Print PDF

I was recently asked to share some literature I had collected regarding care of amputations and amputated parts. Ambulance services worldwide have specific treatment guidelines for traumatic amputations and care of amputated parts. Treatment of the patient for haemorrhage, shock, pain etc. is assumed, and here we are specifically looking at the evidence supporting care of the amputated part.

Little literature exists on storage and preparation of an amputated limb prior to transfer to a reconstructive plastic surgical unit for possible macroreplantation. The key concept paramedics must bear in mind is that warm ischemia time should be limited, and this, along with other aspects of care of amputated limbs are often misinterpreted by healthcare professionals (Oomann et al.)

This can be achieved by wrapping the amputated body part in saline-soaked gauze or by indirect cooling (placing the body part in a container and then placing the container on ice). Simple though this may seem, it is common for potentially replantable limbs to be inadequately cooled or further damaged and hence unsalvageable, as described by Lloyd et al. The chance for successful reattachment decreases the longer the warm ischaemia time.

The extremity should not be exposed directly to ice. According to a study by Sapega et al., metabolic deterioration in amputated limbs progressively declined with decreasing temperature of tissue to 10 degrees Celsius. However, at 5 degrees Celsius, no additional benefit was detected, and at 1 degree Celsius tissue damage was noted. Many unsalvageable limbs are as a result of coming in direct contact with ice.

The general overall advice can be summarised as:

• Rinse part(s) with Normal Saline* if grossly contaminated
• Wrap part(s) in sterile gauze moistened with Normal Saline* or dry dressing.
• Place part(s) into plastic bag or container.
• Place bag/container into separate container filled with ice.
• Do not allow part(s) to come into direct contact with ice, do not freeze, and do not submerge in water.

*The American College of Surgeons Guidelines for Management of Amputated Parts in 1996 recommend using Lactated Ringers instead of Normal Saline. You can view the ACS Guidelines here – https://www.facs.org/~/media/files/quality%20programs/trauma/publications/amputatedparts.ashx

A useful section outlining the care of the patient, and amputated part is available in the current ATACC manual. Download the ATACC manual for free from http://www.atacc.co.uk

References

Mitsuo Y (2003) Indications and Limits of Digital Replantation JMAJ 46(10): 460–467, 2003 (free full text) 

 

Boulas HJ1. Amputations of the fingers and hand: indications for replantation. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):100-5. PMID: 9682072. With hand and digital replantation now widely available in most urban settings, initial treating physicians must be aware of the factors that may influence outcome, so that informed decisions can be made regarding referral for replantation and appropriate early treatment. The author outlines the fac [...]

 

Lloyd MS1, Teo TC, Pickford MA, Arnstein PM. Preoperative management of the amputated limb. Emerg Med J. 2005 Jul;22(7):478-80. PMID: 15983081. Little literature exists on storage and preparation of an amputated limb prior to transfer to a reconstructive plastic surgical unit for possible macroreplantation. This paper describes practical measures used to prolong ischaemia time allowing macroreplantation, tissue harvesting, or fashioning of [...]

 

Oomman A1, Tickunas T, Javed M, Yarrow J, Azzopardi E, Azzopardi E, Whitaker IS. Changes in perceptions regarding correct preoperative storage and transfer of amputated digits: A 5-year follow-up. Microsurgery. 2014 Jan;34(1):76-7. PMID: 23913368.