Medication In-Service: Michigan EMS Medication In-Service: Ketorolac (Toradol)

Course Objectives Identify the location of ketorolac (Toradol) in the SEM Drug Box, as well as how it may be packaged. Describe the pharmacokinetics and pharmacodynamics of ketorolac (Toradol). List the indications and contraindications of ketorolac (Toradol). Describe how to administer ketorolac (Toradol), as well as list the applicable medication concentration, route and dose(s) per the applicable protocols.

Introduction Purpose As of June 1, 2018, the following medications were added to the Southeast Michigan Regional Medication Boxes (SEM Drug Box): Ketamine Ketorolac (Toradol) Push Dose Epinephrine Ondansetron (Zofran) ODT

Introduction Purpose This CE will focus on: Ketorolac (Toradol)

Location in the SEM Drug Box One 15mg vial will be stocked in the drug box

Location in the SEM Drug Box Ketorolac will not be supplied in the A-Pack

Pharmacokinetics and Pharmacodynamics Class of medication Nonsteroidal anti-inflammatory drug (NSAID) Used for treating inflammation and pain Other NSAIDs include: Ibuprofen, naproxen and aspirin Toradol is more effective than other NSAIDs in reducing mild to moderate pain from both inflammatory and non- inflammatory causes

Pharmacokinetics and Pharmacodynamics Mechanism of action Anti-inflammatory medication Ideal medication for mild to moderate acute pain resulting from an injury

Pharmacokinetics and Pharmacodynamics Route of administration IV: Ensure the medication is delivered slowly over at least 15 seconds IM: Provide the injection slowly

Pharmacokinetics and Pharmacodynamics Onset and duration of action Patients will experience pain relief approximately 30 minutes after administration Effect consistently lasts between 4-6 hours Maximum effect is 1-2 hours after administration The sooner that ketorolac (Toradol) is administered, the sooner the patient’s pain will be relieved

Pharmacokinetics and Pharmacodynamics Half-life Approximately 5 hours in the adult patient Half-life increases in the elderly and those with renal impairments

Pharmacokinetics and Pharmacodynamics Side effects Side effects of ketorolac are more commonly found with larger dosages Keep in mind that 15mg is a small dose

Pharmacokinetics and Pharmacodynamics Side effects Abdominal pain Nausea Indigestion Headache

Pharmacokinetics and Pharmacodynamics Side effects Less common side effects GI bleeding and ulcers Susceptible to anemia and increased bleeding time The above are likely to occur when higher doses are taken for several days

Indications Ketorolac (Toradol) SHOULD be administered in the following situations: Patients presenting with mild to moderate pain is rated a 1-4 on the Wong Pain Scale

Indications Ketorolac (Toradol) SHOULD be administered in the following situations: Often used in treating pain associated with kidney stone pain May be considered a first line medication for known or suspected kidney stone pain independent of the pain scale score

Contraindications Ketorolac (Toradol) should NOT be administered in the following situations: Allergy to ketorolac or other NSAIDS such as aspirin or ibuprofen

Contraindications Ketorolac (Toradol) should NOT be administered in the following situations: Pregnancy, active labor or women who are breastfeeding

Contraindications Ketorolac (Toradol) should NOT be administered in the following situations: Renal impairment

Contraindications Ketorolac (Toradol) should NOT be administered in the following situations: Bleeding or high risk of bleeding Patient with a history of GI bleeding, ulcers, or perforation should not receive ketorolac

Contraindications Ketorolac (Toradol) should NOT be administered in the following situations: A patient already receiving NSAIDs such as aspirin or ibuprofen should not receive ketorolac (Toradol)

Applicable protocols Pain Management (procedure section) Ketorolac (Toradol) Adult 15mg IM/IV Pediatric 1mg/kg IM/IV Max dose 15mg

How to administer ketorolac Remove ketorolac (Toradol) from the SEM Drug Box

How to administer ketorolac Verify the correct medication and dosage Concentration: 15mg in 1mL Dose: Adult: 15mg Pediatric: 1mg/kg (max 15mg)

How to administer ketorolac Draw the medication from the vial You’ll need: Syringe Needle Alcohol prep

How to administer ketorolac Administer the medication IV or IM IV: Ensure the medication is delivered slowly over at least 15 seconds IM: Provide the injection slowly IV IM

How to administer ketorolac Monitor the patient Monitor the patient for the desired effect The medication will take effect within 30 minutes Reassess the patient’s pain on the Wong Pain Scale

Medication Section 9 Every medication available in the SEM Drug Box and A-Pack is now detailed in “Section 9 Medications” of the State of Michigan EMS Protocols Click here to access to digital document

Medication Section 9 Ketorolac (Toradol) 9-30 Applicable Protocols Indications Contraindications Dosing: Adult Pediatrics Expected Effects Side Effects

Medication In-Service: Michigan EMS Medication In-Service: Ketorolac (Toradol) Thank you for utilizing this Instructor Resource Guide in preparation for delivery of continuing education. This course is intended to serve as an introduction and overview of the new protocols. LSAs will need to facilitate further education to ensure their providers are informed of changes to specific protocols. Questions???