Tramautic Amputations

An amputation is the surgical or traumatic separation of a body part from the body.1 It is estimated that one out of every 200 individuals in the United States has had an amputation.2 Medical conditions like peripheral vascular disease (PVD) account for most surgical amputations, which are most often planned procedures that occur within operative suites in healthcare facilities. In contrast, traumatic amputations are not planned and usually occur outside of the hospital setting. More than 30,000 traumatic amputations occur every year.3,4 This article focuses on traumatic amputations involving adult patients in the prehospital environment. EMS providers who are knowledgeable and well trained in the management of traumatic amputations may contribute significantly to the successful reattachment of amputated body parts and reducing patient morbidity and mortality.5

Basic Anatomy
A traumatic amputation can involve any body part, including the arms, hands, fingers, legs, feet, toes, ears, nose, eyelids and genitalia. Upper limb amputations account for more than 65% of traumatic amputations.2 While anyone can be involved in an amputation, most victims are between ages 15 and 40. 2,3,6,7 A majority of the victims (80%) are male.3,7

The upper limbs include the fingers (phalanges), hand (metacarpals), wrist (carpals), forearm (radius/ulna), upper arm (humerus), shoulder blade (scapula) and collar bone (clavicle) (see Figures 1 and 2). Neurovascular structures include subclavian, axillary, brachial, radial, median and ulnar arteries. Axillary, radial, median and ulnar nerves are also present.8

Lower extremities include the pelvis (ilium, ischium, pubis), upper leg (femur, patella), lower leg (tibia/fibia) and foot (tarsals, metatarsals, phalanges) (see Figures 3 and 4). Neurovascular structures include the abdominal aorta, femoral, popliteal and anterior/posterior tibial arteries. Lower extremity nerves include sciatic, tibial and perineal.8

Amputation Terminology
Amputations are either complete or incomplete (partial).5,6 In a complete amputation, there are no tissues, ligaments, muscles or other anatomical structures connecting the amputated part to the body. A partial amputation is one in which an anatomical structure, such as a ligament, tendon or muscle, is still intact between the body and the amputated anatomy. Although the body part may not be functional at the time and complete amputation may appear to be imminent, the body part is still connected to the body. In a partial amputation, every effort should be made to preserve this connection.

Amputations can involve proximal or distal anatomy. Proximal amputations involve anatomy that is attached closely to the body's core, such as an entire arm at the shoulder joint or a leg at the hip joint. Distal amputations involve anatomy that is distant from the core of the body, such as fingers or toes. Distal amputations are more common than proximal amputations.9,10

Specific phrases may be used when describing the anatomy involved in the amputation. For example, if the patient's leg is amputated below the knee, it may be referred to as a below-the-knee amputation, or "BKA." An amputation occurring above the knee may be referred to as above-the-knee amputation, or AKA.

Amputations can also be described according to their association with other injuries and the patient's condition. Simple amputations are those that do not involve extrication, shock is not present and additional injuries, such as multisystem trauma, are absent. Complex amputations are associated with complicated extrication, the presence of shock or the presence of additional injuries.

Mechanisms Of Amputation
There are numerous scenarios that can involve a traumatic amputation. Common examples include industrial, farming and motor vehicle accidents. The use of power equipment, including electric saws, lawn mowers and snow-blowers, also puts people at risk2,6,7,9,11 (see Tables I and II).

In a traumatic amputation, specific mechanisms of injury (MOI) tend to be involved. Crush, guillotine and avulsion mechanisms are three of the most common forms of traumatic amputation.6,12 Other possible mechanisms are listed in Table III. Crush injuries tend to be the most common and can result in significant tissue damage and injury. Because of the injury associated with crush mechanisms, amputations resulting from these forces are less likely to be successfully reattached. In contrast, guillotine injuries involve sharp edges, resulting in less tissue disruption. As a result, body parts that are amputated by guillotine forces are likely to have better reattachment and recovery outcomes.6,12

Avulsion injuries tend to have the poorest outcomes with regard to reattachment. A classic example involves a ring avulsion, where a finger with a ring on it becomes caught on an object as the individual is falling. The injury that results from this "catching" can range from partial degloving of the skin to complete loss of the finger. Structures proximal to the point of amputation, such as tendons within the forearm, may be involved when a finger or hand is subject to an avulsion injury. Neurologic, arterial and venous vessel interruption can occur, and soft tissue damage or destruction is also likely. These factors result in a lower likelihood that a successful reattachment will occur.6,12,13

Prehospital Assessment
Begin the assessment with an overview of the scene.8,14,15 During this time, the MOI involved in the amputation may be identified. This time can also be used to determine the type of BSI that will be most appropriate.

Once the patient is reached, priorities include assessing the patient's airway, breathing, circulation and neurologic status. Complete a mini-neurologic exam as soon as possible. This can be performed using tools like the Glasgow Coma Scale (GCS) and the AVPU system, where the patient is noted to be alert, responsive to verbal stimuli, responsive to painful stimuli or unresponsive.

Obtain an initial or baseline set of vitals when feasible. Vital signs should include condition of the patient's skin (e.g., cool, moist, pale), heart rate, blood pressure and respirations. Capillary refill time and distal neurologic assessments should be included for any affected extremity.8,14,15

After conducting an initial assessment, it should be possible to determine the next plan of action. If, for example, the patient is in shock (e.g., tachycardia, pale/cool skin, hypotension), or has additional injuries (e.g., multi-trauma), the patient should be managed accordingly. This may include supporting the patient's airway, breathing and circulation. It may also require immediate management of life-threatening injuries and deferring salvage of the amputated anatomy until additional resources are available. In an amputation, the specific steps taken will be guided by the patient's overall condition, the severity of the amputation and the amount of elapsed time.8,14,15

Providers should also conduct a patient and bystander interview. If possible, determine the patient's past medical history, allergies, prescribed medications and overall state of health. Also attempt to determine how much time has passed since the incident occurred. The reason for this is that time is tissue. The chance for successful reattachment decreases the longer the amputated part is not perfused. The patient's medical history and timeline of the event can also be used by the hospital to assist in determining the appropriate treatment to pursue. If at all possible, try to determine the patient's dominant side and provide this information to the hospital.5,8,12,14,15

Prehospital Treatment Of Amputation
Treatment provided for the patient who has suffered an amputation is influenced by numerous factors. Management of potentially life-threatening conditions is the first priority. Management of victims of amputations from blunt trauma is complicated by the concern for additional injuries. Blunt trauma amputations are often caused by mechanisms of high-energy transfer, such as motorcycle accidents, auto-pedestrian accidents, significant crush injuries and work-related accidents involving large machinery. These accidents often involve the potential for multi-system trauma, and the provider must stay alert to the possibility of other injuries. It is critical to remember that the most obvious injury is not always the most significant.

Your next steps will be influenced by many factors, including the mechanism of injury, body part involved in the amputation, presence of additional injuries, estimated fluid loss and proximity to a hospital.

Incomplete (partial) Amputation
Partial amputations should be assessed and treated as if they are fully intact. Regardless of the amount of injury, in the prehospital setting, partial amputations should be considered eligible for reattachment. If an extremity is involved, it should be splinted. Dressings, such as a saline-moistened sterile dressing, placed over exposed tissue will help to reduce additional contamination or injury. Initial efforts to control bleeding should include direct pressure and use of pressure points. Elevation may be considered.3,5,8,12,14-18 Similar to splinting an extremity, assess distal neurologic function and circulation prior to and following any manipulation. If available, pulse oximetry may be used as the patient is assessed and treated.19

Complete Amputation
If there is complete amputation and the anatomy is retrieved, it should be handled with the goals of preservation and reattachment in mind. Cover the amputated anatomy with a saline-moistened gauze, tightly seal it in a clean or sterile plastic bag and place the bag over ice. Providers should make every effort to avoid direct contact of amputated tissue with ice, as this can result in tissue damage.5,6,8,12,14,20

Anatomy that has been located
It is important to avoid delays in the treatment or transport of the patient and/or the amputated body part(s) that have been located. One reason is that the exact amount of time that an amputated part can survive before reattachment occurs has not been completely agreed upon in the medical community. Traumatic amputation tissue survival time continues to be researched. In the prehospital setting, timely delivery of the patient and any amputated parts to the emergency department should be a priority (see Table IV).17,18

Anatomy that has not been located
In cases where the amputated part has not yet been found, a comprehensive search may be initiated. The amount of time and resources used when searching for amputated anatomy varies with each scenario. Factors such as the involved amputated anatomy, scene dynamics, mechanism of injury, number of patients and availability of resources will influence this decision. Whenever possible, efforts should be made to locate and salvage amputated anatomy, as successful reattachment may significantly enhance the patient's outcome and post-incident level of function.19,21

Entrapment & Extrication
Extrication from entrapment should be accomplished with preservation of the limb in mind. Unless it is absolutely necessary to get the patient to a safer environment (e.g., out of a burning vehicle), the entrapped anatomy should not be pulled with force, as this may cause more injury. Dismantling the machinery may be the best option for extrication, and this may take hours to accomplish.

If dismantling the machinery is not possible, or for other reasons a "field" amputation is anticipated, providers are encouraged to consult with medical control. It may be possible for the prehospital crew to request that a physician (e.g., surgical team, "go team" or similar) be dispatched to the scene to assist with the amputation and additional treatments, such as local anesthesia. Providers should consider this option, as there are documented cases involving successful field amputations.19,22-24

Reattachment & Revascularization Following Amputation
Depending on the type of amputation, the anatomic location and degree of damage, reattachment and revascularization are possible. Reattachment differs from revascularization. Reattachment, which involves the reattachment of a completely severed piece of anatomy, has occurred for decades, and success rates as high as 90% have been reported.5,6,12 In contrast, revascularization is reconstruction of the blood supply to an incompletely amputated body part. Successful revascularization is a major factor in the success of reattachment and usefulness of a reattached limb.

Several factors influence reattachment success. Amputations caused by sharp objects tend to have higher reattachment success rates than cases involving blunt trauma. Reattachment is less successful in cases where nerve injury is involved. Time and tissue damage are also factors. The longer an amputated part is without circulation, the less likely the reattachment will be successful. Amputated parts that contain significant amounts of soft tissue are less tolerant of reduced circulation. The amount of damage, preservation efforts and the amount of contamination also influence the success of the reattachment.5,6,12

The patient's overall health, including underlying medical conditions, will influence the chances of a successful reattachment. Poor nutrition, psychologic conditions and medical conditions (e.g., diabetes, hypertension) are all associated with lower success rates. EMS providers should not promote inappropriate expectations to the patient with respect to reimplantation. The final outcome is not often immediately obvious, and expectations should be left until a detailed evaluation is completed in the hospital.

Reattachment side-effects and complications
Following reattachment, the patient may experience side-effects or complications, regardless of their age, gender, race or medical history. Examples include wound breakdown, skin problems, edema, joint contracture (limited range of motion), pain and infection. Deficits may also be encountered with reattachment. Examples include reduced mobility, incomplete neurological recovery or cold weather intolerance.5,6,12

The patient with an amputation may develop phantom limb sensations, such as tingling, itching, numbness or pain where the amputated body part used to be. Phantom sensations can be frequent or intermittent and can be debilitating. The sensations may last from only a few moments to hours.5

Long-term and comprehensive care are often involved in managing amputation cases. This includes rehabilitation, the potential for additional surgeries and psychological support. Following an amputation, the individual may perceive that there is a social awareness associating his amputation with being an incomplete person, which may result in the individual believing he is an incomplete person compared to others. This can have immediate and long-term consequences that impact his immediate post-surgery recovery, the ability to return to society in an effective manner, and his long-term mental and overall health. Healthcare providers at all levels will need to be attentive to the patient's potential need for psychological support. By recognizing such needs, recovery from the amputation may be supported, leading to better overall outcomes.4-6,12,19,21,26

It is possible for EMS providers to be called to assist patients after they have been discharged from the hospital or rehabilitation facility. This can occur at any time after discharge from the initial treatment center, and can occur for a variety of reasons, including bleeding from wound sites, fever and chills associated with infection and phantom pain. While not often life-threatening, these events can be very troubling and must be approached with appropriate expertise, understanding and sensitivity to what the patient is experiencing.

Remaining & Intact Anatomy
If the amputation involves an extremity and there is a stump remaining, the stump should be immobilized whenever possible. Control external bleeding using direct pressure and elevation. In complete amputations, there may be minimal bleeding from the stump, as the vessels may spasm and retract. Partial amputations may involve more hemorrhage. Tourniquets are rarely necessary for control of hemorrhage from a wound. In most cases, appropriately applied direct pressure will be all that is necessary.

In the rare event that an exsanguinating hemorrhage cannot be controlled with direct pressure, a tourniquet may be effective. A single-cuff tourniquet (sphygmomanometer or blood pressure cuff) placed around the arm or leg proximal to the amputation site can be effective at stopping both venous and arterial bleeding without damaging or crushing underlying structures. Before application, elevate and manually exsanguinate the involved extremity, if possible. Then, inflate the cuff to 250-300 mmHg (or at least 70 mmHg above the systolic blood pressure), clamp the tubing, remove the bandage and lower the extremity. The maximum time a tourniquet can be left in place is generally 30 to 45 minutes, and is often limited by pain in conscious patients. A tourniquet can cause injury by producing ischemia, compressing and damaging underlying tissues, and can jeopardize the survival of marginally viable tissue, so it will need to be monitored closely. Remove all tourniquets before releasing the patient to another care provider. When tourniquets placed prior to EMS's arrival need to be removed, consider having a cuff in place and ready to inflate for the rare case when direct pressure will not adequately control hemorrhage.25

Placing a saline-moistened sterile dressing over the stump will help to reduce additional contamination or injury. After bandaging the stump, it should be elevated to minimize swelling and control bleeding.3,5,12,14-18

Stump wounds should not be clamped or excessively manipulated. If the stump is dirty or has debris in it, use normal saline for irrigation. Do not use alcohol, hydrogen peroxide, iodine or other antiseptics for irrigation, as they can cause additional tissue damage.3,5,8,12,14-18

In the prehospital setting, it is not necessary to manipulate or otherwise examine the remaining stump or tissue. This can aggravate the tissue and may cause additional trauma. When treating a remaining stump or amputated anatomy, it should be handled with caution and managed appropriately.3,5,8,12,14-18

Intravenous access should be obtained, and volume replacement or administration of medications (e.g., analgesia) initiated as appropriate. Fluid selection will most often be either normal saline or lactated Ringer's. The amount of fluid administered will be influenced by the patient's overall condition and local protocols. If aggressive volume replacement is not indicated, intravenous access can be used as a "keep-vein-open" and medication route.8,14,15

Pain relief is often indicated and can play a significant role in the prehospital management of victims of amputations. The use of analgesia will be influenced by a variety of factors, including the patient's overall condition, allergies, provider judgment, local protocols, available medications and presence of alcohol or drugs. An adult dose of 2-5 mg morphine sulfate, delivered IV, repeated every 3-5 minutes as needed, is commonly used for pain relief. Fentanyl can also be used for analgesia and sedation. An adult dose, in the range of 1-2 mcg/kg, slow IV, may be used. The combination of these two drugs can be very effective: Fentanyl has a rapid onset, but diminished effect after 20 minutes, while morphine has a peak effect about 20 minutes after administration. Local anesthetics, such as Xylocaine or bupivacaine, can provide more targeted pain control in certain cases. Although these are often not immediately available in the prehospital setting, they are available in most emergency departments.

This may be an indication for having a physician respond to the scene when extrication issues prevent timely transport. The actual medicine and dosage may vary, depending on medical control or local protocols.5,6,8,14-20

In amputations, it can be critically important to document the times when events occurred. If possible, determine when the initial incident occurred. In a complete amputation, if the body part was located prior to your arrival, try to determine when and where the part was located. If the body part was located while EMS was on scene, note the time of discovery. Other times to consider recording include the time that the body part was wrapped and when icing began. Having this type of detailed information may help to determine if reattachment of the amputated part is possible.5,6,20

Communications
When communicating with a hospital, communications/dispatch center or other facility (e.g., transplant center) regarding the patient's condition, provide basic information (e.g., medical history, allergies, vitals), as well as amputation-specific details. This may include the exact location of the amputation, the mechanism of injury, when the initial injury occurred, treatment provided and the patient's overall condition. Early notification can play a role in the patient's outcome. In some cases, it can take significant time for a hospital to mobilize all necessary resources to care for some types of amputations (such as fingers), and early notification with key information can maximize patient care by providing more timely access to those resources.19

Destination
In situations where there is only one hospital or a single trauma center, the destination choice is easy. In situations where there are more options, it should be clear which hospital, if any, is capable of performing reattachment and revascularization procedures. At the time of this writing, many areas of the country do not have personnel to perform these procedures. Local protocols should clearly direct prehospital caregivers how to choose a destination when caring for a patient with a traumatic amputation. In general, amputations proximal to the wrist or ankle should be directed to a high-level trauma center. Resuscitation and evaluation of the amputated part can be continued while speciality reattachment centers are consulted as needed.

Conclusion
The ability to effectively manage an incomplete or complete traumatic amputation can influence the long-term outcome of the patient's extremity, his mental health and his ability to regain near-normal levels of functioning. Prehospital providers are encouraged to remain abreast of contemporary treatment and management options. By taking a positive approach, you can render optimal patient care while contributing to a reduction in patient morbidity and mortality.

References
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5. Haggerty M. Gale Encyclopedia of Medicine. Health A to Z. Traumatic Amputations. www.healthatoz.com/healthatoz/Atoz/ency/traumatic_amputations.jsp.
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7. Occupational Safety and Health Administration. OSHA Fact Sheet: Amputations. www.osha.gov/OshDoc/data_General_Facts/amputation-factsheet.pdf.
8. Hubble M, Hubble J. Principles of Advanced Trauma Care. Albany: Delmar Thompson Learning, 2002.
9. Edwards S, Osterman A. Elbow and Above Elbow Amputations. www.emedicine.com/orthoped/topic10.htm.
10. Edwards S, Osterman A. Wrist and Forearm Amputations. www.emedicine.com/orthoped/topic620.htm.
11. Loder R. Demographics of Traumatic Amputations in Children. Implications for Prevention Strategies. The Journal of Bone and Joint Surgery. www.ejbjs.org/cgi/content/abstract/86/5/923.
12. Langdorf M, Kazzi K. Replantation. www.emedicine.com/emerg/topic502.htm.
13. Marx J, Hockberger R, Walls R. Orthopedic Emergencies. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th Ed. Philadelphia: Elsevier, 2004.
14. Bledsoe B, Porter R, Shade B. Paramedic Emergency Care. Upper Saddle River: Brady Prentice Hall, 1997.
15. Campbell J. Basic Trauma Life Support for Paramedics and Advanced EMS Providers. Englewood Cliffs: Brady, 1995.
16. Roberts J, Hedges J. Management of Amputations. Clinical Procedures in Emergency Medicine, 4th Ed. Philadelphia: Elsevier, 2003.
17. Markovchick V, Pons P, Wolfe R. Emergency Medicine Secrets. Philadelphia: Hanley & Belfus, Inc., 1993.
18. Pons P, Markovchick V. Prehospital Emergency Care Secrets. Philadelphia: Hanley & Belfus, Inc., 1998.
19. Augustine J. Prehospital Rounds: Work Injury. Emerg Med Serv. www.emsresponder.com/publication/article.jsp?pubId=1&id=1825.
20. St. Anthony's Hospitals Prehospital Services. Centura Health. (2003) Fentanyl. Denver Metropolitan Paramedic Protocols. www.sahems.org/stanthonyemsweb/protocols/DMPPPDF.pdf.
21. Microsurgeon.org. Thumb replantation. www.microsurgeon.org/thumb.htm.
22. CBS News. Climber Describes Amputation Ordeal. www.cbsnews.com/stories/2003/05/02/national/main551979.shtml.
23. Ciavaglia J. (2006). Rare amputations save life of man caught in machine. Philly Burbs. www.phillyburbs.com/pb-dyn/articlePrint.cfm?id=621295.
24. Kampen K, Krohmer J, Jones J, et al. In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehosp Disaster Med. http://pdm.medicine.wisc.edu/kampen.htm.
25. Sanders R. The tourniquet: Instrument or weapon? Hand 5:119, 1973. www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=4715692&query_hl=3&itool=pubmed_docsum.
26. Wilhelmi B, Lee W. Hand, Amputations and Replantation. www.emedicine.com/plastic/topic536.htm.

Paul Murphy, MA, MSHA, EMT-P, has clinical and administrative experience in healthcare organizations.

Chris Colwell, MD, is the medical director for Denver Paramedics and the Denver Fire Department, as well as an attending physician in the ED at the Denver Health Medical Center, Denver, CO.

Gilbert Pineda, MD, FACEP, is medical director for the Aurora Fire Department and Rural Metro Ambulance, Aurora, CO, as well as an attending physician in the ED at The Medical Center of Aurora and Denver Health Medical Center.

Tamara Bryan, BS, EMT-P, has more than a decade of healthcare experience, including clinical and project management roles.

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