Field Amputation: VLOG by Cynthia Griffin D.O., NRP
Vlog Notes!
Indications for field Amputation
This is where we chose Life over Limb.
1. Pt is unstable and there is no other way to extricate them
2. Pt is somewhat stable yet there is no other way to extricate them, may have time sensitive injuries, may need time sensitive surgery, pt needs blood, pt has a bleed you can’t get to
3. Pt is at risk of dying due to the environment (stable or unstable). Pts life is in imminent danger.
Fire, Cold, Oncoming train, Submersion, Structural collapse, Chemical Exposure
4. Pt has a completely mutilated nonsurvivable limb retaining minimal attachment
5. Pt is dead and their limbs are blocking access to potentially live casualties
Example Cases:
Vehicle will explode
Chemical Spill
Gross Instability at the Scene
Rapid Deterioration
Progressing Fire
Rising water
Contraindications:
Having an alternate means of extrication.
Make sure to ask everyone onscene for their ideas.
Make sure all of their clothing around that part has been removed.
Giving analgesia might help.
Some sources say if entrapped in proximal portion and not limb, but this is not true.
Support Personnel
FF – for scene safety or HAZMAT and ICS
HAZMAT
HURT
HOIST team
Police – scene protection
2nd Ambulance – transport of the limb if delayed and pt critical
HEMS – blood, TXA, pt transport
Materials & Equipment
Meds
Sedation & Pain: Need to be able to control pain, may help in extrication
Ketamine – ideal agent
Versed – consider lower doses since this pt is prob already hypotensive
Fentanyl
Morphine
Propofol – beware hypotension
Etomidate
Rocc – if you need them paralyzed, not ideal to have them paralyzed
Succ – avoid since there might be hyperK – although more of a concern w prolonged
Blood & Plasma
TXA
Antibiotics
Cefazolin (Ancef) 2g (25 mg/kg)
If allergic to cephalosporins, Clindamycin 600mg IV (10mg/kg)
If dirt in wound, Gentamicin 1.5-2.5 mg/kg IDW
Tetanus Toxoid 0.5ccIM (if not current w/In past 5 yrs)
Equipment
PPE: Gowns mask, goggles, Gloves (sterile preferred)
Cutting: Use cot to have instruments & equipment available
[Article about cutting tools –Man or Machine? An experimental study of prehospital emergency amputation – C Leech 2016] used CT assessment of the proximal bone
All completed amputation within 91 sec
Cadaveric study
Gigli Saw – 91 sec, quick and can be used in tight spaces, sharp, need elbow room
Stryker Bone Saw - can use with one hand
Hacksaw – 88 sec, took 3 cuts bc jammed on bone, sharp knife, saw blade injury, need to support and traction leg, difficult to angle hacksaw, needs 2 angles, good quality/soft tissue/bone cuts
HURST Tool – large, on large bones can splint
- carbon steel edge curved blades – Holmatro Device in UK (<1 min) 38+15sec
- CU 3020
- Leech only rec this is FF can only reach pt
- manual handling difficult
- loud splintering sound (gross to hear)
-may be difficult to encircle limb
-poor soft tissue quality and bone cuts poorest
No feedback vibration or resistance to know when to stop cutting
-article found that it was 2-7x faster
- Degree of comminution was greater
- Had greater proximal fracture propagation by 40 mm-5cm above the knee.
- Sometimes required 2 cuts.
- Also there is a risk of injury to the provider (reports of finger amputation).
- HURST tools can operate under water as well.
- Can be used under water & to -20°C (hydraulic) w unleaded fuel
- Done by FF – 12.5 kg = 27.5lb
Saw Zaw/DeWalt DC 305 cordless (Reciprocating Saw)– splints a lot
Fastest 22 sec
yet splattered blood and guts everywhere and cut the under tissue,
Jammed on the bone 2x,
aresolation of tissue require FFP3 mask, dust respirator
no feedback when cutting complete,
difficult to see when cutting
easier to use in confined space
Kit:
Touniquets x2 at min
Sterile Gloves
Chlorhexidine
#10 Blade Scalpel x 2
Sterile Kellys / Pean Forceps
Abd Pads
Sterile Raptors
Combat gauze – to cover marrow
Abd pads – to cover stump
6 in Ace Bandage to cover stump
Saline soaked gauze to moisten remaining part
Biohazard bag – for limb
Trauma shears/Sterile Raptors – cut away clothing
Blood tubing
ETCO2
12 lead ECG – worry about crush injury and rhabdo & hyperK
Other meds – Calcium, Bicarb, Neb,
Making the Cut
Remove clothing
Place tourniquet x 2, place proximal to the injury and not over a joint, select the lowest point 2 inches above the site of amputation. If no tourniquet then can use BP cuff, pump to 300 or at least 70 mmHg above systolic
Clean with chlorhexidine (can use betadine)
Use #10 blade to cut through skin and tissue, clean cuts, cut medial to as far lateral as possible. Cut down to the bone. Place Kellys/Pean forceps under the bone and combat gauze (lap sponge, webbing, sterile drape) through to help distract tissue proximally, in order to be able to get to the bone better & allow the saw to cut
Grab the Gigli saw end with the Pean Forceps (Larged Curved Kellys) and cut through the bone, cut while pulling tension until through the bone, 90 degree or V shape, will require proximal stabilization
Place combat cause on end of the bone where the marrow may continue to leak Cut through the remaining tissue with sterile shears
Elevate stump & place moistened saline and ace bandage to end of stump
Tighten both tourniquets if continuing to bleed from tissue
Package the other part in saline moistened gauze in a biohazard bag and place in ice water bath. This can be used as a skin graft even if unable to reattach.
Make sure to do your best to find the missing part, include search & rescue if needed.
Resources:
Bunyasaranand, J., Espino, E., Rummings, K., & Christiansen, G. (2018). Management of an Entrapped Patient with a Field Amputation. The Journal of Emergency Medicine., 54(1), 90-95.
Management of an Entrapped Patient with a Field Amputation
The Journal of Emergency Medicine, Volume 54, Issue 1, 2018, pp. 90-95
John C. Bunyasaranand, Erasmo Espino, Kelli A. Rummings, Gregory M. Christiansen
Download PDF
Time critical’ rapid amputation using fire service hydraulic cutting equipment
Injury, Volume 42, Issue 11, 2011, pp. 1333-1335
M.J. McNicholas, S.J. Robinson, I. Polyzois, I. Dunbar, A.P. Payne, M. Forrest
Download PDF
https://www.firerescue1.com/rescue/articles/192121018-Exclusive-Field-amputation-difference-between-life-and-death/
Christopher Way, BA, Paramedic, Edward de Tar, MD, FACS, Steve Isaacson, BA, Paramedic, Carmen Sincerbeaux, RN, BSN, MA, Marcus Torgenson, MD, FACS, David Wineinger, MD. Exclusive: Field amputation difference between life and death
Feb 8, 2017
Latimer, Andrew. Field Amputation.
http://www.tamingthesru.com/blog/procedural-education/field-amputation
April 30, 2015
Colella, M Riccardo. "Field EMS Physician Limb Amputation Training and Guidelines." MCW : Field EMS Physicians. Medical College of Wisconsin Department of Emergency Medicine, 2015. Web.
https://www.mcw.edu/departments/emergency-medicine/education/section-of-ems-and-disaster-medicine/field-ems-physicians#.VLvV0C5GwZ4
Kampen, K E "In-field extremity amputation: prevalence and protocols in emergency medical services". Prehospital and disaster medicine 11(1):63-66, 1996.
Lorich, Dean G., Devon M. Jeffcoat, Neil R. Macintyre, Daniel B. Chan, and David Leonard Helfet. "The 2010 Haiti Earthquake: Lessons Learned?" Techniques in Hand & Upper Extremity Surgery 14.2 (2010): 64-68.
Macintyre, A. "Extreme measures: field amputation on the living and dismemberment of the deceased to extricate individuals entrapped in collapsed structures". Disaster medicine and public health preparedness (1935-7893), 6 (4), p. 428. 2012.
Mustafa, Ivan A. "Field Limb Amputations Used as an Extrication Option in Complicated Entrapments or Disaster Events." (n.d.): n. pag. United States Fire Administration, Seminole County Fire Department, unk. Web.
Porter, K. M. "Prehospital Amputation." Emergency Medicine Journal 27.12 (2010): 940-42. Web.
Weingart, Scott. "Prehospital Amputation." EMCrit. Emcrit.org, n.d. Web. 11 Apr. 2015.
Zils, Steven W., Panna A. Codner, and Ronald G. Pirrallo. "Field Extremity Amputation: A Brief Curriculum and Protocol." Academic Emergency Medicine 18.9 (2011): E84. Web.
Cliff Reed.
http://resusme.em.extrememember.com/?p=3053
November 25, 2010
Porter KM
Prehospital amputation
Emergency Medicine Journal 2010;27:940-942.
Prehospital Field Amputation paper from JEMS with cut hand
https://www.jems.com/articles/print/volume-43/issue-1/departments-columns/case-of-the-month/hand-entrapment.html
BMJ Cutting Methods
https://emj.bmj.com/content/emermed/33/9/641.full.pdf
Printed out – Man or Machine – experimental prehosp
Leech C, Porter K, Man or Machine? An experimental study of prehospital emergency amputation. Emerg med J 2016; 33: 641-644
Field Amputation Abstract
https://www.jems.com/articles/print/volume-43/issue-1/departments-columns/case-of-the-month/hand-entrapment.html
https://www.theatlantic.com/photo/2017/09/rescue-dogs-at-work-after-mexicos-earthquakes/540933/