How to manage a patient with a history of tachycardia, pulmonary emboli, and current hypotension and fatigue, on Mobic (meloxicam) and Toradol (ketorolac) injections?

Management of Patient with History of Tachycardia, Pulmonary Emboli, and Current Hypotension on NSAIDs

Discontinue both Mobic (meloxicam) and Toradol (ketorolac) immediately due to significant risk of cardiovascular complications in a patient with history of pulmonary emboli and current hypotension. 1

Rationale for NSAID Discontinuation

Ketorolac (Toradol) is explicitly contraindicated in this patient for several critical reasons:

• The FDA label specifically states that ketorolac causes "an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke" 1
• The patient's history of pulmonary emboli places her at high risk for recurrent thromboembolic events
• Current hypotension (94/64) makes NSAID use particularly dangerous
• The combination of two NSAIDs (Mobic and Toradol) increases the risk of adverse events
• Ketorolac is only indicated for short-term use (≤5 days) 1

Cardiovascular Assessment and Management

1. Immediate monitoring:

   • Continuous cardiac monitoring for arrhythmias
   • Regular blood pressure checks (every 1-2 hours initially) 2
   • Oxygen saturation monitoring 3

2. Arrhythmia management:

   • The patient's heart rate is currently in the 90s and in sinus rhythm
   • Previous event monitor showed symptomatic sinus bradycardia or low-grade PACs and PVCs
   • For tachycardia episodes, if they recur and are hemodynamically significant:
     • Beta-blockers are first-line for rate control in most patients with tachycardia 3
     • Consider metoprolol as it has been shown to be effective for rate control 3

3. Hypotension management:

   • Increase oral fluid intake with added salt (patient reports not typically using salt)
   • Consider IV fluid challenge if hypotension persists
   • Monitor for signs of dehydration which may be masked by beta-blockade 2
   • Avoid verapamil or diltiazem due to the patient's hypotension and mitral valve issues 3

Pulmonary Embolism Considerations

Given the patient's history of pulmonary emboli and current symptoms:

• Assess for signs of recurrent PE (dyspnea, tachycardia, hypoxemia) 4, 5
• Consider ECG to look for signs associated with PE (S1Q3T3, T inversion in V1-V2) 6
• Risk factors for PE complications include tachycardia ≥110 bpm, SBP ≤100 mmHg (both present in this patient) 7
• If PE is suspected, prompt diagnostic testing (D-dimer, CT pulmonary angiogram) is warranted 8

Pain Management Alternatives

Since NSAIDs must be discontinued, consider:

• Optimize current Suboxone therapy (patient reports not taking it consistently)
• Acetaminophen for breakthrough pain
• Non-pharmacological approaches: physical therapy, heat/cold therapy
• Consider pain management consultation for alternative strategies

Follow-up Plan

1. Schedule follow-up within 1 week to reassess cardiovascular status
2. Monitor renal function with regular creatinine measurements
3. Consider cardiology referral for further evaluation of mitral valve issues
4. Educate patient on warning signs requiring immediate medical attention:
   • Chest pain
   • Shortness of breath
   • Palpitations
   • Dizziness or syncope

Key Pitfalls to Avoid

• Do not restart NSAIDs in this patient given her cardiovascular risk profile
• Avoid misinterpreting tachycardia as primary arrhythmia rather than compensatory response to hypotension 2
• Do not use medications that could worsen hypotension (calcium channel blockers, high-dose beta-blockers)
• Avoid overlooking potential recurrent PE as a cause of the patient's symptoms

This patient's combination of cardiac issues (mitral valve prolapse, tachycardia), history of pulmonary emboli, and current hypotension creates a high-risk profile that is significantly worsened by NSAID use. Immediate discontinuation of both NSAIDs and careful monitoring are essential to reduce cardiovascular risk.