What to do if a patient experiences bradycardia and lip swelling after taking Ketorolac (ketorolac tromethamine)?

Management of Bradycardia and Lip Swelling After Ketorolac Administration

Immediately stop ketorolac and treat this as a potential anaphylactic reaction requiring prompt intervention with epinephrine and supportive care.

Initial Assessment and Management

1. Stop ketorolac administration immediately and maintain IV access 1
2. Assess ABCs (Airway, Breathing, Circulation) and level of consciousness 1
3. Position the patient appropriately:
   • If hypotensive: Trendelenburg position
   • If respiratory distress: Sitting up
   • If unconscious: Recovery position 1

Treatment Algorithm

For Bradycardia:

1. Administer atropine 600 μg IV (0.6 mg) for bradycardia 1
2. If patient is on beta-blockers: Consider glucagon 1-5 mg IV over 5 minutes, followed by infusion (5-15 μg/min) titrated to clinical response 1
3. Monitor vital signs every 15 minutes until symptoms resolve 1

For Lip Swelling (Angioedema/Anaphylaxis):

1. Administer epinephrine 0.01 mg/kg (1mg/mL dilution, maximum 0.5 mL) intramuscularly into lateral thigh if criteria for anaphylaxis are met 1
   • Can repeat every 5-15 minutes if needed
2. Administer antihistamines:
   • Diphenhydramine 1-2 mg/kg or 25-50 mg IV slowly
   • Ranitidine 50 mg diluted in 5% dextrose to 20 mL total volume, injected IV over 5 minutes 1
3. Administer corticosteroids: Equivalent to 1-2 mg/kg of methylprednisolone every 6 hours 1
4. Fluid resuscitation if hypotensive: Rapid infusion of 1-2 liters normal saline at 5-10 mL/kg in first 5 minutes 1

Monitoring and Follow-up

1. Observe for at least 24 hours after a severe reaction 1
2. Document the reaction thoroughly including pre-infusion assessments, description and grading of the reaction, and management 1
3. Prescribe an epinephrine auto-injector and educate patient on its use before discharge
4. Refer to allergist for evaluation of NSAID allergy

Important Considerations

• Ketorolac can cause serious hypersensitivity reactions including anaphylaxis, which may present with bradycardia and angioedema 2, 3
• Bradycardia occurs in approximately 10% of patients with allergic anaphylaxis during anesthesia 1
• Lip swelling (angioedema) is a concerning sign of potential anaphylaxis 1
• Patients with asthma are at higher risk for severe reactions to NSAIDs including ketorolac 4
• The combination of bradycardia and lip swelling strongly suggests an anaphylactoid/anaphylactic reaction rather than an isolated side effect 3, 5

Prevention of Future Episodes

• Document ketorolac allergy prominently in medical records
• Avoid all NSAIDs until allergist evaluation, as cross-reactivity may occur
• Consider alternative analgesics from different drug classes (acetaminophen, tramadol, etc.)
• Provide patient education about NSAID allergy and symptoms requiring immediate medical attention

Pitfalls to Avoid

• Do not re-challenge with ketorolac or other NSAIDs before allergist evaluation
• Do not delay epinephrine administration if anaphylaxis is suspected
• Do not attribute bradycardia to other causes without considering anaphylaxis in this context
• Do not discharge patient prematurely - observe for at least 24 hours after severe reactions
• Do not forget to document the reaction for future reference