Is ketorolac (Toradol) safe to use in patients with mild Traumatic Brain Injury (TBI)?

Ketorolac Use in Mild Traumatic Brain Injury

Ketorolac can be safely administered for post-traumatic headache in patients with mild TBI, provided there is no evidence of intracranial bleeding on CT scan and the patient is hemodynamically stable. 1

Clinical Decision Algorithm

Step 1: Confirm Mild TBI and Obtain Neuroimaging

• Patients with mild TBI (Glasgow Coma Scale 14-15) should undergo brain CT scan if they meet high-risk criteria including signs of skull fracture, post-traumatic seizures, focal deficits, or coagulopathy 2
• CT imaging has high negative predictive value for excluding neurosurgical intervention needs in mild TBI 2
• If CT shows any intracranial hemorrhage, ketorolac is contraindicated 2

Step 2: Assess Bleeding Risk Factors

Before administering ketorolac, verify the patient does NOT have:

• Active intracranial bleeding on imaging 2
• Coagulation disorders or anticoagulant therapy 2
• Antiplatelet therapy that increases bleeding risk 3
• Hemodynamic instability (maintain systolic BP >110 mmHg) 4

Step 3: Consider Ketorolac as Effective Analgesic Option

Recent evidence demonstrates ketorolac is superior to acetaminophen for post-traumatic headache control:

• At 6 hours post-administration, ketorolac 60 mg IV produced significantly lower pain scores than acetaminophen 1 g IV (P = 0.006) 1
• Pain reduction was greater with ketorolac at both 2 hours (P = 0.01) and 6 hours (P = 0.001) after administration 1
• Ketorolac caused less drowsiness than acetaminophen at 2 hours (P = 0.038) 1

Key Safety Considerations

Contraindications in TBI Context

• Absolute contraindication: Any evidence of intracranial hemorrhage on imaging 2
• The European guideline on major trauma explicitly warns that NSAIDs like ketorolac can impair platelet function and increase bleeding risk 2
• In isolated head injury with intracranial hemorrhage, hemostatic drugs and interventions that affect coagulation have been associated with harm 2

Appropriate Use Parameters

• Duration: Limit to ≤5 days to minimize bleeding complications 5
• Dosing: Follow current guidelines (typically 30-60 mg IV/IM, not exceeding 120 mg/day) 5
• Age consideration: Elderly patients have markedly increased bleeding risk with prolonged use 5

Clinical Pitfalls to Avoid

Common Errors

• Do not assume all post-TBI headaches require NSAID therapy - post-traumatic headaches often have mixed features and may respond to other interventions 6
• Do not use ketorolac in patients with "complicated" mild TBI (those with positive CT findings showing hemorrhage or contusion), as 6-10% of mild TBI patients have imaging evidence of intracranial injury 2
• Avoid in patients requiring thromboprophylaxis - pharmacological thromboprophylaxis should only begin after bleeding has been controlled for at least 24 hours 2, 6

Monitoring Requirements

• Ensure hemodynamic stability is maintained throughout treatment 4
• Monitor for new or worsening neurological symptoms that might indicate delayed hemorrhage 6
• Watch for signs of gastrointestinal or operative site bleeding, which increases with dosages >5 days 5

Alternative Considerations

If ketorolac is contraindicated due to bleeding concerns:

• Acetaminophen remains a safer alternative, though less effective for pain control 1
• Opioids may be considered but carry risks of drowsiness and delayed gastrointestinal recovery 5
• Non-pharmacological interventions should be employed as adjuncts 7

The critical distinction is between "uncomplicated" mild TBI (normal CT) where ketorolac is safe and effective, versus "complicated" mild TBI (abnormal CT with hemorrhage) where ketorolac is contraindicated due to antiplatelet effects and bleeding risk. 2, 1