Extremity Amputation

Thankfully the procedure is only rarely necessary and on some occasions may only require cutting remaining skin bridges with scissors. The indications are:

• An immediate and real risk to the patient’s life due to a scene safety emergency
• A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
• A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation
• The patient is dead and their limbs are blocking access to potentially live casualties

The recommended procedure is:

1. Ketamine dissociative sedation/anagesia
2. Apply an effective proximal tourniquet
3. Amputate as distally as possible
4. Perform a guillotine amputation
5. If there is continued bleeding tighten the tourniquet and/or apply a second tourniquet
6. If necessary apply haemostats to large blood vessels
7. Leave the tourniquet in situ
8. Apply large trauma dressing and bandage
9. Once the patient is extricated perform rapid sequence intubation
10. Transport to hospital
11. If the amputated part can be freed transport this with the patient

Remember: the requirement for prehospital amputation other than cutting minimal soft tissue bridges is rare. However pre-hospital critical care physicians should be trained and equipped to amputate limbs in order to save life. Familiarise yourself with the location and use of the Gigli saw.

This short video shows the Gigli saw being used on a deer carcass at the GSA-HEMS base:

The Medical College of Wisconsin has produced videos on pre-hospital extremity amputation. Their technique differs from ours in that they have a powered bone saw, but some of the principles remain the same and the videos use cadaveric limbs so are useful to watch if you’ve never seen an amputation:

Reference
Prehospital amputation Emerg Med J 2010 27: 940-942