Time is tissue: EMS management of amputation

Our cohosts discuss bleeding control, early tourniquet use and transportation to a trauma center

May 19, 2021 11:41 PM •

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.

Amputation epidemiology

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.

Amputation pathophysiology

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.

Amputation assessment

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.

Amputation management

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.

Amputation ABCs

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

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.

Listen: EMS management of amputation

Training Day: Chest seals, tourniquets and trauma dressings

Challenge EMS providers’ critical thinking and appropriate skill deployment with these 3 penetrating trauma scenarios, ranging from moderate hemorrhage to exsanguination

References

American Ambulance Association Clinical Medical Director Podcasts Stop The Bleed Trauma

American Ambulance EMS Podcast

Looking for some fun EMS education? Hosted by American Ambulance’s Medical Director, Dr. Danielle Campagne, along with her UCSF-Fresno colleagues, Drs. Patil Armenian and Saajan Bhakta, discuss practical, pertinent and evidence-based topics that you can use today to take care of your community. They also bring in guests from all parts of the EMS world to highlight the heroes among us, and share their unique take on challenging situations. Join us, let’s learn together and thrive.

Danielle Campagne, MD, FACEP, is a board-certified emergency medicine physician. She was an honors student at Fresno State and received her bachelor’s degree in Biology. She received her medical degree from USC School of Medicine and completed her residency in Emergency Medicine at UCSF-Fresno. Dr. Campagne is an associate professor of clinical emergency medicine at UCSF and works at Community Regional Medical Center in Fresno, California. She currently serves as vice chief of emergency medicine at UCSF Fresno. She has spoken internationally on orthopedic topics in emergency medicine in places such as the Netherlands, Italy, Spain and Vietnam. She has spoken nationally at the American College of Emergency Physicians Scientific Assembly and the Society of Emergency Medicine PAs. She has published on a wide range of EMS/wilderness, medical education and orthopedic topics. She is the co-editor for Oxford Press’s Emergency Medicine Board Review textbook and also serves as the associate editor for the orthopedics section in EM:RAPs ComPendium textbook. Dr. Campagne is also active in EMS and currently serves as medical director for American Ambulance in Fresno, and serves as the course chair for the UCSF High Sierra Wilderness and Travel Medicine Conference.

Patil Armenian, MD, FACEP, is a board-certified physician in Emergency Medicine and Medical Toxicology. She received her B.S. with honors in physiological science and classical civilization from UCLA and her medical degree from the Boston University School of Medicine. Her residency in Emergency Medicine was completed at UCSF Fresno where she served as chief resident in her final year. She completed a Medical Toxicology fellowship at UCSF in San Francisco. She is an associate professor of clinical emergency medicine at UCSF and works at Community Regional Medical Center in Fresno as a staff physician and co-director of Medical Toxicology.

Dr. Armenian’s primary focus is in identification of drug intoxication outbreaks, including novel drugs of abuse, such as fentanyl analogs. Additional areas of expertise include prehospital care of poisoned patients, stimulant drug use and traumatic injury patterns, and MDMA intoxication and treatment. She helped start the successful inpatient toxicology practice at Community Regional Medical Center in Fresno, which accepts transfers from all of Central California. In addition to clinical duties, Dr. Armenian also does expert witness and peer review work in medical toxicology and emergency medicine, works closely with local law enforcement on illicit drug outbreaks, and has a strong interest in prehospital emergency medicine.

Saajan Bhakta, DO, is currently an Emergency Medicine resident at UCSF Fresno. He obtained his Bachelor’s of Science degree with Honors from UC San Diego, majoring in Biochemistry and minoring in Music. He then attended medical school at Western University of Health Sciences. In medical school, he was privileged to be a part of the Sigma Sigma Pi honors society and graduated on the Dean’s List. He served as a volunteer for several organizations, including local free clinics as well as large community-wide projects such as Care Harbor LA. Dr. Bhakta traveled to Nepal shortly after a devastating earthquake, providing disaster relief and prehospital medical care to those most affected. During residency at UCSF-Fresno, he has been involved with medical student and resident teaching, as well as Park Medic training. Through these experiences, he has garnered an appreciation and excitement for emergency medical services, and hopes to continue advancement in the field through education.