Answer: 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