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Controversies And Cutting Edge

Use Of Antibiotics

With the exception of an open fracture, antimicrobial treatment for penetrating extremity wounds is often a source of controversy. Generally accepted indications for empiric antibiotic therapy are associated fractures, shotgun injuries, or wounds with large associated soft-tissue involvement. Studies by Ordog and Dickey demonstrated that patients with low-velocity missile injuries can be successfully treated as outpatients, without antibiotics.127,133 When antibiotics are deemed necessary, Knapp et al found no difference in outcomes when comparing oral and IV antibiotics.134 Risk factors for infection include delays in wound care, inadequate wound care, wounds > 2 cm in length, gross contamination, poor patient compliance, diabetes, and vascular injury.127,133 Patients with grossly contaminated injuries, high-velocity weapon injuries, and shotgun injuries should be admitted for surgical debridement.

When fractures are present, antibiotics are indicated. In a study of 1104 open fracture wounds, Patzakis and Wilkins found the key to reducing infections was early antibiotic administration.135 Fackler stated that one should strive to achieve adequate circulating blood levels of a penicillin-spectrum antibiotic in all gunshot wound patients as soon as possible.136 Surgical debridement for open fractures is typically done within 6 hours, but recent studies have shown that extending this window up to 24 hours has shown no change in the rate of osteomyelitis as long as antibiotics have been started in the ED.137

Cervical Spine Clearance

Many patients with gunshot wounds arrive with cervical collars in place despite a lack of neck trauma by history, and many more patients have cervical collars placed at the time of arrival to the ED. Two retrospective studies suggest that cervical collars do not need to be applied to patients with isolated gunshot wounds to the head because blast and fall injuries are generally not present, and the spinal stabilization only increases the difficulty with airway control.138,139 Another study suggests that cervical collars do not need to be placed in patients with penetrating trauma to the head, neck, or torso if they are asymptomatic of spinal injuries.140


Emergency department thoracotomy (EDT) can be a potentially life-saving intervention for patients with penetrating thoracic injuries, but it has been used in certain instances for penetrating abdominal injuries as well. While large studies are lacking because of the relative infrequency of EDTs, some retrospective analysis suggests that it may have a limited role for penetrating abdominal trauma when clamping of the aorta may allow time to find the source and stop the bleeding. A recent study of prelaparotomy EDT found that of the 50 patients with abdominal exsanguinations from penetrating trauma, 8 patients survived neurologically intact to hospital discharge, thus suggesting a role for EDT in penetrating abdominal trauma.141 Another recent study by Moore et al suggested that an EDT should be considered futile in any penetrating trauma when CPR has been ongoing for 15 minutes or more.142

Synthetic Blood Substitutes

Synthetic hemoglobin-derived, disease-free, oxygen-carrying substitutes have been suggested to be useful in trauma patients when allogenic blood products are not available or in patients who cannot receive blood products. Several studies have addressed the use of these products over the last decade with primarily favorable results. For example, Gould et al first examined this topic by comparing a synthetic blood substitute (PolyHeme®) to allogenic blood transfusion in trauma patients. They found that there were no adverse side effects in the synthetic hemoglobin group, and they required fewer units of transfused blood. The synthetic group did, however, have a lower overall hemoglobin.143

A recent multicenter trial evaluated the role of 6 units of synthetic hemoglobin within the first 12 hours of injury versus prehospital crystalloid and standard in-hospital blood product use in 714 trauma patients. This prospective trial found less allogenic blood product use in the experimental group and suggested that synthetic hemoglobin would be useful when blood products were not available. The study concluded that the synthetic blood product group did not have statistically different adverse events, but it did have a 3% risk of myocardial infarction compared to 1% in the allogenic blood product group. However, mortality was slightly higher in the synthetic group (13.4% vs 9.6%), and multiple organ failure was higher as well (7.4% vs 5.5%).144 This study suggests that if traditional blood products are not available, the risk-to-benefit ratio favors using synthetic hemoglobin.

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Last Modified: 07/19/2018
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