- Why this topic important?
- Accidental injury is the most common cause of death in the United States in individuals between the ages of 1 and 45
- Falls are the most common reasons for hospital admissions in this older age group and account for 87% of fractures.
- Open fractures are high-energy injuries with an increased risk of infection due to potential exposure of bone and deep tissue to a variety of environmental debris.
- What is the Gustilo and Anderson classification of open fractures?
- Definition: a grading system that offered prognostic information about the outcome of infected fractures created by Gustilo and Anderson in 1976 described their treatment of 1025 open fractures.
- Grade I: Wound less than 1 cm long, punctured from below.
- Grade II: Laceration 5 cm long; no contamination or crush; no excessive soft tissue loss, flaps, or avulsion
- Grade III: Large laceration, associated contamination or crush; frequently includes a segmental fracture.
- IIIA: Involves extensive soft tissue stripping of bone
- IIIB: Periosteal stripping has occurred
- IIIC: Major vascular injury present
- Infection rates for open fractures
- Type 1
- 0-2% risk of developing an infection
- Type II
- 2-12% risk of developing an infection
- Type III
- 10-50% risk of developing an infection
- Type 1
- What does the Eastern Association for the Surgery of Trauma (EAST) guidelines recommend for grade 1, 2, and 3 open fractures?
- Systemic antibiotic coverage directed at gram-positive organisms should be initiated as soon as possible after injury.
- Additional gram-negative coverage should be added for type III fractures.
- High-dose penicillin should be added in the presence of fecal or potential clostridial contamination (e.g., farm-related injuries).
- In type III fractures, antibiotics should be continued for 72 hours after injury or not 24 hours after soft tissue coverage has been achieved.
- Once-daily aminoglycoside dosing is safe and effective for types II and III fractures.
- What pharmacologic agents can we use for Grade 1+2 open fractures
- Preferred: Cefazolin 2 g (3 g if > 120 kg) IV q8h
- Clindamycin 900 mg IV q8h
- Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h
- Duration of prophylaxis: 24 hours
- What pharmacologic agents can we use for Grade 3 open fractures
- Preferred: Ceftriaxone 2g q24 x 2 days
- Based on a study by Rodrigeuz et al in 2014 that reported significantly decreased use of aminoglycoside and glycopeptide antibiotics with no increase in skin and soft tissue infection rates.
- Severe beta-lactam allergy: Clindamycin 900 mg IV q8h + levofloxacin 500 mg IV q24h
- Preferred: Ceftriaxone 2g q24 x 2 days
- Is there additional coverage for contamination with soil or fecal material?
- Ceftriaxone 2 g IV q24h + metronidazole 500 mg IV q8h
- Severe Beta-lactam allergy: Levofloxacin 500 mg IV q24h + metronidazole 500 mg IV q8h
- Is there additional coverage for contamination with standing water:
- Preferred: Zosyn 4.5 g q8
- Severe beta-lactam allergy: Levofloxacin + Flagyl
- When should we give Td/Tdap for open fractures?
- >10 years clean wound
- >5 years dirty wound
- Do studies show that having EM PharmDs involved helped with the antibiotic selection
- Harvey et al. Impact of an emergency medicine pharmacist on initial antibiotic prophylaxis for open fractures in trauma patients. Am J Emerg Med. 2018 Feb;36(2):290-293.
- P: 146 Trauma patients with open fractures at Level 2 trauma center in Lakeland FL
- I: Pharmacist participating during trauma resuscitation
- C: Prior time without pharmacists’ involvement in trauma resuscitation
- O: More patient’s initial antibiotic prophylaxis was in accordance with the EAST guideline recommendations with a PharmD compared to none.
- 81% versus 47% Pharm vs no-pharmacist present (p < 0.01)
- Median door-to antibiotic time was 14 mins
- Harvey et al. Impact of an emergency medicine pharmacist on initial antibiotic prophylaxis for open fractures in trauma patients. Am J Emerg Med. 2018 Feb;36(2):290-293.
References via QxMD Read
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