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Penetrating Abdominal Trauma Medication

  • Author: Patrick Offner, MD, MPH; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Apr 27, 2014
 

Medication Summary

In general, medications used to treat victims of penetrating abdominal trauma fall into discrete categories. Analgesics, anxiolytics, antimicrobials (skin and enteric flora), immune boosters (tetanus booster), and neuromuscular blockers comprise the major classes of pharmacotherapeutic agents used for these patients.

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Analgesics

Class Summary

Pain control is essential to quality patient care. Appropriate and sufficient pain control is important. Concerns still exist regarding pain control in patients undergoing observation. A reasonable protocol should be developed by institutions in consultation with the trauma service or consulting surgeon. Postoperatively, analgesics are essential to ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens.

Morphine sulfate (MS Contin, Oramorph SR, Duramorph)

 

Morphine is the drug of choice for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; the dose is commonly titrated until desired effect is obtained.

Fentanyl citrate (Duragesic, Onsolis, Actiq, Fentora)

 

Fentanyl is a potent narcotic analgesic with much shorter half-life than morphine sulfate. This agent is a common choice for procedural sedation analgesia. It is excellent for analgesic action of short duration during anesthesia and immediate postoperative period. It is also an excellent choice for pain management and sedation, with short duration (30-60 min) and easy to titrate.

Fentanyl is easily and quickly reversed by naloxone. After the initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter. Most patients are controlled with 72-h dosing intervals when using transdermal dosage form, although some patients require 48-h dosing intervals.

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Anxiolytics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

Lorazepam (Ativan)

 

Lorazepam is a sedative-hypnotic with short onset of effects and relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain, lorazepam may depress all levels of the CNS, including the limbic and reticular formation. This agent is an excellent choice when the patient must be sedated for longer than 24 h.

Midazolam hydrochloride (Versed)

 

A shorter-acting benzodiazepine sedative-hypnotic, midazolam is useful in patients requiring immediate and/or short-term sedation. It is also useful for its amnestic effects. This agent is frequently used for procedural sedation.

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Antibiotics

Class Summary

Antibiotic prophylaxis is proven to reduce postoperative surgical infections after penetrating abdominal trauma.

The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group has published evidence-based consensus guidelines addressing the use and duration of antimicrobial prophylaxis after penetrating abdominal trauma. They recommended, in the absence of hollow viscus injury, administering a single dose of a broad-spectrum antimicrobial agent that provides both aerobic and anaerobic coverage.

No specific agent is recommended, but it may be a single agent with beta-lactam coverage or combination therapy with an aminoglycoside and clindamycin or metronidazole. In patients with a hollow viscus injury, antimicrobial prophylaxis should be extended to 24 hours.[35]

While some controversies still exist regarding therapy for seriously injured patients, for the emergency physician, the key point is to start antibiotics in the ED. If the patient requires emergent laparotomy and must be rapidly transported, it may be done upon arrival in the operating room.

Cefotetan

 

Cefotetan is a second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rod infections, and anaerobic bacteria. It inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; it inhibits the final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.

Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefotetan. Antibiotics have proved effective in decreasing the rate of postoperative wound infection and improving outcome in patients with intraperitoneal infection and septicemia.

Metronidazole hydrochloride (Flagyl)

 

Metronidazole is an imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. It is used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Gentamicin sulfate

 

An aminoglycoside antibiotic for gram-negative coverage, gentamicin is used in combination with an agent against gram-positive organisms and one that covers anaerobes. This is not the drug of choice. Consider gentamicin if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.

Dosing regimens are numerous; adjust dose based on creatinine clearance and changes in volume of distribution. Gentamicin may be administered IV or IM.

Vancomycin hydrochloride (Vancocin)

 

A potent antibiotic directed against gram-positive organisms and active against enterococcal species, vancomycin is useful in the treatment of septicemia and skin-structure infections. It is indicated for patients who cannot receive or who are unresponsive to penicillins and cephalosporins or who have infections with resistant staphylococci.

For penetrating abdominal injuries, vancomycin is combined with an agent active against enteric flora and/or anaerobes. To avoid toxicity, the current recommendation is to assay trough levels after the third dose, with the sample drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment.

Vancomycin is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures.

Ampicillin sodium-sulbactam sodium (Unasyn)

 

This combination of a beta-lactamase inhibitor with ampicillin covers skin, enteric flora, and anaerobes. It is not ideal for nosocomial pathogens.

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Neuromuscular Blocking Agents

Class Summary

Many patients with penetrating abdominal trauma require urgent airway control. Neuromuscular blocking agents produce paralysis and are administered immediately after the induction agent in rapid-sequence intubation.

Succinylcholine (Anectine Chloride, Quelicin)

 

Succinylcholine is a prototypical depolarizing neuromuscular blocker; it is ultra–short-acting and predictable in onset (< 1 min) and duration (4-6 min). This agent is highly ionized and relatively fat-insoluble; it does not readily cross placenta. Pediatric patients must be pretreated with atropine to avoid bradycardia and cardiac arrest. Bradycardia may also occur in adults but more commonly is associated with administration of either a higher dose or a second dose.

Vecuronium bromide

 

Vecuronium is a prototypical, nondepolarizing, neuromuscular blocking agent that reliably results in muscular paralysis. For intubation and maintenance of paralysis, a continuous infusion may be used. Infants are more sensitive to neuromuscular blockade activity; recovery is prolonged by 50%, although the same dose is used. Vecuronium is not recommended for use in neonates.

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Immune Enhancement

Class Summary

Penetrating abdominal trauma resulting in wounds contaminated with either dirt or debris or wounds caused by metallic objects carry a risk of Clostridium tetani infection. Tetanus results from elaboration of an exotoxin by C tetani.

A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.. Patients who may not have been immunized against C tetani products (eg, immigrants) should receive tetanus immune globulin (Hyper-Tet).

Tetanus toxoid adsorbed or fluid

 

This agent induces active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children older than 7 years are tetanus and diphtheria toxoids. It is necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, this agent may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the mid thigh laterally.

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Contributor Information and Disclosures
Author

Patrick Offner, MD, MPH Chief, Surgical Critical Care, Department of Surgery, Trauma Services, St Anthony Central Hospital

Patrick Offner, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, Colorado Medical Society, Western Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Katie Jo Stanton-Maxey, MD Assistant Professor, Department of Surgery, Indiana University School of Medicine

Katie Jo Stanton-Maxey, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Roy Alson, MD, PhD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: Air Medical Physician Association, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and World Association for Disaster and Emergency Medicine

Disclosure: Nothing to disclose.

Alfred B Cheng, MD Staff Physician, Department of Emergency Medicine, New York University, Bellevue Medical Center

Disclosure: Nothing to disclose.

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lewis J Kaplan, MD, FACS, FCCM, FCCP Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society

Disclosure: Nothing to disclose.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul A Testa, MD, JD, MPH Attending Physician, Department of Emergency Medicine, New York University School of Medicine

Paul A Testa, MD, JD, MPH is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

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Management of penetrating abdominal trauma. CT = computed tomography; DPL = diagnostic peritoneal lavage; RBC = red blood cells.
Penetrating abdominal trauma. Tangential gunshot wound to the liver.
Penetrating abdominal trauma. Strangulated small bowel in a patient with a previous gunshot wound to the abdomen.
Note that the resident is carefully maintaining the position of the impaled stop sign post, so as not to dislodge the shaft. The shaft was removed in the OR along with the patient's right colon.
This is an operative photograph of an extremely rare injury: a midureteral transection from a gunshot wound. The patient was shot with a MAC-10 machine gun and sustained liver injury as well as injuries to the duodenum, colon, terminal ileum, sigmoid colon, rectum, gallbladder, bladder, and left femur. He underwent a damage control operation and survived his injuries after 3 subsequent operations.
This liver injury was sustained by the patient shot with a MAC-10 machine gun. The injury has been opened to control bleeding branches of the portal and hepatic veins as well as the hepatic arterial radicles. Several biliary ducts were ligated, and the back wall of the gallbladder can be identified in the depths of the wound. A cholecystectomy was required for management of the wound.
The patient's small intestine clearly protrudes through his anterior abdominal wall following a stab wound caused by a machete. The operative repair and recovery were uneventful.
A standard diagnostic peritoneal lavage (DPL) catheter is secured in place following an open DPL. An aspirating syringe is attached to the catheter via extension tubing as the initial step in the evaluation for intraperitoneal blood.
An ED thoracotomy has been performed, and the aorta is cross-clamped. Note the proper positioning of the ratchet mechanism of the rib spreader to allow extension of the incision to the right chest for a clamshell thoracotomy if needed. This patient arrived with a weak pulse and a systolic blood pressure of 40 mm Hg and promptly died on the ED stretcher. An ED thoracotomy was performed for cardiopulmonary-cerebral resuscitation.
This 22-year-old woman sustained a gunshot wound to the left flank. At exploration, she had a through-and-through laceration of her spleen. The bleeding was arrested by finger compression of the splenic hilum while it was mobilized. A splenectomy was performed because the bullet went through the hilum.
A 34-year-old man flipped over the handlebars of his motorcycle and landed on a wrought-iron fence. His helmet was knocked off when he landed. The medics cut the fence apart and transported the patient and fence to the ED (see image). On presentation, the patient's vital signs are as follows: rectal temperature, 95.3°F; heart rate, 126 beats per minute; respiration rate, 24 (labored); and blood pressure, 94/62 in his left arm. Intubation, bilateral upper extremity intravenous access, 2000 mL intravenous fluid, AP CXR, and operation is the correct sequence in which to resuscitate the patient to address the ABCs.
 
 
 
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