Question: With the expansion of Analgesia/pain relief being delivered to all paramedics. Is there going to be an addition to the standing order for the expansion of Ketorolac to the pediatric population either for ACP or PCP?

The OBHG Medical Advisory Council must take many factors into consideration when developing medical directives such as evidence based medicine, benefits of the directive versus risks and costs to paramedic services.  That being said there have been many changes surrounding analgesia directives (pediatric analgesia for ACP, PCP/ACP adult analgesia) in the past few years, including the introduction of new analgesics and the revision of indications and contraindications for these analgesics.  As QA data is collected, medical council incorporates this information into the further development and revision of the directives to ensure that the maximum benefit is received by patients, while minimizing the risks/adverse outcomes (as exemplified by the recent revisions to the adult analgesia directive).

In response to your question, the short answer is that the balance of evidence currently suggests that the use of ketorolac in the pediatric population is not indicated.  The FDA (U.S. equivalent of Health Canada) has placed a black box warning (the adverse effects must be weighed carefully against the benefits) on ketorolac and the safety and efficacy in children has not been established (1).  In addition, the pediatric population often requires medication doses to be based on weight.  As a result of this, these are instances that are at higher risk for medication errors.  This risk must be weighed against the benefit of the drug in questions effect on morbidity and mortality.  When it comes to ketorolac, the benefit of a medication delivered by an IM route (which can be a very stressful, uncomfortable and fear inducing event for this population group) must be weighed against the risk (potential drug dosing error, psychological stress of IM injections in the pediatric population).   However, medicine is ever evolving and as more evidence is collected, the scope of analgesia may extend further into the pediatric population.

1. Product Monograph: ketorolac tromethamine injection, USP (Keotorolac tromethamine) 30mg/mL, NSAID analgesic, Hospira Healthcare Corporation, Date of Revision Dec 17, 2012

Analgesia,Pain/Sedation/Nausea

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