Ketorolac tromethamine

1. …OR THE UGLY DUCKLING IN PRE-HOSPITAL PAIN
MANAGEMENT
HERFRANK LOYO
AEMT
#630

3. …We must all die. But that I can save
him from days of torture, that is what I
feel as my great and ever new
privilege. Pain is a more terrible lord of
mankind than even death itself…

4.  PAIN. AWARENESS. PRIMAL INSTINCT.
 Greeks and Romans were the first to advance a theory of sensation.
 Brain and nervous system have a role in producing the perception of pain.
 Renaissance period: 1400s and 1500s-that evidence began to accumulate in
support of these theories.
 14th-15th Century: Leonardo Da Vinci: the brain was the central organ
responsible for sensation.
 (1664) René Descartes described what to this day is still called a "pain
pathway."
 19th Century: Physician-scientists discovered that opium, morphine, codeine,
and cocaine could be used to treat pain. Led to development of ASA.

5. a Future includes a better
understanding of pain,
along with greatly improved
treatments to keep it in
check.

7. CENTRAL
PERIPHERAL
OPIOIDS
(NARCOTICS)
NONOPIOIDS
(NON NARCOTICS)
CNS DEPRESSION
MORPHINE AND DERIVATES
CODEINE
AGENTS IN COUGH SUPPRESSANTS
INHIBITION
OF PROSTAGLANDIN
SYNTHESIS
SALICYLATES
NSAID’s
ACETAMINOPHEN

8. Nonsteroidal anti-inflammatory drug (NSAID) indicated for
the short-term (up to 5 days in adults), management of
moderately severe acute pain that requires analgesia at the
opioid level
Member of the pyrrolo-pyrrole group of nonsteroidal anti-
inflammatory drugs (NSAIDs) in the group of Acetic Acids
derivates.
Chemical name for ketorolac tromethamine is (±)-5-benzoyl-
2,3-dihydro-1H-pyrrolizine-1-carboxylic acid, compound with
2-amino-2-(hydroxymethyl)-1,3-propanediol

9.  Ketorolac was developed in 1989 by Syntex Corp. It was
approved for medical use in the United States in 1989.
 Ketorolac is used for short-term management of moderate to
severe pain.
 Ketorolac is also an adjuvant to opioids medications and
improves pain relief.
 Ketorolac is indicated for short-term management of
moderate to moderately severe pain requiring analgesia at
the opioid level.

10.  Ketorolac tromethamine is a racemic mixture of [-]S- and
[ + ] R-enantiomeric forms, with the S-form having analgesic
activity.

11.  Agent with analgesic and antipyretic properties, is used to
treat and control acute pain. It is a peripherally acting
analgesic.
 The biological activity of ketorolac tromethamine is
associated with the S-form. Ketorolac tromethamine
possesses no sedative or anxiolytic properties.

12.  KT is largely metabolized in the liver. The metabolic
products are hydroxylated and conjugated forms of the
parent drug. The products of metabolism, and some
unchanged drug, are excreted in the urine.
 About 92% of a given dose is found in the urine,
approximately 40% as metabolites and 60% as unchanged
ketorolac. Approximately 6% of a dose is excreted in the
feces.

13.  Onset: Varies. Within minutes.
 The peak analgesic effect occurs within 2 to 3 hours and is
not statistically significantly different over the recommended
dosage range. The greatest difference between large and
small doses by either route is in the duration of analgesia.
 Duration: Varies. But hours.

14.  IM Dosing:
 Patients <65 years of age: One dose of 60 mg.
 Patients >/=65 years of age, renally impaired and/or less than 50 kg
(110 lbs) of body weight: One dose of 30 mg.
 IV Dosing:
 Patients <65 years of age: One dose of 30 mg.
 Patients >/=65 years of age, renally impaired and/or less than 50 kg
(110 lbs) of body weight: One dose of 15 mg.

15. Pediatric Patients (2 to 16 years of age): The pediatric population
should receive only a single dose of KT injection, as follows:
 IM Dosing:
 One dose of 1 mg/kg up to a maximum of 30 mg.
 IV Dosing:
 One dose of 0.5 mg/kg up to a maximum of 15 mg.

16.  Management of Moderate to severe acute pain when opioids
are contraindicated or refused by patient.
 Noncyclic mastalgia
 Cancer and tumor pain
 Biliary tract pain.
 Pain due to kidney stones
 Hemorrhoids and perianal pain
 Migraine and undifferentiated headache
 Neck and back pain. Radicular syndromes
 Odontalgia
 Several indications in ophtalmic pain management
 Sickle cell crisis

17.  Previously demonstrated hypersensitivity to Ketorolac tromethamine.
 Active peptic ulcer disease, OR patients with recent gastrointestinal
bleeding or perforation and in patients with a history of peptic ulcer
disease or gastrointestinal bleeding.
 Advanced renal impairment or in patients at risk for renal failure due
to volume depletion.
 Labor and delivery because, through its prostaglandin synthesis
inhibitory effect, it may adversely affect fetal circulation and inhibit
uterine contractions, thus increasing the risk of uterine hemorrhage.

18.  Nausea.
 Vomiting.
 Bloating, gas.
 Loss of appetite.
 Sweating, dizziness, drowsiness, blurred vision,
 Dry mouth.
 Irritation at the injection site and abnormal tastes may also
occur.
 GI ulceration, bleeding and perforation, postoperative
bleeding, acute renal failure, anaphylactic and anaphylactoid
reactions and liver failure

19.  In late pregnancy, as with other NSAIDs, Ketorolac tromethamine
should be avoided because it may cause premature closure of the
ductus arteriosus.
 use of Ketorolac tromethamine in patients who have coagulation
disorders should be undertaken very cautiously, and those
patients should be carefully monitored.
 Patients on therapeutic doses of anticoagulants (e.g., heparin or
dicumarol derivatives) have an increased risk of bleeding
complications if given Ketorolac tromethamine

20.  Ketorolac Tromethamine it is NOT a Smooth Muscle
Relaxant Agent.
 Even though it is a member of the NSAID’s class, it’s
antiinflamatory effect is minimal.
 Ketorolac Tromethamine it is NOT only indicated in
pain management due to Kidney Stones.

21.  Washington County Protocols:
 Paramedic Skill
First line of treatment in these conditions:
 Renal= Kidney Stones: Mild, Moderate, Severe.
 Non-Cardiac Chest Pain: Mild, Moderate Severe.
 Migraine: Mild, Moderate Severe.

22. Ketorolac may be found in some form under the
following brand names:
 ACULAR®
 ACUVAIL®
 OMIDRIA®
 SPRIX®
 TORADOL®