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Am Fam Physician. 2001;63(9):1825

Patients who present to the emergency department following acute limb injury are often treated with intravenous morphine for analgesia. Although morphine is inexpensive and effective, it is also associated with serious adverse effects and has the potential for abuse. Intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) could provide effective analgesia with fewer side effects, but they are substantially more expensive than morphine. Rainer and colleagues compared the effectiveness and relative costs of morphine and ketorolac as analgesia in patients with acute blunt limb injury.

They studied patients 16 years and older who presented to an emergency department in Hong Kong with isolated blunt limb injury. Patients who presented at night or on weekends were not included in the study. Other reasons for exclusion were dementia, hemorrhage, pregnancy, asthma, chronic lung disease and any contraindication to either of the study medications. The 149 eligible patients were randomly assigned to receive ketorolac (10-mg loading dose followed by 5 mg every five minutes to a maximal dosage of 30 mg, if required) or morphine (5-mg loading dose followed by 2.5 mg every five minutes to a maximal dosage of 15 mg, if required). With the assistance of a research nurse, patients completed a visual analog scale to assess pain levels at baseline and every five minutes for 30 minutes following the initial injection. Thereafter, pain was assessed every 30 minutes for 90 minutes and again after six hours. Routine observations and monitoring for adverse effects were maintained on all patients. The patients and staff did not know which drug had been injected.

The 75 patients who were treated with ketorolac were comparable to the 73 who received morphine with regard to age, sex, type and location of injury, and initial pain scores. The likelihood of pain relief at rest was higher in the patients who received morphine, but the difference was not statistically significant (see the accompanying table). Conversely, pain on activity was relieved to a greater extent with ketorolac, with the difference at the 75 percent level being statistically significant. Patients who received morphine had significantly more side effects, principally dizziness, drowsiness and nausea. Patient satisfaction was also significantly higher in the group that received ketorolac. When all additional related costs were taken into account, the mean cost of analgesia per person was significantly lower in the patients treated with ketorolac.

The authors conclude that intravenous ketorolac provides more effective pain relief with fewer adverse effects and reduced overall cost than morphine in the emergency department situation.

Activity levelHazard ratio*Pvalue
At rest:
50 % reduction in pain0.83 (0.60 to 1.15)0.271
75 % reduction in pain0.84 (0.60 to 1.16)0.279
Complete pain relief0.93 (0.66 to 1.30)0.654
With activity:
50 % reduction in pain1.18 (0.85 to 1.63)0.330
75 % reduction in pain1.49 (1.05 to 2.12)0.027

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