Toradol/ketorolac for major trauma pts

[back2bRN]

Sooo, here's the question....

do/would you give toradol to a trauma pt. Fall >25 ft thru many obstacles (wood ect) with +3 blood & +3 protein in urine and decreased output ? VS WNL. A&O x4. Pain mid thoracic.

FYI, I didn't b/c of potential for increased bleeding, impaired kidney function, potential for surgery ect.

[Tonjia]

Toradol is contraindicated in major trauma. period

[manncer]

I agree that it is not a wise choice and it could be a fatal choice.

[Escape5]

I generally don't find Toradol ordered in major trauma, at least in the ED. We usually give small doses of Fentanyl in the initial trauma assessment since it is short-acting, less risk of hypotension, potent enough to provide some pain relief while we are finishing 2ndary and adjuncts (placing splints, log-rolling, waiting for scans.) It's all specific to the doc I'm sure.

[kxvc]

I would question the toradol. I wouldn't give it.

[EMT/68W2]

here is a unique situation to consider... just some thoughts would be nice

You have a pt who was involved in a MVA involving a semi-trailer and another large/heavy vehicle in an area (outside the US) who is complaining of severe shoulder and arm pain. HOWEVER he also has hit his head (was wearing a helmet) but is confused, but not confused enough to not know he is in excruciating pain... vitals are GCS 12, HR:96 BP: 130/72 RR: 20 SPo2: 98% on room air Pupils: PERRL. No worrisome trauma other than the neck and head. No cranial fractures, no obvious spinal fractures. no bleeding/bruising other than from abrasions on face. Air evac is delayed, you only have a 10mg auto-injector of morphine (and ampules of naloxone of course) and a 30mg dose of Toradol. The pt must be kept engaged in answering questions, talking, etc or he faints and must be re aroused. however due to suspected CNS compromise morphine may not be the best answer as it will depress the CNS however Toradol is also contraindicated due to reduced platelet aggregation (may not be the best if you suspect a subdural hematoma ) Now do you let the poor guy lay and suffer(increasing the overall stress factor on the pt physically as well as psychologically) or do you give the morphine (keeping in mind its a 10mg autoinjector and therefore you cannot control the amount given nor the rate of absorption) or would the only other analgesic option be the toradol (one dose, to take the edge off if you will, while awaiting the air evac) would one dose of toradol compromise the bodies ability to clot to such an extent as to do more harm than good?

**im not asking for a generic yes or no answer, please give reasoning behind your rational (I already know the contraindications so please dont assume i dont know them)

Thanks in advance!!! :)

[Christy1019, ASN, RN]

WBC would be high after a trauma without the presence of infection (FYI). Most md's do not want a pt with a head injury to receive narcotics. It's just simply unsafe to give right away. I would think the initial dose of Toradol would be fine. It's the multi doses that I would question.

I understand your thought process of avoiding narcs w/head injuries, however smaller doses shouldn't significantly decrease their LOC, and decreasing their pain can help lower/prevent elevated ICP as well as lower BP, HR, and resp rate in someone who may be HTN, tachycardic, or hyperventilating due to severe pain and anxiety s/p trauma. Helping their pain may also help the patient tolerate laying relatively still while having to remain flat in a c collar, which may prevent further injury to the pt.

I agree that one dose of toradol will probably not harm the pt, however I don't feel that it is adequate pain management for significant traumatic injuries, and why risk using it anyways on the off chance it COULD harm the pt, especially one who is confused/possible head injury and can't tell you they're pregnant, only have one kidney/kidney disease, or have some sort of bleeding disorder...

Just my

[Lunah, MSN, RN]

The pt must be kept engaged in answering questions, talking, etc or he faints and must be re aroused.

Why? Keeping a patient awake isn't going to change anything going on in the brain. Let the poor guy pass out! Personally I'd probably give morphine if I thought he needed pain control ... you could always give Narcan later if need be. No Toradol if you suspect a bleed.