see: [Robert Hedges - management of amputaitons](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=1092), [ABC of prehospital medicine - surgical amputation](x-devonthink-item://FE9A2759-455A-4056-BEE5-E9D190E90FEA?page=120&start=2952&length=19&search=Surgical%20amputation) see also: [[Tourniquet]] #pre-hospital #procedures > ***Interesting case:*** > [Tasmania amputation of kayaker with leg trapped in rock](https://www.abc.net.au/news/2025-06-29/franklin-river-rescue-man-stuck-lithuanian-valdas-leg-amputated/105420916) ## Pre-hospital care - Amputated part is wrapped in moist gauze and placed in a plastic bag, then placed into a second plastic bag containing ice. - If finger is completely cut off, do the following: - Gently clean the amputated part with water or, if possible, with sterile saline solution. - Cover it in a moistened gauze wrap. - Place it in a watertight bag. - Place the bag on ice in a sealed container or another watertight bag. - Do not allow the amputated part to be in direct contact with ice. ## Limb viability bone, tendon and skin can tolerate - 8 - 12 hours of warm ischaemia - ​24 hours of cold ischaemia > digital re-implantation may be successful after 94 hours of cold ischaemia muscle will necrose after - 6 hours of warm ischaemia - 12 hours of cold ischaemia > - robert hedges says Irreversible ischemic injury occurs in muscle tissue after 2-4 hours of warm ischemia and 6-8 hours of cold ischemia > - **Digits** have less muscle tissue, ∴ less susceptible to ischemic damage (warm ischemia 6-12 hours and cold ischemia 12-24 hours) ## Finger tip amputations ***\< 1 cm2*** - multiple layers of tulle gras / gauze dressing - heal as quickly as with skin grafting ***\> 1 cm2*** - usually require grafting ### Contraindications to digital re-implantation - presence of other severe injuries - ​significant chronic illness - amputated part is severely crushed or contaminated - ​\> 50 years of age - avulsion injury - cooling of the amputated part delayed \> 6 hours - only one finger (not thumb or index) amputated - ​reimplantations proximal to the insertion of the flexor digitorium superficialis tendon on the middle phalanx may not improve overall hand function ## Amputation procedure ***Indications*** - An immediate and real risk to patient's life due to a scene safety emergency - Deteriorating patient physically trapped by limb where they will almost [certainly die](https://www.abc.net.au/news/2025-06-29/franklin-river-rescue-man-stuck-lithuanian-valdas-leg-amputated/105420916) during time to secure extrication - Patient is deceased and their limbs are blocking access to potentially live casualties > [!pearl] Steps to perform pre-hospital amputation > 1. plan for actions after extrication > 2. wear appropriate PPE and eye protection > 3. apply effective proximal haemorrhage control with [[Tourniquet]] and **record the time** > 4. IV [[Procedural sedation|sedation]] if patient is conscious > 5. Amputate as distally as possible > 6. use a [[Scalpel sizes|scalpel]] to incise the skin circumfrentially at the level of intended amputation > 7. Cut down through the s/c tissues and open the fascia containing underlying muscle groups > 8. Identify muscle groups using gloved hand and divide wiht tuff cut scissors > 9. Divide the bone wiht a Gigli saw > 10. Divide any residual soft tissue attatchments with scissors and remove the limb > 11. Release the patient > 12. Reassess the tourniquet and tighten further if any haemorrhage from stump > 13. Apply artery forceps to visible large blood vessels. Dress teh stump with haemostatic gause and circumfrential pressure bandages > 14. Give [[TXA]] and PPx antibiotics > 15. Transfer to major trauma centre > 16. try to bring the amputated part