From the FDA Drug Label
The use of aspirin in patients with aspirin- sensitive asthma has been associated with severe bronchospasm which can be fatal Since cross reactivity, including bronchospasm, between aspirin and other nonsteroidal anti-inflammatory drugs has been reported in such aspirin-sensitive patients, ketorolac tromethamine should not be administered to patients with this form of aspirin sensitivity and should be used with caution in patients with pre-existing asthma Patients should be informed of the following information before initiating therapy with an NSAID and periodically during the course of ongoing therapy. Patients should also be encouraged to read the NSAID Medication Guide that accompanies each prescription dispensed Advise patients to be alert for the symptoms of cardiovascular thrombotic events, including chest pain, shortness of breath, weakness, or slurring of speech, and to report any of these symptoms to their healthcare provider immediately
The next step in managing the patient's symptoms after initial treatment with IVF, Phenergan, and Toradol 30mg IM is to monitor the patient closely for signs of adverse reactions, such as:
- Cardiovascular thrombotic events
- Gastrointestinal bleeding or ulceration
- Renal impairment
- Skin reactions, including exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN)
- Follow up with the patient to assess the effectiveness of the treatment and to check for any potential side effects, as the patient has already shown improvement after the initial treatment. 1 1
From the Research
The next step in managing this patient's symptoms after initial treatment with IV fluids, promethazine, and ketorolac 30mg IM would be to assess the patient's response to these interventions and consider transitioning to oral medications for continued symptom control. Given the patient's improvement after the initial treatment, as reported by Laura RN, it is essential to continue symptom management while minimizing potential side effects and complications. The most recent and highest quality study, 2, suggests that a lower dose of ketorolac, such as 15mg, may be as effective as higher doses for acute musculoskeletal pain, which could guide future dosing decisions if additional pain management is needed. However, the current focus should be on transitioning to oral medications. If the patient shows sustained improvement, prescribe oral ondansetron 4-8mg every 8 hours as needed for nausea and oral ibuprofen 600mg every 6 hours or naproxen 500mg twice daily for pain. Ensure adequate hydration by recommending 2-3 liters of fluid intake daily and consider adding a proton pump inhibitor like omeprazole 20mg daily if the patient has gastrointestinal symptoms. Follow up within 24-48 hours to reassess symptoms. If symptoms persist or worsen despite these measures, consider alternative diagnoses and additional testing such as laboratory work or imaging studies. This approach allows for continued symptom management while transitioning from parenteral to oral medications, addressing both the acute symptoms and preventing their recurrence while monitoring for any complications or underlying conditions that may require further intervention, as supported by the principles outlined in 3 and 2.