January 19, 2024

Welcome back to UH EMS-I’s Pharmacy Phriday! This week, we continue a review of protocol changes in the 2024 UH protocols that relate to the medications within our drug boxes. This installment focuses on Ketorolac, a medication found within the adult “Pain Management” protocol. Ketorolac is not a new medication within the protocols, but verbiage has changed to allow its administration along with other pain medications, an idea often referred to as multi-modal pain control. 

Multi-modal pain management can be defined as the use of multiple analgesic medications (opioids as well as non-opioids) and procedural interventions to decrease pain at varying locations in the pain pathway. This multi-modal approach is not new to EMS as we have been using procedures such as repositioning, immobilization, application of ice, reassurance, etc., along with various medications for years.

Pain management, both in general and within the pre-hospital setting, has received considerable attention over recent years and has become much more aggressive. Pain has been identified as a problem that negatively affects outcomes for our patients. Management of that pain has been linked to improved patient satisfaction, improved clinical outcomes, reduced number of clinical complications, and an overall reduction in healthcare costs.

Pain is a complex topic of study that often looks at the process that includes the various pain receptors, inflammation at injury sites, various chemicals released due to an injury, nerves, spinal cord, brain, and the subjective perception of pain. The way pain is managed considers this complex process, and a multi-modal approach addresses the different areas of the process. 

Opioids have been the traditional medication in pain management for many years but come with potential side effects, both immediate and long-term, that can be concerning. A multi-modal approach to pain management does not necessarily eliminate the use of opioids but rather allows the wise use of opioids in combination with other interventions. NSAIDs, like Ketorolac, are an important piece of multi-modal pain management. Inflammation affects the receptors associated with pain sensation and the pain process, and the use of an NSAID in reducing that inflammation can reduce the need for opioids significantly. 

Ketorolac is an NSAID like ibuprofen and aspirin but is much more effective. One source cites it as having 30 times the strength of regular aspirin. It is a non-narcotic, non-habit-forming medicine that is effective in reducing mild to moderate pain from both inflammatory and non-inflammatory causes by reducing hormones that cause inflammation and pain in the body. 

The indications for the use of Ketorolac listed within the protocol include moderate pain, kidney stones, and flank pain. Ketorolac can also be considered in cases when the patient has a history of allergies to opioids or narcotics, is in recovery from an addiction, or refuses a narcotic medication for fear of abuse. And now, within the 2024 protocol, Ketorolac can be used as the sole medication or in conjunction with the other medications listed in the algorithm when initial treatments have not been as successful as desired. 

Ketorolac has contraindications and side effects that need to be considered prior to administration. Contraindications, as listed in the UH protocols, include a known sensitivity to NSAIDs, age greater than 65 years of age, recent GI bleeding or a CVA, pregnancy or breastfeeding, and asthmatics with sensitivity to NSAIDs (Ketorolac is known to cause bronchospasms in these patients). Other contraindications that should also be considered before use are a history of severe renal disease or kidney transplant, bleeding disorders, patients using blood thinners, anti-coagulants, or other NSAIDs, or if the possibility of emergency surgery exists.   

It is worth noting that our UH protocols highlight the need to differentiate abdominal pain from flank pain (indicating kidney stone pain or renal colic). Patients experiencing abdominal pain other than kidney stones should not receive Ketorolac due to the risk associated with bleeding and other serious side effects that involve the abdominal region and organ systems.

Though side effects are less common in cases of the short-term, low-dose levels used by our EMS providers, the patient should be monitored for edema, hypertension, nausea, heartburn, dizziness, and bleeding, as well as immediate allergic and anaphylactic reactions. The dosing of Ketorolac under UH protocols is 15 mg IV/IO or 30 mg via the IM route. No repeat or pediatric doses are recommended for the pre-hospital setting per our UH Protocols.

Till the next installment of Pharmacy Phriday, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

July 28, 2023

Dear colleagues:

Welcome back to UH EMS-I's Pharmacy Phriday. You are probably well aware now of how inflammation is a great defense mechanism for the body after an injury, but how it also tends to cause other problems. Steroids, like Solumedrol, are one classification of medications that can combat this inflammation. But sometimes steroids are not the best choice, especially for pain management. Another option is a non-steroidal anti-inflammatory drug (NSAID). Aspirin tends to lead this group in popularity, but Ketorolac (Toradol) is a stronger alternative for some patients. Not a steroid (but has similar effects) and not an opioid (but comparable in strength), Toradol can be administered either IV or IM and also helps with fevers. Although relief varies by patient, it generally works well for kidney stones and moderate pain from musculoskeletal injuries, chronic back pain, and minor trauma.

Unfortunately, there are quite a few contraindications for using it besides being allergic to NSAIDs. It can increase the risk of bleeding, so it should not be given to anyone with the following:

• ulcers

• head injuries

• strokes

• other possible internal bleeding

Pregnant women and those nursing should not receive it, as well as elderly over the age of 65. Asthmatics have shown a higher risk of having a bronchospasm with Toradol given IM, so choosing another pain medication would be prudent. Finally, pediatric patients should not be given Toradol. But probably one of the biggest risks with administering Toradol has nothing to do with the drug but with what its name is. Medications with similar names are prone to errors. Ketorolac can easily be mistaken for Ketamine (Ketalar) at 3 am. Ketamine is more potent and weight-based, so it is thinned down, and the dose is calculated prior to use for pain management, while Ketorolac is given full strength.

Sincerely,



The UH EMS-I Team

University Hospitals