Question: In the 2015 ALS Companion Document Version 3.3 pg 13, it states this: "A clinical consideration states "Suspected renal colic patients should routinely be considered for Ketorolac". More correctly, this statement should include NSAIDS like Ibuprofen. Ketorolac is preferred when the patient is unable to tolerate oral medication.
There is some confusion over the interpretation of this. I read this statement as suspected renal colic patients should be routinely screened for an NSAID (not just Ketorolac), and therefore should be given ibuprofen first instead, unless the patient cannot tolerate oral medication. My PPC is saying differently that you should be considering Ketorolac first, since the companion document cannot overrule the ALS Directives. What is the true purpose of this statement then?
**Update Feb 1, (ALS-PCS v4.9): The Condition of Unable to tolerate oral medications was removed for Ketorolac, to allow for paramedics to use more clinical judgement in selecting the most appropriate medication based on clinical presentation. The Clinical Considerations section now reads as, Patients presenting with suspected renal colic may receive either ketorolac or ibuprofen.
The current analgesia medical directive does generate a lot of confusion. The current directive is the result of compromises made at the time the directive was negotiated. There is an updated comprehensive adult analgesia medical directive currently making its way through the Ministry approval process. The new directive will allow for more liberal use of analgesia. Until it is released, the direction is, assuming no contraindications, to give a patient with suspected renal colic and a history of previous renal colic an NSAID. The directives clinical considerations allow for the use of ketorolac as a first line NSAID for this patient population only. Suspected renal colic patients should routinely be considered for ketorolac administration (meaning, first line) because of the anti-inflammatory action and smooth muscle relaxant effects (reduces the glomerular filtration rate which reduces renal pelvic pressure and stimulation of the stretch receptors) as well as its inhibition of prostaglandin production makes them ideal agents to treat renal colic. Ketorolac should not be administered in conjunction with ibuprofen as they are both NSAIDs and concomitant administration of both would increase the adverse effects.