Rosen & Barkin's 5-Minute Emergency Medicine Consult (49 page)

ED workup includes obtaining an accurate history and physical exam, stabilizing the patient and injured part, and consultation or transfer if replantation is an option.

Preoperative lab studies, cultures from wounded area

Radiographs of both amputated part and stump are important, but should not delay transport.

Determined by surgical consultant for replantation

• Involves neurologic, vascular, and soft tissue integrity and potential for replantation/revascularization
  
• Do not miss other major injuries with concurrent trauma.
  

TREATMENT

• Collect all amputated body parts, including pieces of bone, tissue, and skin.
  
• See “Initial Stabilization” for care of amputated parts during transport.
  
• Transport patient and body parts to the nearest microvascular replantation center unless other major injuries require transport to the nearest trauma center:
  
  • Air transport from remote locations should be considered if ischemia time is of concern.
    

• Consult surgical specialist as early as possible.
  
• Establish IV access.
  
• Limit blood loss:
  
  • Elevate injured limb.
    
  • Direct pressure using bulky pressure dressing or pressure points if ineffective.
    
  • Use tourniquet if above methods fail to give desired hemostasis (BP cuff 30 mm Hg > systolic BP [SBP]).
    
  • Partial amputations bleed more because of lack of both retraction and spasm of blood vessels.
    
• Avoid further damage to injured part:
  
  • Avoid vascular clamps, cautery, vessel ligation, or debridement.
    
  • Avoid repeated exams of the stump or amputated part.
    
• Care of amputated part (complete and partial):
  
  • Remove gross contamination/foreign material.
    
  • Gently irrigate with saline (avoid antiseptics).
    
  • Wrap in gauze moistened with saline.
    
  • Place in clean, dry plastic bag or specimen cup.
    
  • Place sealed bag/cup in ice water (half water, half ice) or refrigerate at 4°C.
    
  • Never place directly onto ice or into ice water.
    
  • Avoid dry ice to prevent freezing.
    
• Care of the stump:
  
  • Irrigate with saline and cover with saline dampened gauze.
    
  • Splint if necessary; keep partial amputations as near anatomic position as possible.
    
  • Keep any fragments of tissue (even if seemingly insignificant) because they may be used for skin, bone, or nerve grafting
    
  • If limb amputation, may cannulate proximal artery with 18G cannula and irrigate with tissue preservation formula, but this should be at the discretion of the surgeon
    
• Maintain normal blood volume with IV fluids or blood products if necessary.
  

• Tetanus prophylaxis
  
• Adequate IV analgesia
  
• Patient NPO
  
• Prophylactic antibiotics if devitalized tissue, exposed bone, or contamination:
  
  • Cover
    Streptococcus
    ,
    Staphylococcus aureus
    , and
    Clostridium perfringens
    
• All patients are candidates for surgical repair until a specialist deems otherwise.
  
• Limit ischemia time of the amputated part (i.e., early transfer if necessary).
  
• Patient considerations in decision to replant:
  
  • Age
    
  • Occupation/handedness
    
  • Degree of motivation
    
  • General physical condition and underlying diseases, particularly diabetes mellitus, peripheral vascular disease
    
• Indications for replantation (no absolute indications):
  
  • Thumb, any level (supplies 40% of hand function)
    
  • Multiple digits
    
  • Hand amputations through the palm and distal wrist
    
  • Individual digit distal to flexor digitorum superficialis tendon insertion and proximal to distal interphalangeal joint (DIP)
    
  • Some single-digit ring avulsion injuries
    
  • Arm proximal to midforearm (if sharp or moderately avulsed)
    
  • Virtually all pediatric amputations (younger patients have lower success rates but better functional outcomes)
    
• Contraindications to replantation:
  
  • Severely crushed or mangled parts
    
  • Injuries at multiple levels
    
  • Psychotic patients who willfully self-amputated the part
    
  • Single-digit amputations proximal to the flexor digitorum superficialis muscle insertion
    
  • Amputated parts with tendons avulsed from musculotendinous junctions
    
  • Lower extremities rarely attempted and usually in children
    
  • Unstable patients secondary to other serious injuries or diseases
    
  • Older patients or those with contraindications to general anesthesia
    
  • Inappropriately prolonged ischemia time
    
• Fingertip amputations: Most common type of upper extremity amputation:
  
  • Distal to DIP joint
    
  • Primary goals of treatment:
    
    • Maintenance of length
      
    • Good soft-tissue coverage
      
    • Painless fingertip with durable and sensate skin
      
    • Nail preservation
      
  • Better dorsal prognosis than ventral
    
  • No exposed phalanx:
    
    • Irrigate with saline, apply petrolatum-soaked gauze and allow to heal by secondary intention (best result in wounds <1 cm
      ²
      ).
      
  • Small amount of exposed phalanx:
    
    • Shorten bone with rongeur below level of the tissue and close by primary intention or allow to heal by secondary intention.
      
    • Any bone left exposed requires additional operative procedures and consultation.
      
    • Replantation is an option for cosmetic reasons or for occupational consideration (e.g., musicians).
      
  • Considered open fractures if phalanx exposed, thus antibiotics are indicated.
    
  • Preserve nail bed and nail to optimize function and cosmesis.
    
  • Treat subungual hematomas.
    
  • Splint to prevent trauma to healing fingertip.
    
  • Consultation required if significant loss of bone or soft tissue for possible graft or flap
    
• Nonlimb amputations (penis, ear, nose): Amputated parts should be cared for similarly as above and emergently referred to a specialist for replantation:
  
  • Penile amputations: Most often secondary to self-mutilation and psychiatric illness
    
  • Successful replantation unlikely beyond 24 hr of cold ischemia or 6 hr of warm ischemia
    
  • Ear amputations: Should be considered for replantation by appropriate specialist
    
  • Nose amputations: Replantation has been successfully performed with variable results.
    

• All pediatric amputations considered for replantation
  
• Fingertip amputations often left to heal by secondary intention:
  
  • Spontaneous regeneration of fingertip occurs in children even with volar fingertip amputations.
    
  • Pediatric fingertip amputations distal to the lunula of the fingernail can be successfully replanted (unlike adults).
    

Advanced age not an absolute contraindication to replantation; however, underlying medical problems often make older patients poor surgical candidates.

• First Line: Cefazolin: 0.5–1.5 g IV or IM q6–q8h (peds: 25–100 mg/kg/d divided q8h, max. 6 g/d)
  
• Second Line: Vancomycin 15–20 mg/kg IV q12h
  
• If concerned about clostridia, consider using Piperacilin/Tazobactam 80 mg/kg IV q8h
  

FOLLOW-UP

Hospitalization is required for all patients undergoing replantation or revascularization.

• Mild fingertip amputations or mild degloving injuries with adequate repair and stable vasculature
  
• Close surgical or orthopedic follow-up is required.
  

• Know exact mechanism and time of injury
  
• Refer as early as possible
  
• Transfer imaging and amputated parts with patient, stored in appropriate medium
  

Patients discharged but with significant skin loss should be considered for skin grafting and have close surgical follow-up.

• Every effort should be made to minimize ischemia time
  
• Expeditious consultation or transfer to appropriate surgeon and team is paramount.
  
• Avoid any direct contact of the amputated part with ice
  
• Perform thorough ATLS survey to avoid missing other less obvious, but potentially life threatening, injuries
  

• Davis S, Chung KC. Replantation of finger avulsion injuries: a systematic review of survival and functional outcomes.
  J Hand Surg
  . 2011;36(4):686–694.
  
• Lloyd MS, Teo TC, Pickford MA, et al. Preoperative management of the amputated limb.
  Emerg Med J.
  2005;22(7):478–480.
  
• Lyn ET, Mailhot T. Hand, Runyon M. The Genitourinary System; Mckay M, Mayersak R, Facial Trauma. In: Marx J, Hockberger RS, Walls RM, et al., eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  , 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010.
  
• Maricevich M, Carlsen B, Mardini S, et al. Upper extremity and digital replantation.
  Hand
  . 2011;6:356–363.
  
• Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation.
  Plast Reconstr Surg
  . 2011;128(3):723–737.
  

CODES

• 885.0 Traumatic amputation of thumb (complete)(partial), without mention of complication
  
• 886.0 Traumatic amputation of other finger(s) (complete) (partial), without mention of complication
  
• 887.4 Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, without mention of complication