Friday, January 9, 2009

Interesting case

Had a younger patient present a while ago, had been in a high speed MVA the day before. Had been seen at an outside facility, and was evaluated thoroughly including negative CT scan examinations of C-spine, Head, and Abdomen/Pelvis. He was discharged with a prescription for pain meds, but was unable to fill them as his/her car was destroyed. Patient presented with increasing and worsening pain, primarily in the left shoulder, and left chest wall. Stated that toradol had worked well for him in the past. As it had been last given almost 24 hours previously, was given an additional dose of 60mg IM with excellent pain relief. Discharged after negative xrays and satisfactory exam, and told to fill existing pain med script, and follow up with primary care.

2 days later patient presents again to the ER, this time in ARF. Creatinine is in the mid 2 range upon admission. Admitted to the hospital, worked up, creatinine rose to the low 4's, but with good care and with being hydrated adequately, had complete resolution of ARF. Got a subsequent somewhat terse e-mail from one of the hospitalists regarding usage of toradol, and how it "should never be given in the ER, because of numerous cases like this", and how I caused thousands of dollars in extra expenses. I politely replied that I was aware of the potential nephrotoxic effects of toradol, but that the incidence of these events was very low, somewhere around 1%. I asked them to provide data to support their assertion. It is always possible that there are studies available that I am not aware of. As much as I try, you simply cannot read every single medical study that comes out. I also sent the case to Departmental Peer Review.

Bottom line was that after a thorough literature search, the incidence of ARF with toradol administration was 1.04%, and with the administration of narcotics.....1.37% So the committee concluded that my care was completely in line with current practice parameters, and that toradol posed no severe risk of nephrotoxicity. I was vindicated.

This all occured a couple of years ago, but was an interesting experience.


alexy said...

there is not toradol on ER in our country, we use just AINES, maybe bendicepines, or morfine just in cases. but we do well with avg AINES. we use what we have if we had toradol sure we will use it. do you use regular AINES on ER?

physasst said...

Are you referring to NSAID's. I am sorry, I am not familiar with the term AINES?

cynic said...

AINES = Anal Insertion Narcotic Enema Solution.

On another note, good to hear you were not found of any wrongdoing. I would have done the same.