Replantation in Emergency Medicine Medication

Updated: Sep 12, 2017
  • Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD  more...
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Medication

Medication Summary

Prophylactic antibiotics are indicated with amputation, crush, or degloving injuries. Devitalized tissue is a good culture medium for bacterial contaminants. Common pathogens are Staphylococcus aureus (the most likely organism) and group A streptococci, whereas Clostridium species and organisms from the Enterobacteriaceae family are less common. Gram-negative and anaerobic bacteria are more commonly found with extensive tissue damage or with wounds grossly contaminated with soil, saliva, or feces. In these cases, perform Gram staining and cultures before initiating antibiotic therapy.

If the amputation is from a human bite, antibiotic coverage should include streptococci, Eikenella corrodens, anaerobic bacteria, and staphylococci. Use oral amoxicillin and clavulanate for human bites without amputation. Use intravenous ampicillin and sulbactam or ticarcillin and clavulanate for amputations or established infections caused by human bites. A combination of penicillin G and an antistaphylococcal antibiotic is also acceptable for minor bite wounds.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens.

Cefazolin (Ancef, Kefzol)

First-generation semisynthetic cephalosporin; binds one or more penicillin-binding proteins; arrests bacterial cell-wall synthesis and inhibits bacterial growth; primarily active against skin flora, including S aureus.

Ampicillin and sulbactam (Unasyn)

Drug combination that involves a beta-lactamase inhibitor with ampicillin; covers skin organisms, enteric flora, and anaerobes; not ideal for nosocomial pathogens.

Ticarcillin and clavulanic acid (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth; antipseudomonal penicillin and a beta-lactamase inhibitor covers most gram-positive and gram-negative organisms, as well as anaerobes.

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Analgesics

Class Summary

Pain control is essential to quality patient care, ensuring patient comfort and promoting pulmonary toilet. Most analgesics have sedating properties, which are beneficial for patients with painful skin lesions.

Fentanyl (Duragesic)

More potent narcotic analgesic with a much shorter half-life than morphine sulfate; drug of choice for conscious sedation analgesia; ideal for analgesic action of short duration during anesthesia and in immediate postoperative period. For patient needing long-term pain control, sustained-release fentanyl transdermal patch (Duragesic) may control pain with 72-h dosing intervals; some patients require dosing intervals of 48 h. Onset of transdermal fentanyl patch analgesia is delayed for 8-12 hours, so acute pain control must be provided prior to full effect of patch. Overdose has been reported, so start with lowest dose/hour patch (25 mcg/h).

Morphine (Astramorph, MS Contin, Duramorph, Oramorph)

Drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used and are commonly titrated until desired effect is obtained.

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