What are the guidelines for using Toradol (Ketorolac) in patients with rib fractures?

Guidelines for Using Toradol (Ketorolac) in Patients with Rib Fractures

Ketorolac (Toradol) can be used for short-term pain management (≤5 days) in patients with rib fractures as part of a multimodal analgesic approach, with evidence showing it may decrease pneumonia risk and reduce opioid requirements. 1, 2

Indications and Benefits

• Ketorolac is indicated for short-term (≤5 days) management of moderately severe acute pain that requires analgesia at the opioid level 1
• Use of ketorolac in trauma patients with rib fractures has been associated with decreased likelihood of pneumonia development 2
• Ketorolac administration can significantly decrease narcotic requirements and improve pain scores in patients with traumatic rib fractures 3
• Studies show ketorolac use in rib fracture patients does not increase the incidence of acute kidney injury or bleeding events 4

Dosing Guidelines

• Therapy should always be initiated with IV or IM dosing of ketorolac, with oral tablets used only as continuation treatment 1
• For patients age 17-64: 20 mg PO once followed by 10 mg every 4-6 hours as needed, not exceeding 40 mg/day 1
• For patients age ≥65, renally impaired, and/or weight <50 kg: 10 mg PO once followed by 10 mg every 4-6 hours as needed, not exceeding 40 mg/day 1
• The total combined duration of use of ketorolac (IV/IM and oral) must not exceed 5 days 1

Risk Stratification for Rib Fracture Patients

• Higher risk patients who may need more advanced analgesia beyond ketorolac include those with: 5
  • Age >60 years
  • SpO2 <90%
  • Obesity or malnutrition
  • 2-3 rib fractures, flail segment, or pulmonary contusion
  • Smoking or chronic respiratory disease
  • Anticoagulation therapy
  • Major trauma

Placement in Analgesic Algorithm

• For mild to moderate rib fracture pain without high-risk factors:
  • Start with acetaminophen as first-line treatment 6
  • Add ketorolac as second-line treatment for additional pain control 5, 3
• For severe pain or high-risk patients:
  • Consider regional anesthetic techniques (thoracic epidural or paravertebral blocks) as gold standard for analgesia 5, 7
  • Use ketorolac as an adjunct to reduce opioid requirements 3

Comparative Efficacy

• A recent randomized double-blind clinical trial found that low-dose ketamine (0.25 mg/kg IV) provided better pain relief than ketorolac (30 mg IV) in patients with chest trauma 8
• However, ketorolac remains valuable in multimodal analgesia approaches, particularly for reducing opioid requirements 3, 2

Important Precautions and Contraindications

• Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals 1
• Avoid in patients with:
  • Aspirin/NSAID-induced asthma
  • Pregnancy
  • Cerebrovascular hemorrhage
  • Significant renal impairment 5
• Monitor for potential adverse effects including:
  • Edema
  • Drowsiness
  • Dizziness
  • GI upset
  • Increased diaphoresis 5

Clinical Pearls

• Inadequate pain control in rib fracture patients can lead to splinting, shallow breathing, atelectasis, and pneumonia 9
• Each rib fracture in elderly patients increases the risk of developing pneumonia by 27% and the risk of death by 19% 9
• Patients should be switched to alternative analgesics as soon as possible, with ketorolac therapy not exceeding 5 days 1
• Early administration of ketorolac has been associated with increased ventilator-free days and ICU-free days within 30 days after rib fractures 2