How often do you read the fine-print package inserts that come with medications prescribed for your patients? Reading the drug insert that accompanies the Toradol® (ketorolac tromethamine, Roche U.S. Pharmaceuticals) package and reviewing contraindications might have saved this patient's life.
A 41-year-old healthy male presented in the emergency department with severe aches and pains after moving heavy furniture earlier in the day. His pain was confined to both upper extremities and the abdominal muscles. He indicated good health and had no chronic illnesses.
The only flag that you placed on his record was "allergic to aspirin." Since your agency requires you to place an allergy band on every patient that reports any allergy, you immediately secured a "red-alert" band indicating aspirin allergy on his left forearm. He reported that he had a severe allergic reaction once when he took 10 grains of aspirin and received an antihistamine by injection to help him breathe.
The patient was assessed by the physician, who prescribed ketorolac tromethamine 60 mg IM stat, and a muscle relaxant. He was directed to report to his personal doctor if the pain persisted longer than three days.
What You Know About Ketorolac
According to reported clinical studies,1 ketorolac is a good choice in this situation because it provides pain relief comparable to meperidine or morphine and causes less drowsiness, nausea and vomiting than morphine. Since it is classified as a nonsteroidal anti-inflammatory drug (NSAID), it is indicated for short-term pain.
You have given this drug many times and recall that it should be used with caution in elderly patients and in patients at high risk for bleeding. You remember it has been on the market for about 10 years and you have never heard of a reaction to it.
When you prepared to give the injection, the patient was dressed in his street clothes and anxious to go because his pharmacy closed in 20 minutes and he wanted to start the muscle relaxant that night. You asked the patient if he had ever received this drug before, and he said he had never heard of it. As you administered the drug in the left deltoid, the patient asked if he needed to sign anything since he was in a hurry to get to the drugstore. You told him to return to his physician if the pain persisted, and he signed his record indicating that he understood the discharge instructions.
About 30 minutes later you received a phone call notifying you that EMTs had a 911 call from a woman who said her husband was just treated in the outpatient clinic where he received an injection. Now he was having severe trouble breathing.
The EMTs started the usual IV fluid and prepared to place him on a monitor when they discovered he was not breathing and had no heart rate. CPR was started, but despite their best efforts, the patient died.
Could this be the 41-year-old who looked so healthy just 45 minutes ago and to whom you administered Toradol? What could have happened? What could have gone wrong? You suspect a heart attack; but the man had no typical symptoms, and his heart rate was strong and regular.
Contraindications and Warnings: Are They Real?
Drug information including contraindications are provided for a purpose--to prevent patients from receiving drugs for which they may have an allergic reaction or cross sensitivity.
After the fact, the nurse in this hypothetical case study located the drug insert to the Toradol package and read the contraindications to see if they could have contributed to the patient's difficulties.
Toradol should not be used in patients with previously demonstrated hypersensitivity to ketorolac tromethamine or in individuals with the complete or partial syndrome of nasal polyps, angioedema, bronchospastic reactivity or other allergic manifestations to aspirin or other NSAIDs. Severe anaphylactic-like reactions to Toradol have been reported in such patients.1 In the case of the 41-year-old man, an autopsy revealed an allergic manifestation.
If the nurse had remembered the patient had an alert band and instructed him to remain in the hospital at least 30 minutes more to observe any possible allergic reaction, he would have been under medical care when the reaction occurred.
As nurses, it is our legal and ethical duty to administer only those drugs for which we know the side effects, toxic effects, allergic reactions, immediate desired effects, unusual and unexpected effects and to recognize changes in client's conditions that contraindicate the administration of the medication. We must anticipate those effects that may rapidly endanger a client's life or well-being and be able to take decisive action if untoward effects occur.2
The case cited was hypothetical, but it could have been real. Since the allergic potential is clearly documented in drug references, the nurse is on notice to know of this possibility. The nurse did the correct thing by flagging the chart and placing an alert band on the patient when the allergy to aspirin was revealed. But in the rush of the moment or in the nurse's lack of knowledge, the patient received a medication that he should not have. The second mistake was allowing the patient to leave the outpatient clinic without waiting to determine if an allergic reaction might occur. The lesson here is simple. Know the drug before you administer. It could save a life.
Frances R. Eason, a professor at the School of Nursing, East Carolina University, Greenville, has published two previous articles related to ketorolac and has served as a consultant in cases similar to the scenario in this article.
Toradol ® IM and Toradol ® ORAL. (1991) Syntex Laboratories, Inc. Palo Alto, CA, Drug Insert.
North Carolina Administrative Code. (1996) Chapter 36 Board of Nursing. 0221 License Required. (c) (1) A-H.
Nonsteroidal anti-inflammatory drug indicated for the short-term management of moderately severe acute pain
Not indicated for minor or chronic painful conditions
Available for IV or IM administration as 15 mg in 1 mL and 30 mg in 1 mL in sterile solution. 60 mg in 2 mL of ketorolac tromethamine in sterile solution is available for IM administration only
Dosage should be adjusted for patients 65 or older, for patients under 50 kg (110 lbs) and for patients with moderately elevated serum creatinine. Doses are not to exceed 60 mg in these patients
Contraindicated in patients currently receiving aspirin or NSAIDs because of the cumulative risk of inducing NSAID-related side effects