›Ertapenem 1 g IV
›Preferred by Surgical Infection Society for trauma laparotomy
›Evidence of reduced surgical site infections vs narrow-spectrum alternatives
›Alternative: cefazolin plus metronidazole
›Cefazolin 2 g IV (3 g IV if weight >120 kg)
›Metronidazole 500 mg IV
›Redose cefazolin every 4 hours intraoperatively for prolonged cases
›Duration of antibiotic therapy
›No hollow viscus injury found: single preoperative dose only
›No evidence for extended courses in absence of bowel contamination
›Hollow viscus injury identified: continue <=24 hours postoperatively
›No evidence supports >24-hour courses for reducing SSI or intra-abdominal infection
›Gross fecal contamination or delayed presentation: continue up to 24 hours
›Do not extend beyond 24 hours without evidence of established infection
›Damage control surgery
›Indication: hemodynamically unstable with lethal triad
›Hypothermia <35°C
›pH <7.2
›Coagulopathy (INR >1.5 or fibrinogen <1.5 g/L)
›Phase 1: abbreviated laparotomy
›Hemorrhage control with packing and vascular clamping
›Contamination control with bowel stapling or ligature
›Temporary abdominal closure (vacuum-assisted preferred)
›Phase 2: ICU resuscitation
›Correct hypothermia, acidosis, coagulopathy
›Lactate clearance target
›Vasopressor weaning
›Phase 3: planned return to OR for definitive repair
›24-48 hours after initial damage control
›Definitive laparotomy
›Stable patient with operative indication
›Primary bowel repair or anastomosis preferred when patient is stable
›Ostomy or damage control with delayed anastomosis when contamination or patient instability is high
›Drain placement for pancreatic or biliary injuries
Nonoperative management protocol
›Observation protocol components
›Serial abdominal exams
›Every 4-6 hours by experienced clinician
›Document findings each time
›Serial hemoglobin every 4-6 hours
›Drop >=2 g/dL triggers operative evaluation
›Clear liquids only during observation period
›Minimum 48 hours before discharge consideration
›NOM failure criteria requiring operative intervention
›Development of peritoneal signs
›Hemodynamic instability
›Hemoglobin drop >=2 g/dL
›Fever with rising white cell count suggesting missed bowel injury
›Inability to tolerate oral intake suggesting occult hollow viscus injury
›LWE technique and indications
›Best studied for anterior abdominal stab wounds
›Determines if wound breaches anterior fascia
›Fascia intact: discharge with return precautions
›Peritoneum violated: observation or further workup required
›Not appropriate for GSW (trajectory too unpredictable)
›Not appropriate for posterior or flank wounds
Calcium and electrolyte replacement
›Calcium during massive transfusion
›Calcium gluconate 1 g IV every 4 units pRBC infused
›Target ionized calcium >=1.1 mmol/L
›Hypocalcemia contributes to cardiac dysfunction and coagulopathy
›Electrolyte monitoring and replacement
›Potassium rises during massive transfusion from stored blood
›Magnesium replacement for refractory hypokalemia or dysrhythmias