Date Published

November 5, 2014

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: I have a few questions regarding the new analgesia and moderate to severe pain medical directives.

1. Could you be more specific on what you mean with "current active bleed"? Would this include the possible bleeding attributed with fractures? Blood in urine from damage caused by known kidney stones? Menstrual bleeding?

2. Could you elaborate on the condition of "patient must remain NPO or is unable to take oral medications" for Ketorolac? Does this mean it is only to be given if Tylenol/Ibuprofen cannot be given orally, or they should remain NPO after medication administration?

3. Should we avoid giving Tylenol/Ibuprofen/Ketorolac if patient has already self-medicated with other pain medications? i.e. Percocet, Demerol, etc.

Thank you in advance for your clarification.


1. You are correct that current active bleeding is a contraindication for the administration of ketorolac and ibuprofen. Ketorolac and ibuprofen may inhibit platelet adhesion and aggregation and prolong bleeding time, and therefore should not be administered to a patient with a current active bleed. You've raised a couple great examples that would absolutely contradict the administration of both ketorolac and ibuprofen. If a fracture has caused an uncontrolled bleed (meaning, you cannot control it with a dressing), or if the patient is experiencing hematuria, then do not administer ketorolac or ibuprofen. If the bleeding is controlled with a dressing, then administration would be reasonable provided there are no other contraindications present. Keep in mind that closed fractures such as the femur or pelvis can lead to severe uncontrolled internal bleeding so these patients should not be given ketorolac or ibuprofen. In these cases, look for signs of edema, bruising, etc. Menstruation is not considered a current active bleed. The built up lining the uterus is shed monthly and is not due to a severed artery.

2. You are correct; acetaminophen/ibuprofen should not be administered in conjunction with ketorolac. If your patient meets the conditions of the Analgesia Medical Directive, then treat accordingly. If your patient must remain NPO (examples might include anticipated surgery to repair the injury, nausea, vomiting), then assess the patient for ketorolac administration.

3. The contraindications for ketorolac and ibuprofen administration include ibuprofen or NSAID use within the previous 6 hours. The contraindications for acetaminophen include acetaminophen use within the previous 4 hours. If other pain medications have been used, acetaminophen/ibuprofen or ketorolac may still be administered provided no other contraindications are present.

Examples of NSAIDS can be found on SWORBHP MEDList Website



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