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.
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. A review of opioid equivalents and conversions may be found in the following reference article: http://emedicine.medscape.com/article/2138678-overview
Morphine sulfate (MS Contin, Duramorph, Astramorph, Avinza, Infumorph, Kadian, MorphaBond, Arymo ER)
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. Postoperatively, oral morphine sulfate extended-release formulations may be prescribed for severe pain, with immediate release preparations used for breakthrough pain. Arymo ER is a morphine sulfate abuse-deterrent derivative.
Fentanyl citrate (Duragesic, Onsolis, Actiq, Fentora, Abstral, Ionsys, Lazanda, Onsolis, Sublimaze, Subsys)
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.
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 Intensol)
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.
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. [37]
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 (Cefotan)
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, First-Metronidazole 100, First-Metronidazole 50, Metro)
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
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, First-Vancomycin 25, First-Vancomycin 50, Vancomycin + SyrSpend PH4)
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.
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 (Norcuron)
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.
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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Management of penetrating abdominal trauma. CT = computed tomography; DPL = diagnostic peritoneal lavage; RBC = red blood cells.
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Penetrating abdominal trauma. Tangential gunshot wound to the liver.
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Penetrating abdominal trauma. Strangulated small bowel in a patient with a previous gunshot wound to the abdomen.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
