Maximizing ED Management of Amputations

Authors: Cara Kanter, MD (EM Resident Physician, Temple EM) and Zachary Repanshek, MD (Assistant Professor of Emergency Medicine, Lewis Katz School of Medicine; Assistant Program Director, Temple EM) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

A Clinical Case

A 43-year-old male with a history of IV drug use presented to the Emergency Department after being struck by a train. EMS reported 10 minutes of extraction time. The patient reported copious alcohol use prior to the incident and complained primarily of right leg pain. Physical exam was notable for GCS 13 (E4V4M5), bilateral periorbital ecchymosis with tarsal sparing, and near total amputation of the right lower extremity below the knee.

Background

Numbers Game (1)
  • Roughly 83,000 traumatic amputations in the U.S. yearly
  • Majority of victims are men age 15-40
  • Most common mechanisms: MVC (51%), industrial accidents (19%), agricultural accidents (10%)
  • Most common sites: partial hand amputation (1+ fingers), unilateral upper extremity
Definitions (1,2)
  • Partial Amputation: bone, muscle, or tissue keeps the amputated segment connected to the body
    • More common among civilians
    • Ideal treatment = revascularization
  • Complete Amputation: no connecting tissue
    • More common in military
    • Ideal treatment = reimplantation
  • Sharp/Guillotine Amputation: Well-defined edges, minimal damage to associated anatomy
    • Best prognosis for reimplantation
  • Crush Amputation: extensive soft tissue & arterial damage
    • Reimplantation less likely to be successful
  • Avulsion Amputation: forceful overstretching & tearing of nerves & vascular tissue at many different levels from the site of separation
    • Reimplantation unlikely

 

Pearl #1: ED management is the same for ALL types of traumatic amputation => ALL patients are candidates for reimplantation until a surgeon says otherwise!

 

Diagnosis

History
  • Ischemia time (2)
    • Irreversible muscle necrosis begins at 6 hours of ischemia
    • Temperature & muscle amount in tissue predict tolerable ischemia time
      • Digits: less muscle mass, tolerate more ischemia time
        • Warm ischemia time: 8-12 hours
        • Cool ischemia time: up to 24 hours
      • Limbs: more muscle mass, tolerate less ischemia time
        • Warm ischemia time: 4-6 hours
        • Cold ischemia time: 10-12 hours
      • Mechanism of Injury
        • Guillotine amputations best chance of successful reimplantation
        • Crush/Avulsion amputations have worse prognosis for limb salvage
      • Co-morbidities
        • Young, healthy patients have better chance of successful limb salvage (shocking!)
        • Worse prognosis: smoking, diabetes, PVD, rheumatologic disease
      • Handedness
      • Occupation

 

PEARL #2: ISCHEMIA TIME predicts success for reimplantation!

 

Physical Exam  
  • Primary & Secondary Survey
    • Significant traumatic amputations portend significant internal injuries that may be more immediately life-threatening
    • Control hemorrhage & proceed with ATLS resuscitation as you would any trauma
  • Assess & document a complete exam of the injured extremity
    • Neuro exam
      • Test for sensation & 2-point discrimination in each nerve distribution
    • Vascular exam
      • Capillary refill
      • Pulses via palpation and Doppler, ABIs when appropriate
      • Ribbon sign: tortuous artery in amputated segment, indicates significant vascular compromise (3)
      • Use Allen test in hand injuries
    • Soft tissue & Bone (2)
      • Assess skin, muscle, bone, tendon and nail bed integrity
      • Identify fractures
        • Exposed bone, gross deformity, tenderness, crepitus

 

PEARL #3: Don’t forget ABCDE => look for other injuries that may kill the patient first!

 

ED Management

Care of the amputated segment (1,2,4)
  • Irrigate with saline or sterile water & remove gross contamination
  • Control any bleeding with a pressure dressing
  • Wrap in moistened sterile gauze & seal in water-tight container
  • Place container on ice, in ice water bath, or in refrigerator
  • Do NOT allow limb to freeze!
Care of the stump (2,5)
  • Elevate the limb
  • Irrigate with saline & cover with damp gauze
  • Splint obvious/unstable fractures, keep as near anatomic position as possible
  • Control hemorrhage!
Tourniquet Use
  • Indications for tourniquet use (5,6)
    • Uncontrollable bleeding from a site amenable to proximal placement of a tourniquet
    • Limb amputation or mangled extremity
    • Exsanguinating wound associated with shock
    • Life-threatening hemorrhage inadequately controlled with direct pressure, elevation and other hemostatic methods
  • Pearls of tourniquet application (5)
    • Place the tourniquet as distal as possible, at least 5 cm proximal to the injury
    • Spare joints as much as possible
    • Apply directly onto exposed skin
    • Time of application should be recorded
    • Any amputated limb should be transported with the patient to the hospital

 

PEARL #4: Life over limb!

 

Other Considerations
  • Tetanus prophylaxis
  • Prophylactic antibiotics (2,7)
    • Strep & staph coverage
    • Should be given within 6 hours of trauma
      • Cefuroxime 1.5g IV q8h or Cefazolin 0.5-1.5g IV or IM q6-8h
        • Peds: 25-100mg/kg/d divided q8hr (max 6g/d)
      • MRSA coverage: Vancomycin 15-20mg/kg IV q12h
      • Clostridia coverage: Piperacillin/Tazobactam 80mg/kg IV q8h
    • Immediate surgical consultation – orthopedics, plastics, vascular, trauma! Time is limb!

 

PEARL #5: Traumatic amputation is a surgical emergency! Get the patient to a surgeon ASAP!

 

Review of the Pearls

  1. ED management is the same for ALL types of traumatic amputation => ALL patients are candidates for reimplantation until a surgeon says otherwise!
  2. ISCHEMIA TIME predicts success for reimplantation!
  3. Don’t forget ATLS => look for other injuries that may kill the patient first!
  4. Life over limb!
  5. Traumatic amputation is a surgical emergency! Get the patient to a surgeon ASAP!

 

Case Resolution

The patient was intubated in the trauma bay for airway protection. A CT head obtained demonstrated multiple skull fractures and an epidural hematoma without mass effect. The patient was taken to the OR with trauma surgery for a right through-knee guillotine amputation. A repeat CT head obtained immediately post-op demonstrated an expanding epidural hematoma. The patient went immediately back to the OR with neurosurgery for a hematoma evacuation. The patient was taken back to the OR a few days later with trauma surgery for a formal above-knee-amputation.

 

References/Further Reading

  1. Meenach, Dean. “How to manage traumatic amputations and uncontrolled bleeding.” EMS In Focus. EMS1.com, 30 Apr. 2014. Web. 24 Feb. 2017
  2. Schaider, J. (2015). Amputation Traumatic/Replantation. ROSEN & BARKIN’S 5-MINUTE EMERGENCY MEDICINE CONSULT. Retrieved February 24, 2017 from http://www.r2library.com.libproxy.temple.edu/Resource/Title/1451190670/ch0001s0822
  3. Van Beek AL, Kutz JE, Zook EG. (1978). Importance of the ribbon sign, indicating unsuitability of the vessel, in replanting a finger. Plastic and Reconstructive Surgery, 61(1):32-5.
  4. Stone, C. (2005). Traumatic Amputation. CURRENT ESSENTIALS OF EMERGENCY MEDICINE. Retrieved February 24, 2017 from http://www.r2library.com.libproxy.temple.edu/Resource/Title/0071440585/ch0022s2072
  5. Lee C, Porter KM, Hodgetts TJ. (2007). Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal, 24, 584-7.
  6. Rush RM, Arrington ED, & Hsu JR. (2012). Management of complex extremity injuries: Tourniquets, compartment syndrome detection, fasciotomy, and amputation care. Surgical Clinics of North America, 92(4), 987-1007.
  7. Schmitt SK. Treatment and prevention of osteomyelitis following trauma in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 24, 2017).

4 thoughts on “Maximizing ED Management of Amputations”

  1. Awesome post!

    I forget where I heard this but shouldn’t we placing the tourniquet as proximal as possible and then reapplying once the area is properly exposed and a thorough exam is done? The reason being it’s possible to actually miss some of the bleeding areas.

  2. Awesome post!

    I forget where I heard this but shouldn’t we placing the tourniquet as proximal as possible and then reapplying once the area is properly exposed and a thorough exam is done? The reason being it’s possible to actually miss some of the bleeding areas.

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