Time is tissue: EMS management of amputation
Our cohosts discuss bleeding control, early torniquet use and transportation to a trauma center
Join our UCSF physician team as they discuss the topic of traumatic amputations.
Special guest cohost Dr. Steffani Campbell and Paramedic Ian Ashby join the American Ambulance EMS Podcast to discuss amputations and the importance of early tourniquet use. Listen to the evidence behind the use of tourniquets and hear a lively discussion on how to treat digit amputations.
Amputation case study
Ian responded to a call involving a middle-aged male patient attempted self-harm, however, family found him and were attempting to wrestle away the gun. Unfortunately, the patient’s hand was over the barrel of the gun when it fired. He suffered a traumatic amputation of his thumb. Police and medics were unable to locate any parts of the avulsed appendage. Ian and his team were able to wrap the finger in gauze to control the bleeding and initiated transport. Ian remembers in addition to the wound itself, there was an additional responsibility of managing the patient’s mental health concerns, as well as managing the family on scene.
As you know, traumatic amputation is the traumatic removal of a body part. Amputations are potentially devastating injuries with life-long consequences, and they are true surgical emergencies because reimplantation must be performed within hours to have a chance at salvaging the amputated part. So, an efficient and effective approach to this presentation by the EMS crew can be both life and limb saving.
There are about 83,000 traumatic amputations in the U.S. every year. Amputations occur most frequently in young-to-middle-aged adults, and there is a 5:1 predominance of males to females. Most common causes are motor vehicle accidents, followed by industrial and agricultural accidents, followed by firearms/fireworks/explosives. The most common type of traumatic amputation is partial hand amputation.
Traumatic amputation is associated with significant physical and psychological morbidity. Phantom limb pain is experienced by up to 85% of traumatic amputation survivors. That means that they are experiencing pain that seems to be coming from a limb or other body part that is no longer there. From a psychological standpoint, PTSD is experienced by up to 25% of amputees, and depression by up to half, so this type of injury often has a huge impact on the person’s quality of life.
The first way to describe an amputation is complete vs partial. In a complete amputation, the body part is fully severed from the body. In a partial amputation, there is some kind of tissue that is still connecting the part to the rest of the body. The second characteristic of an amputation refers to the mechanism which caused the amputation. Sharp or “guillotine” amputations have a relatively clean edge and are often caused by sharp machinery or tools such as a knife or ax. These are the most likely to be successfully reimplanted. Crush, avulsion, burn and blast amputations all cause more widespread tissue damage and are less likely to be amenable to reimplantation.
In the case of a complete amputation, it is helpful to quickly assess the potential viability of the injured limb and have a general sense of whether there is a reasonable chance of salvage or reimplantation.
For amputations, in the hospital there is a clinical decision tool called the MESS score: the Mangled Extremity Severity Score and is used for estimating viability of a limb after trauma. It was developed in 1990 by Dr. Johnson, a vascular surgeon in Seattle who created it after witnessing multiple trauma victims die after what he saw as misguided prolonged attempts to save a lower extremity. The factors considered in the MESS score include:
- Ischemia time
- Signs of limb ischemia on exam
- Patient’s age
- Shock (presumably hemorrhagic)
- Injury mechanism
The true score is less useful with current advancements in surgery, however, the information is still important to obtain in the pre-hospital setting.
Upper extremities are of such high importance that reimplantation is often very aggressively attempted on proximal lesions (such as those involving the entire arm). These proximal injuries may not bleed as much as you expect. Arteries can clamp down and may spasm, which can slow bleeding initially but begin to bleed later en route. Big veins don’t have that muscular wall to spasm, so they can continuously bleed.
This is not necessarily true with partial digit amputations. The bleeding from fingertips can usually be stopped with direct pressure. In the hospital, partial finger amputations, especially fingertips, are often not reimplanted as the possibility of side effects and adverse outcomes can outweigh the potential benefit. Priority is placed on maintaining the ability to grasp by salvaging the thumb and at least two other fingers.
Control bleeding as soon as possible. Start with direct pressure. Move on to a tourniquet if bleeding is still not controlled. If you are able to locate the amputated body part, wrap it in moist gauze, place into a plastic bag, then place this bag on ice. Do not store an amputated body part directly on ice. Direct contact with ice causes significant vasoconstriction, thus the tissue will die faster and make reimplantation harder.
Early tourniquet use is associated with a 90% survival rate. It’s important to aim for <6 hours ischemia time to allow the best chance of successful reimplantation. In the last two decades, evidence mostly from combat use of tourniquets shows that they are safe, effective, and often life saving when applied early and correctly. These studies also show that the tourniquet can remain on the limb for up to two hours without any increased risk of requiring amputation of the limb.
If elevation and direct pressure do not control bleeding, and especially if you observe bright red blood spurting from the wound indicating an arterial bleed, it is time to place a tourniquet. The tourniquet should be opened and placed around the limb, as close to wound as possible, but ideally not directly over a joint. Tighten the tourniquet by pulling on the free end until it is quite tight. A common mistake is not tightening the tourniquet enough during the initial application. Turn the windlass (that stick attached to the tourniquet) until you completely stop the distal pulse. Note the application time by writing it on the tourniquet. If bleeding continues, don’t remove a tourniquet, you can apply a second once. This is more frequently required with very muscular or bariatric patients.
If the tourniquet is not tight enough, you risk paradoxical bleeding. This is caused by insufficient pressure that reduces venous, but not arterial, flow potentially leading to devastating hemorrhage and/or compartment syndrome. Compartment syndrome occurs when there is too much pressure in a muscular compartment leading to more tissue damage. Do not loosen the tourniquet for any reason. The providers at the trauma center will remove it when appropriate.
There are some differences in regards to placement of a tourniquet in relation to a wound. Physicians may say as close to the wound as possible. Local CCEMSA protocol says 2-3 inches above a bleeding site, and prehospital trauma life support (PHTLS) dictates placing the tourniquet at the groin or axilla, basically place it “high and tight.”
Why the discrepancy of location? All sources agree that tourniquets are good and save lives. All three agree to place the tourniquet for hemorrhage before the patient goes into shock. If there is life-threatening bleeding on the scene prehospital - PHTLS does not want you wasting precious time trying to locate the bleeding wound in the extremity; just place the tourniquet in the axilla or groin. Get the tourniquet in place in a speedy manner. The bottom line is, tourniquets save lives the earlier they are applied in hemorrhage control.
Remember to also assess ABCs (or CABs in a combat-type situation). When assessing a traumatic amputation:
- Clean the wound
- Control bleeding using a tourniquet if necessary
- Initiate transport to the trauma center
Time is tissue! Aim for transport to the hospital as quickly as possible to allow assessment for reimplantation.
About the hosts
Dr. Steffani Campbell
Dr. Steffani Campbell is an emergency medicine resident with UCSF-Fresno at Community Regional Medical Center. She was born in Salinas, California, and attended UC San Francisco Medical School. Dr. Campbell has pre-hospital experience herself, having previously worked as an EMT in Connecticut.
Ian Ashby is proud to have been born and raised in Fresno. He has worked at American Ambulance for 7 years, and obtained his paramedic license 5 years ago. He joined the agency straight out of high school and hasn’t had a reason to leave.
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Challenge EMS providers’ critical thinking and appropriate skill deployment with these 3 penetrating trauma scenarios, ranging from moderate hemorrhage to exsanguination