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

Ketorolac (Toradol) Use in Rib Fractures

Ketorolac 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 narcotic requirements without increasing acute kidney injury or bleeding risk. 1, 2, 3

Risk Assessment for Rib Fracture Patients

• Rib fractures occur in up to 40% of trauma patients with overall mortality around 10%, with higher rates in elderly patients 4
• Risk factors that predict increased complications include:
  • Age >60 years 4
  • SpO2 <90% 4
  • Obesity or malnutrition 4
  • Multiple rib fractures (2-3), flail segment, or pulmonary contusion 4
  • Smoking or chronic respiratory disease 4
  • Anticoagulation therapy 4
  • Major trauma 4

Ketorolac Dosing Guidelines for Rib Fractures

• Ketorolac should be initiated with IV or IM dosing and oral tablets used only as continuation therapy 1
• For patients 17-64 years: 60 mg IM every 15-30 minutes (maximum 120 mg/day) 4, 1
• For patients ≥65 years or with renal impairment: Use reduced dosing (10 mg PO once followed by 10 mg q4-6 hours, not exceeding 40 mg/day) 1
• Total combined duration of IV/IM and oral ketorolac must not exceed 5 days due to increased risk of adverse events 1

Benefits of Ketorolac in Rib Fracture Management

• Ketorolac use is associated with decreased pneumonia following rib fractures 3
• Studies show ketorolac increases ventilator-free days and ICU-free days within 30 days after rib fractures 3
• Ketorolac significantly reduces narcotic requirements in patients with traumatic rib fractures 5
• Recent research (2021) demonstrates that ketorolac does not increase the incidence of acute kidney injury or bleeding events in trauma patients with rib fractures 2

Multimodal Analgesia Approach for Rib Fractures

• Thoracic epidural (TE) and paravertebral blocks (PVB) are considered gold standard for rib fracture analgesia 4, 6
• For less severe cases or when regional techniques are contraindicated, a multimodal approach including ketorolac can be effective 4, 7
• Acetaminophen (IV or oral) should be included in the multimodal approach 4, 8
• Low-dose ketamine (0.3 mg/kg over 15 minutes) can be an alternative to opioids with comparable analgesic efficacy 4, 9

Contraindications and Precautions for Ketorolac

• Avoid in patients with aspirin/NSAID-induced asthma 4
• Contraindicated in pregnancy and cerebrovascular hemorrhage 4
• Use with caution in elderly patients due to increased risk of adverse effects 1
• Monitor for edema, drowsiness, dizziness, GI upset, and increased diaphoresis 4
• Use the lowest effective dose for the shortest duration consistent with treatment goals 1

Recent Evidence Comparing Ketorolac to Other Analgesics

• A 2024 randomized double-blind clinical trial found that ketamine (0.25 mg/kg IV) provided more significant pain relief than ketorolac (30 mg IV) at 30 and 60 minutes after administration in chest trauma patients 9
• Patients receiving ketamine needed less rescue pain medication than those receiving ketorolac, though they reported more frequent nausea 9
• Early intravenous ibuprofen therapy has also shown benefits in decreasing narcotic requirements and hospital length of stay in patients with traumatic rib fractures 5

Clinical Algorithm for Ketorolac Use in Rib Fractures

1. Assess risk factors and severity of rib fractures 4, 7
2. For high-risk patients (multiple risk factors, severe pain), consider regional anesthesia (TE or PVB) as first-line 4, 6
3. For moderate risk or when regional techniques are contraindicated:
   • Start with IV ketorolac (60 mg IM for adults <65 years; reduced dose for elderly) 4, 1
   • Combine with scheduled acetaminophen 4, 7
   • Add low-dose ketamine if additional analgesia needed 4, 9
4. Transition to oral ketorolac only as continuation therapy 1
5. Limit total ketorolac duration to ≤5 days 1
6. Monitor for respiratory function, as inadequate pain control can lead to splinting, atelectasis, and pneumonia 10