.

As an aside~ worse than childbirth, per a mother...x 2.
 
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