Patient Care, Trauma

Prehospital Field Amputation Leads to Improved Patient Outcome

Issue 1 and Volume 43.

Industrial accident leads to extrication by amputation

Your aeromedical team responds to a 29-year-old female whose right hand has been entrapped between the inside of a hopper wall and industrial auger for five hours.

She’s found in a semi-erect position on top of a platform. Although she’s in pain, she expresses that she’s losing sensation to her hand.

Upon physical examination, you find that her right hand is entrapped proximal to the metacarpophalangeal joints, excluding the patient’s thumb.

Multiple attempts at freeing the hand are made to no avail.

Upon arrival of a second aeromedical team with an emergency medicine physician and hand surgeon on board, the circumstances are explained to her and it’s recommended that she undergo endotracheal intubation and a complete amputation of the hand.

Nerve blocks of the hand are performed by anesthetizing the median, ulnar and radial nerves at the level of the wrist.

The patient, still in a semi-erect position, undergoes rapid sequence intubation with etomidate and succinylcholine. Sedation is maintained by administering push doses of ketamine, versed and fentanyl.

Hemodynamic monitoring and wakefulness are conducted with field telemetry and serial physical exams. To prepare for significant hemorrhage, the patient is administered fresh frozen plasma and Type O-negative blood through an inline warmer. Furthermore, although the patient had a single peripheral IV line, an intraosseous line is also placed.

With the patient intubated and sedated, a final attempt to liberate the hand fails, and the hand surgeon uses rib cutters to amputate the hand at the level of the distal metacarpals while preserving the thumb.

After the amputation, hemostasis is achieved with hemostatic dressings. The patient is extricated and flown to the Level 1 trauma center 40 minutes away for further evaluation.

The patient is discharged from the hospital six days later. After stable soft tissue coverage is achieved, she’s fitted with a bioelectric prosthesis. (See video, p. 20.)

Postoperative photo of hand. Photo courtesy William Ross, MD

Postoperative photo of hand. Photo courtesy William Ross, MD

Discussion

Based on the literature search that was conducted, field amputations are uncommon, and have been conducted by a variety of personnel. There appears to be no yearly prevalence data. A 1992 survey of attendees to the mid-year meeting of the National Association of EMS Physicians (NAEMSP), between 1986 and 1992, indicates that 26 were conducted.1,2 The majority of cases involving amputation in the prehospital setting are described as case reports in large-scale natural disasters and industrial accidents.3–5

In the emergency and disaster medicine literature, it’s generally accepted to amputate the limb as distally as possible.4,6,7 This is consistent with the steering committee recommendations set forth in 2011 by the International Search and Rescue Advisory Group (INSARAG).4

One report describes a field paramedic amputating a lower leg in a motor vehicle accident.8 A three-case series involving upper and lower extremity entrapments describe trauma surgeons attending all cases to complete amputations.4 Even more rare are cases where subspecialist surgeons were on scene to conduct the amputation. The 1992 NAEMSP survey indicates a small majority of the cases, 53.2%, were conducted by trauma surgeons.1,2

In this particular case, a hand surgeon completed the amputation, which limited significant morbidity due to the decision to spare the thumb. The decision to conduct a thumb-sparing amputation was made with trepidation, taking into account that the surgeon had to maneuver his body inside the hopper with the blades above and below him.

After assessing the risks and benefits of amputation at the level of the wrist outside the hopper or at the level of the distal metacarpals, it was decided that the patient would benefit the most from amputation within the hopper in order to limit disability of the entire limb. The patient was intubated in the semi-erect position with rapid sequence intubation. The monitoring of the patient’s pain and wakefulness was conducted by with the physical exam, telemetry, and end-tidal carbon dioxide (EtCO2).

With regard to pain control and sedation, this case seems to be commensurate with current literature. The most common procedural sedation agents in the ED used in isolation or combination are etomidate, ketamine, fentanyl, propofol and midazolam.9 The overall complication rate with ketamine, propofol and versed is about 11%, and complications are primarily hypoxia or apnea.10

The experience in Afghanistan has shown great success with ketamine. Ketmine has an extremely low side effect profile and has been used by personnel with little to no medical training in Afghanistan.11 The majority of these medications are used for procedures that typically last for minutes. In this case, the procedure was completed in 40 minutes with a combination of fentanyl, versed and ketamine.

The American College of Emergency Physicians’ stance on procedural sedation is that it’s acceptable to perform in the ED without any indication of specific agents.12 However, recommended monitoring includes EtCO2 and standard telemetry.

In preparation for significant hemorrhage, the patient was administered plasma and packed red blood cells. Prehospital blood product administration is a controversial topic. There are conflicting data likely due to multiple confounding factors such as flight time and varying injury severity leading to blood product administration. Prehospital blood product transfusion appears to confer an early survival advantage but no difference in overall survival.13

Furthermore, long flight times and head injury are factors that complicate the determination of survival advantage with blood product administration.14 Although there are many practical matters such as storage and temperature regulation, with the appropriate protocols, carriage of blood products appears to be a safe, effective way of resuscitation in the short term.13

INSARAG, which is an organization coordinated under the United Nations, recommend that an entrapped limb should be amputated as distally as possible without endangering the patient or rescue team.4 This is consistent with what was done in the field.

In this case, after conducting the risk/benefit assessment, rather than amputating the hand at the level of the wrist outside of the hopper, it was decided that the best compromise between adverse events to the participants and sparing the patient’s thumb function was to have the surgeon amputate the distal metacarpals by inserting his body through an upper inspection door with the auger blades above and below him. Notably, light was provided by a flashlight held in the surgeon’s mouth during the procedure.

Conclusion

This case describes a patient who was entrapped in the semi-erect position and liberated with a thumb-sparing completion traumatic amputation of the hand. It demonstrates not only the risk/benefit assessment essential to decrease the greatest morbidity to the patient but also the multidisciplinary need for physicians in the field when necessary and unconventional use of resources to improve a patient outcome.

Video: Bioelectric prosthesis following partial hand ampuation. To view the video, please access the digital edition of this issue. Video courtesy William Ross, MD

Bioelectric prosthesis following partial hand ampuation. Image courtesy William Ross, MD

References

1. Kampen KE, Krohmer JR, Jones JS, et al. In-field extremity amputation: Prevalence and protocols in emergency medical services. Prehosp Disaster Med. 1996;11(1):63–66.

2. Sharp CF, Mangram AJ, Lorenzo M, et al. A major metropolitan “field amputation” team: A call to arms … and legs. J Trauma. 2009;67(6):1158–1161.

3. Raines A, Lees J, Fry W, et al. Field amputation: Response planning and legal considerations inspired by three separate amputations. Am J Disaster Med. 2014;9(1):53–58.

4. Macintyre A, Kramer EB, Petinaux B, et al. Extreme measures: Field amputation on the living and dismemberment of the deceased to extricate individuals entrapped in collapsed structures. Disaster Med Public Health Prep. 2012;6(4):428–435.

5. Stewart RD, Young JC, Kenney DA, et al. Field surgical intervention: An unusual case. J Trauma. 1979;19(10):780–783.

6. Capener N. Emergency amputations: Lower limb. Ann R Coll Surg Engl. 1967;40(4):216–222.

7. Osmond-Clarke H. Emergency amputations: Lower limb. Ann R Coll Surg Engl. 1967;40(4):216–218.

8. Kelly JB, Thompson AS, Gervin AA. Field leg amputation by a paramedic. Prehosp Emerg Care. 1999;3(1):77.

9. Tintinalli J, Stapczynski JS, Ma OJ, et al, editors. Tintinalli’s emergency medicine: A comprehensive study guide. McGraw-Hill Education: New York, pp. 253–255, 2016.

10. Smits GJ, Kuypers MI, Mignot LA, et al. Procedural sedation in the emergency department by Dutch emergency physicians: A prospective multicentre observational study of 1,711 adults. Emerg Med J. 2017;34(4):237–242.

11. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. New Engl J Med. 1996;334(7):438–444.

12. O’Connor RE, Sama A, Burton JH, et al. Procedural sedation and analgesia in the emergency department: Recommendations for physician credentialing, privileging and practice. Ann Emerg Med. 2011;58(4):365–370.

13. Holcomb JB, Donathan DP, Cotton BA, et al. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care. 2015;19(1):1–9.

14. Sumida MP, Quinn K, Lewis PL, et al. Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients. Air Med J. 2000;19(4):140–143.