Answer: Great question. As per the Medical Directive, whenever possible, both acetaminophen and ibuprofen should be used together. Ketorolac however should not be administered concurrently with ibuprofen not just because of the NPO restriction, but also because both Ketorolac and Ibuprofen are both NSAIDS and this could increase the likelihood of an adverse drug reaction.
Great point about how vague the terminology is with the contraindication of “Hx cardiovascular disease”.
The intent for this contraindication is a patient with CHF who may also have impaired renal function or a patient with poorly controlled HTN or a patient with severe peripheral vascular disease. The intent with this contraindication was not a patient with a previous isolated remote MI or stable angina or well controlled HTN. That being said, it is very difficult to create a Medical Directive which can be specific enough to account for the subtleties of every patient presentation and medical history. As such, if you encounter a patient with a history of cardiovascular disease as described above, then that patient will be unable to receive ibuprofen by the Medical Directive.
As for Ketorolac, daily ASA is not considered anticoagulation therapy as it affects platelet function and does not result in a true anticoagulated state.