Mandibular Fracture Management in the ED Medication

Updated: Feb 08, 2022
  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Medication Summary

When airway control is needed, rapid-sequence induction is often the preferred method. Rapid-sequence induction utilizes medications to induce unconsciousness and muscle paralysis to facilitate intubation. A cricothyroidotomy kit should be kept at the bedside in case problems arise.

Use of medication, including NSAIDs, narcotics, and local anesthetics, is appropriate for pain control.

Patients with open fractures, which account for the majority of cases, should be given IV antibiotics. [14] Current choices include penicillin or a cephalosporin. For penicillin-allergic patients, clindamycin is a good alternative. If the patient has an open wound, administer tetanus toxoid if the patient is not current.


Nonsteroidal anti-inflammatory drugs (NSAIDs)

Class Summary

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually the drug of choice (DOC) for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usual DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with small bodies, to older persons, and to those with renal or liver disease.

Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Flurbiprofen (Ansaid)

Provides analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, decreasing prostaglandin biosynthesis.



Class Summary

Pain control is essential for quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs and in those with upper GI disease or taking oral anticoagulants.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways, and commonly titrated until desired effect is obtained.



Class Summary

Prophylaxis is given to patients with open fractures. Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active replication, resulting in bactericidal activity against susceptible microorganisms.

Ceftriaxone (Rocephin)

Third-generation cephalosporin that has broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Clindamycin (Cleocin)

Lincosamide useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, inhibiting bacterial replication.


Tetanus toxoid

Class Summary

This agent is used for tetanus immunization. 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 given as the immunizing DOC for most adults and children >7 years of age. Booster doses needed to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid, not diphtheria antigen-containing product.

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



Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

Used for passive immunization of any patient with a wound that may be contaminated with tetanus spores.