Toradol and GI bleed

[strongboy2005]

Had an attending last night give a patient with possible active upper GI bleeding (previous hematemesis and melena, possibly in the process of resolving) a shot of toradol. Is this an acceptable treatment for pain in a patient with upper GI bleed? The attending's concern was not giving opiates because the patient was hypotensive and she didn't want that to worsen, but the toradol struck me as odd because I have read that it is often considered relatively contraindicated in the elderly because of the increased risk of upper GI bleed. In this case, the patient actually had an upper GI bleed. I did not question the attending's rationale because I didn't want to come off like I thought I knew more than her or something, so I was hoping residents/attendings on SDN could clarify this issue for me. Thanks.

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[michaelrack]

Had an attending last night give a patient with possible active upper GI bleeding (previous hematemesis and melena, possibly in the process of resolving) a shot of toradol. Is this an acceptable treatment for pain in a patient with upper GI bleed?.

xxxxxx

 

[deleted109597]

Without knowing more, I would say that I personally wouldn't give that drug.

Of course, I don't give that drug for anything except the unable to tolerate PO kidney stone.

 

[dotcb]

I did a rotation at a medical malpractice law firm. There were many cases of patients who received toradol and subsequently bled to death from things like AAA (suspected renal stone), PUD (suspected biliary colic), etc. And then lawyers claimed delayed Dx and toradol contributed to harm. Not to mention potential nephrotoxicity in older patients. My understanding is that its efficacy is no better than motrin. For this reason, toradol is a medicine I generally don't use at all. If it's bad pain, I use opiates (can use pressor if needed). If it's not - tylenol or motrin and goodbye home.


motrin vs. toradol
http://www.cjem-online.ca/v9/n1/p30

Dr. Wikipedia:
Ketorolac is not recommended for pre-operative analgesia or co-administration with anesthesia because it inhibits platelet aggregation and thus may be associated with an increased risk of bleeding.
Ketorolac is not recommended for obstetric analgesia because it has not been adequately tested for obstetrical administration and has demonstrable fetal toxicity in laboratory animals.
ketorolac should be avoided in patients with renal (kidney) dysfunction. (Prostaglandins are needed to dilate the afferent arteriole; NSAIDs effectively reverse this.) The patients at highest risk, especially in the elderly, are those with fluid imbalances or with compromised renal function (e.g., heart failure, diuretic use, cirrhosis, dehydration, and renal insufficiency).

 

[AmoryBlaine]

I really hate the whole "their blood pressure is too low for dilaudid" crap we get from nurses.

At worst you are introducing a bit of medication induced vasodilation, this is not the same as shock.

There is no BP that is too low for adequate analgesia. If you are really freaked out give them fentanyl.

By this logic every patient in septic shock who is on a vent should receive no sedation whatsoever.

 

[Cerberus]

I'm not a huge fan of toradol. If I think a pt is really having serious pain I give an opioid. If I think they're FOS drug seeker (although those usually have a "toradol allergy") or having minor pain but are the "I'm not really getting a medicine unless it's IV/IM" type I'll give 15mg toradol (I've read that it actually ceilings out at 15mg, despite the usual dose being 30mg).

 

[southerndoc]

I'm not a huge fan of toradol. If I think a pt is really having serious pain I give an opioid. If I think they're FOS drug seeker (although those usually have a "toradol allergy") or having minor pain but are the "I'm not really getting a medicine unless it's IV/IM" type I'll give 15mg toradol (I've read that it actually ceilings out at 15mg, despite the usual dose being 30mg).

I've seen renal colic patients suck up 3 mg of Dilaudid without relief but get instantaneous relief with 30 mg of Toradol.

I've had Toradol before (IV and PO). It works.

 

[la gringa]

I've seen renal colic patients suck up 3 mg of Dilaudid without relief but get instantaneous relief with 30 mg of Toradol.

I've had Toradol before (IV and PO). It works.

works great for musculoskeletal pain - in my personal and professional experience. great for pts w/ no ride and who have already tried po nsaid's at home.

i do steer clear in the elderly, any ddx involving bleeding, and any whiff of renal issues.

 

[WilcoWorld]

I too love Toradol for kidney stones. It works better than narcs. For all other pain I use narcs, antidopaminergics or PO meds.

I wouldn't have managed what you described the way you described it, but perhaps your attending thought the patient was drug-seeking? Personally, I don't give drug-seekers Toradol (it's a waste of time), but I could see how someone complaining of "vomiting blood" (for the 4th time this year...with 2 negative scopes since last September) when they're really suffering from hydromorphopenia might get managed that way.

 

[TrumpetDoc]

Very suspicious of such a study mentions above. Prob motivated to these findings on a "cost" basis...

In practice AND having had a stone...
There is NO COMPARISON between Ibuprofen and Toradol!
And I've seen tntc pts that also demonstrate this.

 

[Pharmavixen]

I really hate the whole "their blood pressure is too low for dilaudid" crap we get from nurses.

At worst you are introducing a bit of medication induced vasodilation, this is not the same as shock.

There is no BP that is too low for adequate analgesia. If you are really freaked out give them fentanyl.

By this logic every patient in septic shock who is on a vent should receive no sedation whatsoever.

👍

Opioids are much MUCH safer drugs than toradol. Pharmacologically speaking, NSAIDs are distinguished by their degree of COX I and COX II inhibition. In a (greatly simplified) nutshell: if COX II inhibition predominates, the drug has a greater CV risk, eg, rofecoxib (Vioxx). If COX I predominates, there's a greater GI risk. So this chart shows how ketorolac has the most predominant COX I inhibition and therefore the most GI risk:

 

[Old_Mil]

Had an attending last night give a patient with possible active upper GI bleeding (previous hematemesis and melena, possibly in the process of resolving) a shot of toradol. Is this an acceptable treatment for pain in a patient with upper GI bleed? The attending's concern was not giving opiates because the patient was hypotensive and she didn't want that to worsen, but the toradol struck me as odd because I have read that it is often considered relatively contraindicated in the elderly because of the increased risk of upper GI bleed. In this case, the patient actually had an upper GI bleed. I did not question the attending's rationale because I didn't want to come off like I thought I knew more than her or something, so I was hoping residents/attendings on SDN could clarify this issue for me. Thanks.

Sometimes in residency attendings teach you what to do.

Other times, they teach you what not to do. This sounds like one of those times.

 

[logos]

Sometimes in residency attendings teach you what to do.

Other times, they teach you what not to do. This sounds like one of those times.

That's a damn fine way of putting it.

They are never too hypotensive for an opiod. Just choose something that is cardiostable like fentanyl or dilaudid. Neither produce any appreciable histamine release or hypotension.

 

[The White Coat Investor]

Soo.....here's a related question I've never really found a good answer for:

Is po toradol (or ibuprofen for that matter) less likely or more likely to exacerbate a GI bleed than IV toradol?

Is it an effect of the drug on the platelets once its in the bloodstream, or is it a direct effect on the gastric lining?

 

[Groove]

Soo.....here's a related question I've never really found a good answer for:

Is po toradol (or ibuprofen for that matter) less likely or more likely to exacerbate a GI bleed than IV toradol?

Is it an effect of the drug on the platelets once its in the bloodstream, or is it a direct effect on the gastric lining?

I remember looking this up about a year ago... The anti-platelet is a given, but it's the question of reactive gastritis or NSAID reactive gastropathy as the GI docs call it as another potential source of exacerbating the source of bleed. I couldn't find a lot of literature that could prove significant "acute" causes from NSAIDS and there seems to be a little bit of argument over the chronic use. Either way... it's one of those dogma things that hasn't been clearly disproven. It's probably more of a theoretical thing in that PO "seems" to be potentially worse, but probably isn't in actuality.

Sorry, I'm late to the party, but I'd say anything anti-platelet in a GI bleed makes me scratch my head a bit. Non-selective COX inhibition just doesn't seem to jive with a bloody gut. I never give Toradol to a GI bleed.

 

[EM2BE]

Branching of the toradol question -

Headaches / Migraines: we have some attendings that use toradol a lot for the typical headache/migraine. Works for many patients. I got used to that practice and there is one in particular that gives me grief if I order it. I know some caution is to be made. For example, pt has HTN (SBP was 180 at arrival) and c/o typical migraine. SBP comes down to 130 in the ED without any intervention. No plan for CT/LP after talking to them, pt doesn't appear ill. Why not give toradol? I know there is a risk for SAH, but if you aren't pursuing it, do you still avoid NSAIDs? Even if the complaint is typical migraine?

Edit: most pts with typical migraine are given reglan and toradol to start here

 

[Groove]

Branching of the toradol question -

Headaches / Migraines: we have some attendings that use toradol a lot for the typical headache/migraine. Works for many patients. I got used to that practice and there is one in particular that gives me grief if I order it. I know some caution is to be made. For example, pt has HTN (SBP was 180 at arrival) and c/o typical migraine. SBP comes down to 130 in the ED without any intervention. No plan for CT/LP after talking to them, pt doesn't appear ill. Why not give toradol? I know there is a risk for SAH, but if you aren't pursuing it, do you still avoid NSAIDs? Even if the complaint is typical migraine?

Edit: most pts with typical migraine are given reglan and toradol to start here

I don't give Toradol to migraines because migraine (especially atypical and moderately severe) comes too close to SAH for comfort in my book. By the time I'm treating the sx, I'm still trying to figure out the best way for me to comfortably rule out a SAH. Every presentation is different, but that's typically how I feel about those types of "moderately severe" HA presentations.

If I'm convinced it's most likely migraine, (typical pattern, frequency, sx, risk stratify aneurysm, etc..), I use compazine or reglan, O2, fluids, benadryl, dim the room and check back in 30. If only marginally better, I try narcs but usually don't start out with them. If they come in demanding narcs and say that's the only thing that ever "gets my HA better", I typically go path of least resistance and just work on getting them out the door as quickly and as safely as possible so I can turn over the bed.

Problem is... your stuck not giving Toradol until you have sufficienctly ruled out a head bleed. If you can't do that at the beginning, then don't give it. My 2 cents.

 

[Arcan57]

I don't give Toradol to migraines because migraine (especially atypical and moderately severe) comes too close to SAH for comfort in my book. By the time I'm treating the sx, I'm still trying to figure out the best way for me to comfortably rule out a SAH. Every presentation is different, but that's typically how I feel about those types of "moderately severe" HA presentations.

If I'm convinced it's most likely migraine, (typical pattern, frequency, sx, risk stratify aneurysm, etc..), I use compazine or reglan, O2, fluids, benadryl, dim the room and check back in 30. If only marginally better, I try narcs but usually don't start out with them. If they come in demanding narcs and say that's the only thing that ever "gets my HA better", I typically go path of least resistance and just work on getting them out the door as quickly and as safely as possible so I can turn over the bed.

Problem is... your stuck not giving Toradol until you have sufficienctly ruled out a head bleed. If you can't do that at the beginning, then don't give it. My 2 cents.

Droperidol (Inapsine) is my first line drug for "only 4mg dilaudid IVP helps my headache". It works surprisingly well and if they develop akathisia as a side effect it makes dispo even easier.

 

[Interpolfanclub]

Droperidol (Inapsine) is my first line drug for "only 4mg dilaudid IVP helps my headache". It works surprisingly well and if they develop akathisia as a side effect it makes dispo even easier.

Inapsine is the truth. Don't have it at my current ED. As I was leaving last night I overheard a belly-painer rolling in by EMS telling the medics how she was allergic to inapsine and every other non-narcotic analgesic (throat swells up and can't breathe) but stadol and nubain and that "D" medication always work. It was the most classic seeking/dependency behavior I've ever seen.

I never give toradol for migraine btw for the reasons mentioned earlier. Reglan, benadryl, lights off etc etc.

 

[Groove]

Droperidol (Inapsine) is my first line drug for "only 4mg dilaudid IVP helps my headache". It works surprisingly well and if they develop akathisia as a side effect it makes dispo even easier.

The attendings at my institution rave about the stuff. I wish we had it, so that I could try it myself on a few patients. I guess that was before the QT black box warning days. Now, because of that.. our hospital won't even carry it. I haven't worked in another hospital yet that carried it either. I feel like I missed out.

 

[Tiger26]

The attendings at my institution rave about the stuff. I wish we had it, so that I could try it myself on a few patients. I guess that was before the QT black box warning days. Now, because of that.. our hospital won't even carry it. I haven't worked in another hospital yet that carried it either. I feel like I missed out.

It's a magic elixir--I use it for migraine, chronic pain, N/V refractory to zofran, agitation--it does it all.

The one drug where people have thanked me for taking away their migraine pain.

The QT stuff is nonsense though--same QT effect as zofran. Our institution published a 16,000 pt case series without adverse events. We even have a QT clinic (yeah, I know) and they give droperidol to patients

 

[TysonCook]

A few pharmacist letters on Toradol and NSAIDS. Pretty quick reads with references.
Agree with above, except concern for SAH in "exact same HA as before" I will use Toradol for those HA's.

 

[Birdstrike]

.

 

[la gringa]

i had a guy rolling around w/ belly pain who needed a HIDA scan and couldn't have narcs. Nurse suggested droperidol.... now i'm in love.

 

[Groove]

Honestly, I'd love to try the stuff. I read the same jazz about the black box warning being bogus, but I literally can't find a place that carries it. Our pharmacists act like it's IV "black plague". Attendings on the other hand swear by it.

 

[WilcoWorld]

Another droperidol fan here. I'm not as surprised by how well it works for migraine (it is an antidopaminergic, after all) as I am by how well it works for all chronic pain - even in narcotic seekers. I think that, being an antipsychotic, it has a really nice "shut the heck up" effect on whiners.

Oh man, that sounds bitter, but the truth is that the patients generally seem quite satisfied by it.

 

[southerndoc]

Honestly, I'd love to try the stuff. I read the same jazz about the black box warning being bogus, but I literally can't find a place that carries it. Our pharmacists act like it's IV "black plague". Attendings on the other hand swear by it.

Our P&T committee has restricted its use to anesthesiologists only. Not sure how that one came about.

 

[deleted109597]

Our P&T committee has restricted its use to anesthesiologists only. Not sure how that one came about.

So have an EM doc sit on the committee and explain how stupid that is.

 

[Belleza156]

I don't give Toradol to migraines because migraine (especially atypical and moderately severe) comes too close to SAH for comfort in my book. By the time I'm treating the sx, I'm still trying to figure out the best way for me to comfortably rule out a SAH. Every presentation is different, but that's typically how I feel about those types of "moderately severe" HA presentations.

If I'm convinced it's most likely migraine, (typical pattern, frequency, sx, risk stratify aneurysm, etc..), I use compazine or reglan, O2, fluids, benadryl, dim the room and check back in 30. If only marginally better, I try narcs but usually don't start out with them. If they come in demanding narcs and say that's the only thing that ever "gets my HA better", I typically go path of least resistance and just work on getting them out the door as quickly and as safely as possible so I can turn over the bed.

Problem is... your stuck not giving Toradol until you have sufficienctly ruled out a head bleed. If you can't do that at the beginning, then don't give it. My 2 cents.

MS IV here. ....do u give benadryl in case the reglan gives a dystonic reaction? I haven't been taught to give benadryl in the initial order.

 

[Rendar5]

yep, Benadryl + reglan if it's iv push. The faster the push, the more likely the akathisia; and that's so unpleasant, and adds yet another re-evaluation step, that I give Benadryl off the bat as a combo.

 

[Apollyon]

I also always order the Benadryl up front. I have zero evidence to support it, but I figure that people that present to the ED with headaches could also have other neuro-electric whatever problems, and I suspect that dystonia is more likely (vs people with just abdominal complaints - notwithstanding that nausea is a component of an "abdominal migraine", and that the abdomen has as many neurons as the brain and spinal cord). Especially if someone is having a headache (subjective), the last thing I want is an objective dystonic reaction, and, being a community doc, I don't have the luxury of "do it, see what happens, and, if it does, do something else". 20mg Reglan and 50mg Benadryl, and, if it's a true migraine (and not opiopenia), that very often does the trick, and patients are eminently grateful.

 

[Groove]

Yes, I give benadryl first.

 

[pinipig523]

Re the initial post by OP, your attending could've used fentanyl if she was concerned about SBP stability.

 

[Jay K]

The thread hijack was informative and useful for me re: migraine Rx with metoclopramide. I use metoclopramide frequently as anti-emesis prophylaxis intra-op, but not so much in awake patients due to the risk for dystonic reactions. Additionally, did not previously know premedication with diphenhydramine makes a good prophylactic for that.

We often encounter patients in preop complaining of headache/migraine and seem to have few options preop (certainly toradol is not a good preop agent to administer). Many patients due to NPO status also complain of caffeine-withdrawal headache. I wonder if metoclopramide would help these types of headaches.

As an aside, I am more reticent of administering medications which have side effect profiles that include QT prolongation particularly in patients already with semi-to-actual QT prolongation on their ECG's; A colleague recently had a patient code in such a manner after administering methadone intraop. We use ondansetron as anti-emetic prophylaxis in a majority of our cases, and I sometimes wonder if some of my colleagues and myself just get lucky.

 

[e30ftw]

if i think someone with cc: HA has a true migraine (ie, typical symptoms, similar to prior migraine HA, etc) the rx is:

10-20mg reglan IV, 50 mg benadryl IV, 1000ml NS IV over 1 hr + dark room +/- narcotics/benzos for anxiety and sometimes 25mg phenergan IV.

this only applies if I truly believe the person to have an actual migraine HA which is intractable to their usual IM triptan home treatment.

the management of HA in the ED is a totally different topic.

 

[Apollyon]

The thread hijack was informative and useful for me re: migraine Rx with metoclopramide. I use metoclopramide frequently as anti-emesis prophylaxis intra-op, but not so much in awake patients due to the risk for dystonic reactions. Additionally, did not previously know premedication with diphenhydramine makes a good prophylactic for that.

We often encounter patients in preop complaining of headache/migraine and seem to have few options preop (certainly toradol is not a good preop agent to administer). Many patients due to NPO status also complain of caffeine-withdrawal headache. I wonder if metoclopramide would help these types of headaches.

As an aside, I am more aware when I think on administering medications which have side effect profiles that include QT prolongation particularly in patients already with semi-to-actual QT prolongation on their ECG's; A colleague recently had a patient code in such a manner after administering methadone intraop. We use ondansetron as anti-emetic prophylaxis in a majority of our cases, and I sometimes wonder if some of my colleagues and myself just get lucky.

And also as an aside, thank you for being one of our anesthesiology colleagues, and not just coming in here and crapping all over us for being "dumb ER docs". I say this sincerely. I think I take away more knowledge from your folks than I give.

 

[deuist]

To help prevent dystonia from reglan pushes, I write my order as

Reglan 10mg in 100mL of NS, infuse via IV over 30 minutes
Benadryl 25mg IV
+/- Toradol 30mg IV

Turn off all of the lights and sounds and come back 1 hour later. That takes care of most folks. I've also started doing cervical injections with marcaine (from Mellick) and occasionally have had some success.

 

[Ruprict]

Since this tread has taken a migraine turn, I'll pose a question we were discussing the other night... if droperidol works so well, why not another antipsychotic, like say haloperidol? We intermittently have drop and it works great. I'm curious if anyone has tried haldol. In theory, it should work just as well as drop, right? We were going to try it, but reglan/benadryl/toradol eventually kicked in.

 

[name?]

Since this tread has taken a migraine turn, I'll pose a question we were discussing the other night... if droperidol works so well, why not another antipsychotic, like say haloperidol? We intermittently have drop and it works great. I'm curious if anyone has tried haldol. In theory, it should work just as well as drop, right? We were going to try it, but reglan/benadryl/toradol eventually kicked in.

I've used haldol as a surrogate for droperidol and it is pretty good from a cyclic vomiting/abdominal migraine/migraine standpoint. I don't have enough experience with droperidol to say it's as good, but it's readily available almost everywhere. QT concerns persist, but as many have pointed out, we regularly use zofran, azithromycin, quinolones etc and their effects are similar. Probably worth checking an EKG if you're stacking too many of these guys on top of one another, though.

 

[deleted109597]

Since this tread has taken a migraine turn, I'll pose a question we were discussing the other night... if droperidol works so well, why not another antipsychotic, like say haloperidol? We intermittently have drop and it works great. I'm curious if anyone has tried haldol. In theory, it should work just as well as drop, right? We were going to try it, but reglan/benadryl/toradol eventually kicked in.

Haldol works pretty good in a pinch. The problem is that many patients know what it is, unlike droperidol, so they refuse it.

 

[Rendar5]

For migraines depakote can work well iv as can keppra.

 

[Rendar5]

For migraines depakote can work well iv as can keppra.

 

[Libertas]

they may know haldol, but what about chlorpromazine? 👍 had good luck with it on floors as an intern