Ankle Fracture Management in the ED Medication

Updated: Jan 31, 2022
  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Medication Summary

Provide sufficient analgesia to patients sustaining an ankle fracture. A variety of medications, ranging from oral acetaminophen to parenteral narcotics, can be used. For procedural sedation, agents include short-acting sedative-hypnotics and opiate analgesics, usually given in combination. In addition, administer tetanus prophylaxis for an open fracture.



Class Summary

Pain control is essential to quality patient care, as it ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Sedating properties of narcotics benefit patients who have sustained a fracture.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

Used to achieve desired anxiolytic and analgesic effects because easily titrated to desired level of pain control or sedation. Reversed by naloxone.

Fentanyl citrate (Duragesic, Sublimaze)

Good choice for immediate pain relief and conscious sedation because of rapid onset and short duration (30-60 min). Easily titrated to desired level of pain control or sedation. Easily reversed by naloxone.



Class Summary

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

Midazolam hydrochloride (Versed)

Short-acting benzodiazepine/sedative-hypnotic used for its anxiolytic, amnestic, and sedating properties. Easily titrated and easily reversed with flumazenil.



Class Summary

In procedural sedation, a benzodiazepine antagonist may be needed to reverse sedation and respiratory depression resulting from benzodiazepines and narcotics.

An opioid antagonist also can be used to reverse oversedation in a patient manifesting significant respiratory depression.

Flumazenil (Romazicon)

Selective antagonist of benzodiazepine receptor.

Naloxone (Narcan)

Prevents or reverses opioid effects including hypotension, respiratory depression, and sedation, possibly by displacing opiates from their receptor. Rapid onset of 1-2 min. Oversedation or respiratory depression should reverse rapidly.



Class Summary

Therapy must cover all likely pathogens in the clinical setting.

Cefazolin (Ancef, Kefzol, Zolicef)

Cephalosporin that binds to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis, and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus.

Total daily dosages are the same for IV and IM routes.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fracture.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infection. Used in conjunction with gentamicin for prophylaxis in patients with open fracture.

Dose may need adjustment for patients with renal impairment.



Class Summary

These agents are used for tetanus immunization. A booster injection is recommended for previously immunized individuals to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients; tetanus and diphtheria toxoids are immunizing agents of choice for most adults and children >7 years; booster doses are needed throughout life to maintain tetanus immunity; pregnant patients should receive only tetanus toxoid—not a diphtheria antigen-containing product.

For children and adults, may be administered into deltoid or mid-lateral thigh muscles. For infants, preferred site is mid-thigh laterally.



Class Summary

Administer tetanus immune globulin to patients who may not have been immunized against Clostridium tetani products.

Tetanus immune globulin (TIG)

For passive immunization of persons with wounds that may be contaminated with tetanus spores.