All posts by TheTraumaPro

Field Amputation for Trauma, Part 2

Yesterday I discussed how uncommon field amputation is, despite all the potential drama. Today, I’ll review the indications for performing it.

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 into 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.
  • Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. It is possible to wait for additional extrication efforts, 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 may be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time that passes, the less likely the extremity will ultimately be functional. 

Obviously a lot of thought and judgment goes into making the decision amputate. It is helpful to have another physician to discuss the facts with, but as the treating surgeon, the ultimate decision is yours.

Tomorrow, I’ll talk about the logistics of getting to the scene of the potential field amputation.

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Field Amputation for Trauma, Part 1

Field amputation is not thought of very often, and for good reason. It is unpleasant, uncommon, and not very safe. I’m going to spend the next few days on this topic, starting with some of the facts.

In reality, field amputation is talked about much more often that it is actually performed. There is one old paper that is cited frequently which consisted of a survey of EMS directors 19 years ago! A total of 143 people responded and noted the following:

  • There were 26 amputations over a five year period
  • The most common mechanism was motor vehicle crash
  • 53% were performed by a trauma surgeon and 36% by an emergency physician. (Who did the other 12%???)
  • No training was available for this procedure
  • Only 2 EMS systems had an existing protocol

An informal poll of trauma surgeons at the recent American College of Surgeons meeting in San Francisco showed that only 5 had ever been called to do a field amputation, and only 2 had actually done it.

Uncommonly performed procedures are always problematic. It is extremely difficult to keep skills sharp and to remember the protocol (or even where to find it). Furthermore, these procedures are prone to error and pose considerable risk to all. 

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Reference: In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehospital and Disaster Medicine 11(1):63-66, 1996.

Emergency Thoracotomy Video

I did get a lead on a decent video of an emergency thoracotomy that combines most of the principles I laid out last week. It shows a nicely done thoracotomy with exposure of the heart. Aortic crossclamping is not performed, but overall it’s pretty good. All narration is in Thai, so many of you may not be able to follow the conversations.

Trauma In Wine Country?

Nope. Sorry. The two don’t mix. I just finished attending the American College of Surgeons meeting in San Francisco, and now I’m moving up to the Napa Valley for a few days. However, enjoying the sights, food and wine here is not conducive to writing coherently.

So I’m taking a few days off to concentrate on other things. I’ll return on Tuesday with several days of material on field amputations. I’m also teaching several sessions at the TCAA Trauma Director course and their Trauma Performance Improvement course. I’ll be tweeting some of the more interesting content as I sit in on some of the others’ sessions.

Talk to you again on Tuesday. Cheers!

Emergency Care Of Bleeding From Dabigatran

Finally, a consensus report has been finalized by the Institute for Clinical Systems Improvement (ICSI) regarding bleeding in patients taking dabigatran (Pradaxa). I’ve written about the special problems posed by patients who are injured while taking this drug and related ones. I’ve also provided some management algorithms for consideration while complete ones were crafted. Well, here they are.

A workgroup of experts from hospitals here in Minnesota were convened to consider and provide a framework for managing these patients. A document was released recently to help guide their care.

To summarize, patients who experience a severe bleed, say from trauma, should be managed with:

  • Holding the medication
  • Evaluating bleeding. In trauma, this will generally involve CT scan.
  • Consider the need for surgery
  • Give activated charcoal if the drug was taken within 2 hours
  • Consider dialysis
  • Transfuse blood if hemoglobin / hematocrit needs to be improved
  • Infuse plasma after 4 units of red cells, and cryoprecipitate after 8 units packed cells / 4 units plasma if needed
  • Consider prothrombin complex concentrate or activated Factor VII in extreme cases

Click here to download the official document from ICSI.

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