Field Amputation


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

  1. Remove clothing

  2. 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

  3. Clean with chlorhexidine (can use betadine)

  4. 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

  5. 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

  6. Place combat cause on end of the bone where the marrow may continue to leak Cut through the remaining tissue with sterile shears

  7. Elevate stump & place moistened saline and ace bandage to end of stump

  8. Tighten both tourniquets if continuing to bleed from tissue

  9. 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.

  10. 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/