Traumatic injuries resulting in total or partial amputations of fingers, hands, arms, nose, ears, eyelids, tongue, genitalia, legs, feet or toes all require specific amputation related assessments and treatments. Unlike assessing other injuries and illnesses as paramedics, traumatic amputations generally require immediate treatment to stop the exsanguination and maintain haemodynamic stability.
Anatomy behind an Amputation
It is important to have a basic understanding of the anatomy behind an amputation. The upper limbs include the fingers (phalanges), hand (metacarpals), wrist (carpals), forearm (radius/ulna), upper arm (humerus), shoulder blade (scapula) and collar bone (clavicle). Neurovascular structures include subclavian, axillary, brachial, radial, median and ulnar arteries. Axillary, radial, median and ulnar nerves are also present.
Lower extremities include the pelvis (ilium, ischium, pubis), upper leg (femur, patella), lower leg (tibia/fibula) and foot (tarsals, metatarsals, phalanges. Neurovascular structures include the abdominal aorta, femoral, popliteal and anterior/posterior tibial arteries. Lower extremity nerves include sciatic, tibial and perineal.
Types of Amputations
Amputations can be complete or incomplete. In a complete amputation, there are no tissues, ligaments, muscles or other anatomical structures connecting the amputated part to the body. A partial amputation is one in which an anatomical structure, such as a ligament, tendon or muscle, is still intact between the body and the amputated anatomy. Although the body part may not be functional at the time and complete amputation may appear to be imminent, the body part is still connected to the body. In a partial amputation, every effort should be made to preserve this connection. Amputations can involve proximal or distal anatomy. Proximal amputations involve anatomy that is attached closely to the body’s core, such as an entire arm at the shoulder joint or a leg at the hip joint. Distal amputations involve anatomy that is distant from the core of the body, such as fingers or toes. Distal amputations are more common than proximal amputations. A common distal amputation is cutting a finger off (through the guillotine movement of a knife) or a finger avulsion (by getting a ring finger caught while falling).
Mechanism of Injury of Amputations
Crush, guillotine and avulsion mechanisms are three of the most common forms of traumatic amputation. Crush injuries are the most common and can result in significant tissue damage and injury. Because of the injury associated with crush mechanisms, amputations resulting from these forces are less likely to be successfully reattached. In contrast, guillotine injuries involve sharp edges, resulting in less tissue disruption. As a result, body parts that are amputated by guillotine forces are likely to have better reattachment and recovery outcomes.
In general, when assessing a traumatic amputation I will assess the person’s Airway and Breathing while I approach them (by simply asking their name and hopefully getting a response) and then will resolve any problems with Circulation by applying direct pressure, raising the limb and in most likely applying an arterial tourniquet. If you do not have a tourniquet on you a BP cuff raised to 250-300 mmHg will work to stop the bleeding. Make sure to mark a T (for tourniquet) on the patient’s forehead and the time of application. Although it looks bad, in general a single traumatic limb amputation should not be a complex case for a paramedic to attend.
Once haemorrhage control has been establish priority should be given to urgently transporting the patient to hospital (remember time is closely related to success of reattachment of the limb). Oxygen therapy should be provided en route because oxygen is a potent vaso-constrictor which will assist in haemorrhage control. IV access should also be established and fluid available if the person becomes hypotensive. It should be noted that surgeons as a general rule prefer their patients to be “drier” rather than “wetter” prior to surgery, as multiple studies have demonstrated that excessive IV fluid administration increases a patient’s coagulation times and increased risk of bleeding.
How to Preserve the Amputated Limb
Preserve the amputated part as follows:
1. Moisten appropriately-sized sterile gauze with sterile saline solution.
2. Wrap the severed part in the moistened sterile dressing, preserving all amputated material.
3. Place the severed part in a watertight container (plastic bag).
4. Place the container on ice or cold packs (if available).
5. Never freeze the amputated limb directly as this causes damage to the microvasculature and reduces the chance of reattachment.