Ketorolac
Ketorolac tromethamine
Brand names:Toradol, Sprix
A parenteral NSAID used in EMS for moderate to severe pain management when oral NSAIDs are not appropriate. In PA Statewide ALS Protocols, ketorolac is available as a Possible Medical Command Order for pain in musculoskeletal trauma, renal colic, and migraine headache. Not included in standard TCCC doctrine.
Pharmacology and Actions
Ketorolac is a non-selective cyclooxygenase inhibitor that blocks prostaglandin synthesis centrally and peripherally. Compared to ibuprofen, ketorolac has more potent analgesic effects relative to anti-inflammatory effects, and it can be administered parenterally. The drug does not bind opioid receptors and does not produce respiratory depression, euphoria, or dependence.
Indications
- Moderate to severe pain when oral NSAIDs are inappropriate (PA Possible MC Order)
- Renal colic pain (kidney stones) in protocols permitting NSAID use
- Migraine headache pain in patients without contraindications
- Musculoskeletal trauma pain when NSAID use is not contraindicated
- Postoperative pain in hospital settings
Absolute Contraindications
- Known ketorolac or NSAID allergy
- Active gastrointestinal bleeding or peptic ulcer disease
- Suspected or confirmed bleeding from any source
- Known kidney disease, kidney failure, or kidney transplant
- Severe hepatic impairment
- Third-trimester pregnancy or active labor
- Recent NSAID administration within prior 6 hours
- Patients with hemorrhagic stroke or suspected intracranial hemorrhage
Precautions and Side Effects
Same NSAID class effects as ibuprofen: GI irritation, renal impairment risk, platelet inhibition, and bronchospasm in NSAID-sensitive asthmatics. Ketorolac use should be limited to 5 days total due to increased risk of GI and renal complications with prolonged administration. IV/IM administration may cause injection site pain. Avoid in patients on anticoagulants or with bleeding diathesis. Renal dose adjustment is required in elderly patients and those with impaired creatinine clearance.
Adult Dosing
Pediatric Dosing
PA Possible MC Order for pediatric patients 2 years and older: 0.5 mg/kg IV/IO/IM, maximum 15 mg IV or 30 mg IM. Pediatric ketorolac is uncommon in prehospital settings and requires Medical Command order.
Pharmacokinetics
Peak Effect: IV: 1 to 2 hours. IM: 1 to 2 hours.
Duration: 4 to 6 hours
Storage and Handling
Store ampules and vials at controlled room temperature (15 to 30 degrees Celsius). Protect from light. Sprix nasal spray has specific storage requirements per manufacturer.
Reconstitution:
Ketorolac IV/IM is supplied as a sterile solution at 15 mg/mL or 30 mg/mL. No reconstitution required.
TCCC and TECC Role
Ketorolac is not included in TCCC 2026 doctrine. The parenteral NSAID role in tactical analgesia is addressed through meloxicam (oral, in the CWMP) rather than an IM or IV NSAID. Ketorolac's use case is primarily civilian EMS where parenteral NSAID analgesia is appropriate for renal colic, migraine, and select musculoskeletal pain in patients without bleeding risk. TEMS providers operating in a civilian EMS framework may use ketorolac under their agency protocol when scope permits.
Ketorolac is the parenteral analgesic providers reach for when they want strong NSAID-class pain relief without opioids, in a patient who cannot take PO. Renal colic is the classic indication: it works fast, it does not cloud mental status, and it does not require controlled substance documentation. The downside is the same as all NSAIDs: any patient with potential bleeding (trauma, anticoagulants, GI history) is the wrong patient. Verify the patient has not taken an NSAID in the prior 6 hours before administering.
Treating ketorolac as a substitute for an opioid in trauma pain. The bleeding contraindication makes ketorolac inappropriate for most trauma indications, particularly penetrating trauma, head injury, or any patient who may require surgery. The drug is excellent for non-traumatic pain (renal colic, migraine, dysmenorrhea) but should not be the trauma analgesic of choice.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
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Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Ketorolac
| IV/IO | PA Possible MC Order: 15 mg IV slow push. Single dose in EMS setting; repeat dosing requires hospital evaluation. (10 minutes) |
| IM | PA Possible MC Order: 30 mg IM, single dose. IM injection is less painful when given in the gluteal muscle. (30 minutes) |
| IN | Sprix intranasal: 31.5 mg (one spray each nostril) every 6 to 8 hours. Not commonly carried in prehospital EMS. (20 to 30 minutes (Sprix)) |
| PO | Oral ketorolac 10 mg every 4 to 6 hours is available but rarely used; the drug is most often parenteral. (30 to 60 minutes) |