Date Published

March 13, 2023

Updated For

ALS PCS Version ALS PCS Version 5.2


Why does Ketorolac in the Analgesia Medical Directive have normotensive as a condition, when other NSAID directives do not include a SBP condition?


There are 2 main reasons for this:

1) Patients who are volume depleted (which may present as hypotension) may be dependent on renal prostaglandin production to maintain renal perfusion and, therefore, glomerular filtration rate. In such patients, the use of drugs which inhibit prostaglandin synthesis has been associated with further decreases in renal blood flow and may precipitate acute renal failure.

2) This condition was put in place for safety due to the risk of increased bleeding with NSAIDs. Ketorolac historically was reserved for severe pain. Although Current active bleeding is a Contraindication; sometimes bleeding is not apparent, for example a ruptured Abdominal Aortic Aneurysm (AAA) that can cause severe pain without obvious external bleeding. NSAIDs, inhibit platelet adhesion and aggregation and prolong bleeding time. Therefore, for an SBP < 100mHg (which may be due to covert bleeding), ketorolac should be withheld.

Although the Conditions for Ketorolac have now changed (to allow for paramedic clinical judgement and discretion), the same principle can be employed: If a patient is not normotensive, they should not receive an NSAID, since occult bleeding may be worsened.

Please note that although Ibuprofen does not carry a Condition for Normotension, should you suspect occult bleeding, you may certainly withhold this medication. As always, make sure to document your rationale.



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