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Home > Topics > Medical / Clinical
July 29, 2014
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Sticking to the basics
by Patrick Lickiss

Clinical solution: Near-amputation in a boating accident

You arrived to find a 23-year-old male whose right leg has been nearly amputated above the knee. Did you get your treatment right?

By Patrick Lickiss

In the previous scenario, you responded to a 23-year-old male who was struck and run over by a boat while water skiing. The patient had suffered a near amputation of his right leg above the knee. He was bleeding significantly even though bystanders had been applying direct pressure. 

Treatment

One of the first treatment priorities in trauma patients after ensuring a patent airway is the control of major hemorrhage. EMS trauma classes teach the ABCs of patient assessment with “C” standing for circulation and including perfusion and hemorrhage.[1] 

EMS providers were previously advised to use a tourniquet only as a last resort for fear of causing tissue death in the part of the limb beyond the tourniquet. However, the experience of military physicians over the last 10 years has demonstrated that a tourniquet may be safely applied for up to two hours with little to no risk of nerve or tissue damage.[2] 

Based on these findings, tourniquets have been deployed with increasing frequency among civilian EMS agencies. Many agencies have altered protocols to encourage early use of tourniquets in the control of hemorrhage. 

Given the distance of this patient from a hospital, the difficulty in extricating him back to a transporting unit and the extent of his injury, use of a tourniquet is indicated. While a folded cravat was traditionally used in EMS as a tourniquet, several commercial options have become available. 

Regardless of which method is used, the guidelines for applying a tourniquet are consistent: The device should be applied just proximal to the wound (within three or four inches) and should be tightened to the point that arterial flow is stopped.

Hemorrhaging may actually increase in severity and volume if the tourniquet only stops venous flow. If one tourniquet is not sufficient to stop blood flow a second one may be used as well.[3]

The goal of most pre-hospital trauma care is to stabilize a patient and allow him to survive to reach definitive care. Definitive care in this instance means surgical services. 

Patients suffering from major trauma were once treated under a concept called the golden hour. While there has been some question about the accuracy of the term, time is still extremely important.

Given that this patient is in need of emergency surgical intervention, it is more appropriate for him to be transported directly to the regional trauma center. Since that facility is 90 minutes away by ground the use of air medical services may be beneficial. 

Outcome

After performing a rapid trauma assessment on your patient, you apply a commercial tourniquet to his leg above the site of the injury. While you begin treatment, you ask dispatch to start the air ambulance to the landing zone at the ranger’s station.

With the bleeding stopped, you and the sheriff’s deputy transfer the patient to your boat and start back to the dock. The ALS crew meets you as you pull up and you provide a turnover report.

The patient’s blood pressure has remained stable since the tourniquet was placed so the paramedic elects to start an IV TKO. Ten minutes after your arrival at the dock the air ambulance is overhead. The patient is loaded and transported to the regional trauma center. 

Given the extent of the patient’s injuries, surgeons at the trauma center are forced to amputate above the knee. While there was initially a significant amount of blood lost, surgeons credit the application of the tourniquet with allowing the patient to survive through surgery.

The patient recovers quickly and has been discharged to a rehabilitation facility for physical and occupational therapy and fitment of a prosthesis. 

References

1. American College Of Surgeons Committee On Trauma. "Patient Assessment and Management." Prehospital Trauma Life Support. Burlington, MA: Jones & Bartlett Learning, 2011. 114-115. 

2. Kragh, JF, TJ Walters, DG Baer, CJ Fox, CE Wade, J Salinas, and JB Holcomb. "Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma." J Trauma 64(2008): 49-50. Web.

3. American College Of Surgeons Committee On Trauma. "Patient Assessment and Management." Prehospital Trauma Life Support. Burlington, MA: Jones & Bartlett Learning, 2011. 200

Comments
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Dennis Kerrigan Dennis Kerrigan Wednesday, July 30, 2014 11:03:00 AM Maine EMS bleeding protocol calls for tourniquet placement proximal to the knee or elbow, even for distal extremity bleeding given the 'splinting' effect that the dual bones of the tib / fib or ulna / radius provide, thus apparently less effective arterial pressure constriction than if the tourniquet is placed over the humerus or femur. I'm curious if other states follow this tourniquet placement guideline, as opposed to 3 or 4 inches proximal to the wound as this article advocates.
Doug Fraser Doug Fraser Wednesday, July 30, 2014 1:37:57 PM Dennis, I helped with the British Columbia TK guidelines and that's our direction as well, although there are some saying that may not be a problem in the context of a complete amputation proximal to the distal joint.
Robert Martin Robert Martin Saturday, August 02, 2014 12:54:15 PM Dennis, those guidelines mirror the Army's and are both safer and more effective than the placement recommended in this article.
Josh Buck Josh Buck Sunday, August 03, 2014 9:10:18 AM Same in Minnesota.

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