Episode 5: Amputation

/ timnutbeam

Amputation

 

 

Welcome to PHEMCAST episode 5: Amputation

One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done.

This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements.

This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy.

 

Which patients / scenarios:

  1. An immediate and real risk to the patient’s life due to a scene safety emergency.
  2. A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
  3. 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.
  4. The patient is dead and their limbs are blocking access to potentially live casualties.

 

Which kit:

  • CAT x 2
  • Scalpel
  • Gigli saw (and spare)
  • Arterial forceps x 4
  • Tuff Cut scissors
  • Appropriate dressing (e.g. Israeli combat bandage)

 

Preparation:

  • Sedation or anaesthesia
  • Brief team
  • Plan next phase

 

Stages of amputation process:

  • Apply an effective proximal tourniquet.
  • Amputate as distally as possible.
  • Perform a guillotine amputation.
  • Apply haemostats to large blood vessels.
  • Leave the tourniquet in situ.

(consider IV antibiotics if can be delivered as concurrent activity)

 

Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure.

 

References:

Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2.

Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. .

Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–

Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3.

Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466.

McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

11 thoughts on “Episode 5: Amputation”

  1. Pingback: Episode 5: Amputation | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

  2. Thanks guys, another great podcast!
    As for the question-for a non-physician team stuck in this clinical situation I believe it would be extremely difficult for both the Paramedics on scene and the Dr offering top cover. The lack of any other options would have to be absolutely absent. I believe that there would need to be a great deal of trust between both parties and may depend on an existing working relationship them. The decision may also be aided by advances in telemetry monitoring if they are available. Either way a VERY big call, but a completely possible situation

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  3. As usual a great podcast.

    The comment above is really pertinent with regard to non-physician teams attending these sort of incidents. (I’m thinking about a dual CCP team with remote top-cover). A lot comes down to the person providing top-cover knowing the skills and abilities of the CCP and being confident enough to trust their judgement.

    My approach in this scenario I guess would be:

    1) To try and find any way at all of getting a pre-hospital critical care doctor out to the scene – in the ‘north’ part of the south-west of england we’re generally to find someone who is available – even out of hours, although still not 100%

    2) Try to get an idea of really how time-critical it is that the limb be amputated – hard to do over the phone and needs the right questions to be asked.

    3) Try to think laterally about all the other options that could be considered before jumping to amputation – this might involve a 3-way discussion with the fire incident commander, CCP and top-cover consultant. This would also involve a discussion around the realistic time-frame in which those options could be implemented.

    4) If it was established that amputation by a CCP was the only way forward then I would want to talk it through step-by-step with them before they started and make sure they were completely comfortable with the procedure and the potential complications (including the sedation required, post extrication packaging etc..)

    5) I’d ensure that I was keeping a detailed written record of the conversations I’d had and the advice / authorisation that I’d given. Would also speak to ambulance control and ask them to enter some notes onto the ambulance electronic log. Might well also speaking to the Trauma Team Leader at the receiving MTC to give them a heads-up and get them prepared.

    6) Extensive debrief after the incident would go without saying.

    Gets even harder if it’s a standard ambulance crew without a CCP present….!

    Ed

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  5. Thanks Dave and Ed for comments. Agree that knowing the team on scene would be vital to even consider the remote-permission option and I would want to have practiced the technique together, ideally at a cadaveric workshop, previously. You raise important points about recording keeping too, Ed, cheers.

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  6. Great podcast and it is great to get an issue like this out there. With reference to the use of Holmatro. The issue we discussed after our trial in 2009 was who would perform the procedure on scene. As you eluded to in your podcast, firefighters with a ‘trauma’ interest would be happy to do this. I am convinced that the majority may not be so happy (despite what they may say!) and I am also not so sure of the implications from an organisational (fire service) perspective….Fantastic debate though.

    Just some further info. The Holmatro cutters are now also available in battery driven and with regards to sterilization after the procedure, the cutters (with a hose) are a sealed unit so can be fully sterilized.

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    • Thanks Ian, I think you are right, would need very careful discussion with the firefighter involved. And thanks for the extra info regards holmatro

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  7. Great podcast and can understand the thought process relating to the amputation process for the doctors etc on scene. As a firefighter I believe some not all would be okay to carry this out!!
    One situation that has happened that I would be interested in regards to amputation relates to a person trapped by a lower limb at risk of drowning/hypothermia would amputation still be a viable option, the patient wasn’t in pain, able to give consent? How would that be carried out?

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    • Thanks Gareth. I think the case you mention is the one that got Caroline thinking about this issue in the first place. The difficulty is with predicting that hypothermia was going to be fatal and when that might happen and therefore when to decide that amputation is the only option. Consent is tricky in the context of stress – and we are planning to do a whole podcast on consent in the future.

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