Background
Trauma has a variety of causes, including burns, lacerations, gunshot wounds, falling from a height, animal or human interactions, or motor vehicle accidents. Trauma may impact single or multiple organ systems. Although overall medical management of trauma will vary based on patient presentation, initial treatment focuses on patient stabilization.
Fluid Resuscitation
IV isotonic crystalloid fluids (eg, lactated Ringer’s solution, 0.9% sodium chloride) are commonly used. Avoid fluid overload by administering frequent small boluses.
Hypertonic saline can be especially useful for small-volume resuscitation but should be avoided in patients with dehydration, hypernatremia, or hyperosmolarity.
Colloids (eg, hetastatch, tetrastarch) are another option for small-volume resuscitation.
Fluid resuscitation is contraindicated if the patient is euvolemic or in cardiogenic shock. Avoid colloids and hypertonic saline in patients with intracranial hypertension or hypernatremia.
Analgesia
Opioids (eg, fentanyl, hydromorphone, morphine) are the preferred agents. Administer IV, either as frequent boluses or as a continuous infusion.
Consider adjunctive systemic analgesics (eg, ketamine, IV lidocaine) and local anesthetics (eg, bupivacaine, lidocaine) for patients in significant pain.
NSAIDs should be avoided initially due to the risk for renal injury in hypovolemic patients. NSAIDs may be considered during postacute care.
Antifibrinolytics
Acute trauma is associated with hyperfibrinolysis, and aminocaproic acid or tranexamic acid can be considered, particularly in patients with evidence of bleeding.
Antibiotics
Open fractures (types I-III) require antibiotic coverage for gram-positive bacteria; first- or second-generation cephalosporins (eg, cefazolin, cefuroxime) are recommended. For type III fractures or full-thickness soft-tissue injuries subject to delayed repair, expanded gram-negative coverage (eg, ampicillin/sulbactam, enrofloxacin) is warranted.
Adjust, de-escalate, or discontinue antibiotics based on clinical status and/or wound culture results.
Additional Considerations
Drugs used during cardiopulmonary resuscitation (CPR)1
Blood pressure support
Epinephrine or vasopressin are indicated for patients with hypotension despite adequate fluid resuscitation and are administered every other 2-minute basic life support cycle.
Antiarrhythmics
Atropine is indicated for bradycardia or when high vagal tone may be contributing to cardiopulmonary arrest. It is recommended to administer the drug only once (as early as possible during CPR).
In dogs with ventricular tachycardia or fibrillation, lidocaine is considered the first-line drug.
Amiodarone can be used if lidocaine is ineffective or unavailable.
In cats with ventricular tachycardia or fibrillation, amiodarone is the preferred agent.
Esmolol is warranted for shockable rhythms that do not convert after the first defibrillation.
Electrolytes
Calcium (single-dose IV) is indicated when hypocalcemia is documented or hyperkalemia contributed to cardiac arrest.
Sodium bicarbonate is optional during prolonged CPR.
Anticonvulsants for status epilepticus2
Benzodiazepines (eg, diazepam IV; midazolam IV [preferred], IM, or intranasal) are first-line agents for dogs and cats.
Levetiracetam (IV [preferred], IM, or rectal) and phenobarbital (IV) are indicated when benzodiazepines fail to control/terminate seizures.
Management of trauma is continually evolving. Understanding how therapies differ in mechanism, onset, and safety is essential for tailoring treatment to each patient. Detailed information on agent selection and use is available through Plumb’s.