Can I give Toradol (ketorolac) for pain management in a patient with a differential diagnosis of subarachnoid hemorrhage (SAH)?

Toradol (Ketorolac) Use in Suspected Subarachnoid Hemorrhage

Toradol (ketorolac) should not be administered to patients with a differential diagnosis of subarachnoid hemorrhage (SAH) due to potential increased risk of bleeding complications.

Rationale for Avoiding Ketorolac in Suspected SAH

• NSAIDs like ketorolac impair platelet function, which could potentially increase the risk of rebleeding in patients with SAH 1
• Research has shown that NSAIDs with prominent anti-inflammatory properties may pose an additional risk factor for hemorrhage in patients with SAH 1
• The risk of "ultraearly rebleeding" (within 24 hours of initial SAH) may be as high as 15%, with 70% occurring within 2 hours of initial SAH, making any medication that affects coagulation particularly risky 2

Pain Management Recommendations for Suspected SAH

• Acetaminophen is the first-line agent for pain management in SAH patients, used by 90% of providers according to international surveys 3
• Opioids are appropriate second-line agents for pain management in SAH, used by 66% of providers 3
• Nimodipine (60 mg every 4 hours for 21 consecutive days) should be administered to all SAH patients, which may help with pain management while improving neurological outcomes 2

Important Considerations in Suspected SAH

• SAH is a medical emergency that is frequently misdiagnosed (up to 12% of cases), requiring a high index of suspicion in patients with acute onset of severe headache 4, 2
• The initial clinical severity of SAH should be rapidly determined using validated scales (e.g., Hunt and Hess, World Federation of Neurological Surgeons) as it is the most useful indicator of outcome 4, 2
• Between symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 4, 2

Diagnostic Approach for Suspected SAH

• Acute diagnostic workup should include noncontrast head CT, which if nondiagnostic, should be followed by lumbar puncture 4, 2
• CT sensitivity is highest (98-100%) within the first 12 hours after SAH, declining to 93% at 24 hours and 57-85% by day 6 2
• Proper lumbar puncture technique and interpretation of cerebrospinal fluid results are critical, looking specifically for xanthochromia and bilirubin 2

Management of Complications

• Maintenance of euvolemia and normal circulating blood volume is recommended to prevent delayed cerebral ischemia (DCI) 4, 2
• SAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario) 4, 2
• For seizure management, antiseizure medications may be reasonable in patients with high-risk features (ruptured MCA aneurysm, high-grade SAH, ICH, hydrocephalus, and cortical infarction) 4

Pitfalls to Avoid

• Avoid any medication that may impair coagulation or platelet function in suspected SAH, including NSAIDs like ketorolac 1
• Avoid phenytoin for seizure prevention as it is associated with excess morbidity and mortality in SAH patients 4
• Avoid delaying diagnosis and treatment, as the risk of early aneurysm rebleeding is high and associated with very poor outcomes 4