Background
Providing analgesia and facilitating patient examination and other diagnostics during the initial stages of fracture management are essential. Medications for ongoing analgesia and/or activity restriction may be needed in the follow-up period.
Initial Medication Management
Analgesia and sedation can be provided via injectable opioids (eg, fentanyl, hydromorphone, methadone, morphine). Benzodiazepines (eg, diazepam, midazolam) can also be used to enhance sedation and relax skeletal muscle. Reversal agents (ie, naloxone, flumazenil) should be readily available for possible significant adverse effects. Injectable NSAIDs (eg, carprofen, meloxicam) are excellent analgesics but should be avoided in patients with hypovolemia or systemic shock because of potential adverse renal effects. NSAIDs may be reserved for postacute care. Local anesthetics (eg, lidocaine, bupivacaine) can be administered locally, regionally, or systemically via continuous infusion (lower doses in cats). Alpha-2 agonists (eg, dexmedetomidine) or acepromazine can be used for additional sedation but should be avoided in debilitated or critically ill patients due to potential adverse cardiovascular effects. Alpha-2 agonists also provide muscle relaxation and analgesia and can be reversed with atipamezole.
In patients with open fractures, wound management (eg, cleaning, irrigation, debridement) and antibiotics are indicated. For all open fractures (types I-III), coverage for gram-positive bacteria is needed, and first- or second-generation cephalosporins (eg, cefazolin, cefuroxime) are recommended. For type III fractures, a second antibiotic with expanded gram-negative coverage (eg, ampicillin/sulbactam, enrofloxacin) is warranted. Antibiotic selection should also be guided by culture and susceptibility results. The duration of antibiotic treatment should be dictated by the patient’s clinical circumstances.
Next Steps
Pain management should continue as long as necessary and follow established pain management guidelines.1,2 In general, oral NSAIDs (eg, carprofen, deracoxib, firocoxib, meloxicam, robenacoxib) are foundational analgesics and can be augmented by gabapentinoids (eg, gabapentin, pregabalin), acetaminophen (dogs only), N-methyl-D-aspartate (NMDA) antagonists (eg, ketamine, amantadine), and/or opioids (eg, tramadol, fentanyl patch, buprenorphine OTM (cats), long-acting transdermal solution [FDA-approved for use in cats], or long-acting subcutaneous injection [FDA-approved for use in cats]).
Trazodone is commonly used in cases in which activity restriction is needed to facilitate healing; oral acepromazine can also be considered.
More information about the safety and efficacy of these drugs is available at Plumbs.com.