IV Pain Management for an 81-Year-Old RA Patient with Head Injury and Paracetamol Allergy
For an 81-year-old patient with rheumatoid arthritis and a head injury who is allergic to paracetamol, intravenous ketorolac is the recommended first-line analgesic option, with morphine as an alternative for more severe pain.
First-Line Treatment: IV Ketorolac
• IV ketorolac is recommended as the first-line treatment for acute pain management in this elderly patient with RA who cannot receive paracetamol 1, 2 • The standard IV dose is 15-30 mg every 6 hours, with careful consideration of reduced dosing in elderly patients 2 • Ketorolac provides effective analgesia without the respiratory depression or cognitive impairment associated with opioids, which is particularly important in an elderly patient with a head injury 1
Alternative Option: IV Morphine
• If pain is severe or inadequately controlled with ketorolac, IV morphine can be administered at a reduced starting dose of 0.05-0.1 mg/kg (lower end of range for elderly patients) 3, 1 • Careful titration is essential due to increased risk of respiratory depression and sedation in elderly patients 1, 3 • Close monitoring for adverse effects is required, particularly given the patient's age and head injury 1, 3
Important Considerations for This Patient
• The patient's age (81 years) requires dose reduction of all analgesics due to altered pharmacokinetics and increased sensitivity to adverse effects 1 • History of rheumatoid arthritis suggests chronic NSAID use, which may affect the efficacy and safety profile of additional NSAIDs 1 • Head injury requires careful monitoring for neurological status, making opioid-sparing strategies preferable 1 • Vital signs stability should be maintained throughout pain management 1
Multimodal Approach
• Consider regional anesthesia techniques (nerve blocks) if appropriate for the location of injury and if expertise is available 1 • Non-pharmacological measures such as proper positioning, ice application, and immobilization should be implemented concurrently 1 • If pain persists despite IV ketorolac and requires opioids, use the lowest effective dose for the shortest duration 1
Monitoring and Precautions
• Monitor vital signs closely, particularly blood pressure, as NSAIDs and opioids can cause hypotension in elderly patients 1, 2 • Assess renal function before administering ketorolac, as elderly patients are at higher risk for NSAID-induced nephrotoxicity 2, 1 • Watch for signs of GI bleeding or cardiovascular complications with ketorolac, especially in elderly patients 4, 2 • If opioids are used, implement preventive measures for constipation and monitor for respiratory depression 3, 1
Contraindications to Consider
• Avoid ketorolac if the patient has renal impairment, history of GI bleeding, or concurrent anticoagulant use 2, 4 • Use caution with morphine if there are signs of increased intracranial pressure from the head injury 3, 1 • Consider drug interactions with the patient's RA medications when selecting analgesics 1