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.
