Management of Gastrointestinal Bleeding After Toradol (Ketorolac) Administration
Immediate Action Required
This patient requires immediate discontinuation of ketorolac, hemodynamic assessment, and urgent evaluation in the emergency department given the significant GI bleeding occurring within 2 hours of NSAID administration. 1
Initial Emergency Department Assessment
Hemodynamic Stratification
- Calculate the shock index (heart rate divided by systolic blood pressure) immediately upon arrival - a value >1 indicates hemodynamic instability requiring aggressive resuscitation 2
- Patients with shock index >1 are classified as unstable and require immediate intervention before diagnostic procedures 2
- Obtain vital signs including orthostatic measurements if the patient is stable enough 3
Laboratory Evaluation
- The platelet count mentioned in the scenario is critical - ketorolac affects platelet aggregation and can cause bleeding complications even with normal platelet counts 1
- Obtain complete blood count with hemoglobin/hematocrit, coagulation studies, and type and cross-match 2
- Check renal function as ketorolac can cause acute renal failure, which may complicate management 1
Risk Stratification Using Oakland Score
For stable patients, apply the Oakland score to determine disposition: 2
- Oakland score ≤8 points = minor self-terminating bleed - can be discharged for urgent outpatient investigation 2
- Oakland score >8 points = major bleed - requires hospital admission for colonoscopy 2
Management Based on Hemodynamic Status
For Hemodynamically Unstable Patients (Shock Index >1)
Proceed directly to CT angiography to localize the bleeding source before planning endoscopic or radiological therapy 2
Critical consideration: Since ketorolac-induced bleeding can occur from upper or lower GI sources, and hemodynamic instability may indicate upper GI bleeding, perform upper endoscopy immediately if CT angiography shows no lower GI source 2
If CT angiography is positive, catheter angiography with embolization should be performed within 60 minutes in centers with 24/7 interventional radiology services 2
For Hemodynamically Stable Patients
Admit for colonoscopy within 24 hours after adequate bowel preparation 2, 4
Consider upper endoscopy first if: 2, 5
- Patient has risk factors for upper GI bleeding (age >65, history of peptic ulcer disease)
- Ketorolac is particularly associated with upper GI complications 1, 6
Transfusion Strategy
Use restrictive transfusion thresholds: 2
- Hemoglobin trigger of 70 g/L with target 70-90 g/L for patients without cardiovascular disease 2
- Hemoglobin trigger of 80 g/L with target ≥100 g/L for patients with cardiovascular disease 2
Endoscopic Management
If colonoscopy identifies a bleeding source with high-risk stigmata (active bleeding, non-bleeding visible vessel, or adherent clot), provide endoscopic hemostasis therapy 4
Endoscopic modalities include: 4, 5
- Bipolar electrocoagulation
- Heater probe
- Clips (mechanical therapy)
- Combination therapy based on bleeding etiology and endoscopist experience
Post-Endoscopy Management
Proton Pump Inhibitor Therapy
After successful endoscopic hemostasis, administer high-dose PPI: 2, 5
- 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 2
- Then transition to oral PPI twice daily for the first 2 weeks 5
Important caveat: This intensive PPI regimen is specifically for patients who receive endoscopic therapy for high-risk lesions 2
Monitoring for Rebleeding
Watch closely for signs of rebleeding: 2
- Fresh melena or hematemesis
- Fall in blood pressure or rise in pulse
- Fall in hemoglobin
If rebleeding occurs, perform repeat endoscopy with attempted endoscopic therapy 2
If second endoscopic therapy fails, proceed to transcatheter embolization or surgery - never proceed to emergency laparotomy unless every effort has been made to localize bleeding radiologically and endoscopically 2, 5
Critical Ketorolac-Specific Considerations
Understanding Ketorolac's Unique Risk Profile
Ketorolac carries the highest risk of GI bleeding among all NSAIDs - it is 5 times more gastrotoxic than other NSAIDs with a relative risk of 24.7 for upper GI bleeding 6
The excess risk with ketorolac: 6
- Is present during the first week of therapy (this patient bled within 2 hours)
- Occurs with both oral and intramuscular administration
- Is dose-dependent and increases with duration of use
FDA warnings emphasize: 1
- Ketorolac can cause serious GI bleeding, ulceration, and perforation that can be fatal
- These events can occur at any time, with or without warning symptoms
- Only 1 in 5 patients who develop serious upper GI events on NSAID therapy is symptomatic beforehand
Platelet Dysfunction Consideration
Ketorolac affects platelet aggregation and should be used very cautiously in patients with coagulation disorders 1
The platelet count obtained in the ER should be interpreted in context: 1
- Even with normal platelet count, ketorolac impairs platelet function
- Patients on anticoagulants (heparin, warfarin) have increased bleeding risk with ketorolac and should receive concomitant therapy only extremely cautiously 1
Prevention of Recurrent Bleeding
Permanently discontinue ketorolac and avoid all NSAIDs in this patient given the severe bleeding response 4, 7
If the patient was on aspirin for cardiovascular disease: 2, 8
- Do not routinely stop aspirin for secondary prevention
- If stopped, restart as soon as hemostasis is achieved (ideally within 1-3 days, maximum 7 days) 2, 7
Test for and eradicate H. pylori if peptic ulcer disease is identified 7
Long-term PPI therapy should be continued if idiopathic ulcers are found or if the patient requires aspirin for cardiovascular disease 7
Common Pitfalls to Avoid
Do not delay endoscopy or radiological intervention while waiting for laboratory results or attempting to correct coagulopathy in unstable patients 8
Do not assume lower GI source - ketorolac-induced bleeding within 2 hours of administration may well be upper GI, particularly given ketorolac's extreme gastrotoxicity 2, 6
Do not use tranexamic acid outside of clinical trials for GI bleeding - evidence is insufficient and historic 2
Do not proceed to surgery without exhausting radiological and endoscopic options first 2