There are basically four indications, two absolute and two relative:

• Absolute #1: entrapped extremity with a lengthy extrication and a physiologically impaired patient who does not respond to fluids. In this case, there is occult blood loss in other areas that is killing your patient, and they need to get out quickly for definitive management.
• Absolute #2: entrapped extremity with a lengthy extrication and an unstable physical environment. Examples include entrapment in a structurally damaged building or a vehicle in danger of falling, exploding, etc.
• Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. Waiting for additional extrication efforts is possible, but vital signs must be monitored closely. At the first sign of recurrent hypotension, it’s time to amputate.
• Relative #2: entrapped extremity and physiologically normal, but extrication may take many hours or be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time passes, the less likely the extremity will ultimately be functional.

Obviously, a lot of thought and judgment goes into deciding to amputate. Having another physician to discuss the facts with is helpful, but as the treating trauma professional, the ultimate decision is yours. If appropriate, there may also be an opportunity to discuss with the patient and/or their family.

In the next post in this series, I’ll discuss who performs the field amputation.