Replantation Treatment & Management

  • Author: Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 11, 2011
 

Prehospital Care

At the scene, collect and preserve all amputated parts, even those crushed and not thought to be useful. Parts not suitable for replantation can provide tendons or bone.

  • Cool the amputated part to 4°C to preserve it; 1 hour of warm ischemia is equivalent to approximately 6 hours of cold ischemia. Hence, cooling can markedly prolong the window of opportunity for replantation or revascularization. An amputated digit, for example, can withstand up to 30 hours of cold ischemia.
  • Wrap the part in saline-soaked gauze and wrap in a towel. Next, place it in a dry, plastic bag. Place this bag on ice, or in a second bag filled with ice and water, as soon as possible. This 2-layer approach avoids submersion of the part in ice water, which causes freezing of the tissues and cell destruction. Dry ice is too cold and causes tissue freezing and cell destruction.[8]
  • Estimate the blood lost at the scene; this information is useful regarding resuscitation prior to surgery. Control bleeding from the amputated stump.
  • Label the bag with the patient’s information.[9, 10]
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Emergency Department Care

Uncontrolled arterial bleeding is the only immediately life-threatening complication likely to be encountered in the ED after injury to the upper extremity. Normal hemostasis involves circumferential constriction of affected arteries and their retraction into the amputated stump. The addition of a pressure dressing usually suffices to control bleeding. With partial arterial lacerations, retraction is prevented, and bleeding control can be more difficult.

Control hemorrhage in the upper extremities with local direct pressure or a pressure dressing. Use of a proximal tourniquet is acceptable, although not preferred, if direct pressure is not effective. The surgeon can clamp and ligate a bleeding vessel, but this can complicate later repair. In the ED, point control with localized pressure over the bleeding vessel or use of a pressure dressing is preferred.

Elevate the arm. Ensure that a poorly applied pressure dressing does not become a tourniquet and cause ischemia in the amputated stump. If a tourniquet is used, use it as briefly as possible, perhaps only during resuscitation for acute hypovolemia. Use of a tourniquet for more than 3 hours may lead to irreversible loss of function. Do not use a tourniquet during an interhospital transfer. A consultant may appropriately use a temporary tourniquet to better identify important structures such as nerves and vessels.

Blind ligation or clamping of bleeding vessels could lead to greater damage because neurovascular bundles place ischemia-sensitive nerves near bleeding vessels. Careless clamping can also lead to vessel thrombosis, which requires shortening of a vessel and/or interposition of a vessel graft.

Do not allow the patient to smoke prior to making the decision to replant or repair the amputation; smoking can cause vasospasm and complicate the procedure.

For partial amputations, splint the involved extremity to prevent further damage. Reduce any malrotation to limit ischemia. Avoid tension on the tissue bridge, which can damage nerves or vessels. Cooling of a partially amputated part is controversial. If no demonstrable perfusion of the part exists, cool it as if it were completely amputated. If a pulse or bleeding from the capillary bed is present, avoid cooling.

Bone, tendon, and skin can tolerate approximately 8-12 hours of warm ischemia and as long as 24 hours of cold ischemia. However, muscle necroses after 6 hours of warm ischemia or 12 hours of cold ischemia. In general, amputated digits may tolerate 12 hours of warm ischemia and 24 hours of cold ischemia. Other major amputations tolerate 6 hours of warm ischemia and 12 hours of cold ischemia because of their larger muscle content. Excessive ischemia time reduces muscle function and can result in myoglobinuria on reperfusion, placing renal function at risk. More proximal amputations involving more muscles must, therefore, be treated quickly.

Any amputation involves bone and tendon injury and is therefore a tetanus-prone wound by definition. Therefore, 0.5 mL of tetanus toxoid (adsorbed) must be administered intramuscularly if the last booster was received more than 5 years earlier. If the patient has not had primary immunization as a child or if the immunization status is unclear, administer tetanus toxoid as well as tetanus immune globulin (500 U intramuscularly) in opposite limbs.

A digital or regional nerve block is not recommended before a hand or a plastic surgeon evaluates the patient because documentation of nerve function prior to surgery is important. Use systemic analgesics with intravascularly administered narcotics.

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Consultations

Consult a microvascular hand surgeon.

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Contributor Information and Disclosures
Author

Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS  Professor of Clinical Emergency Medicine, Department Chair, Associate Residency Director, Department of Emergency Medicine, University of California at Irvine

Mark I Langdorf, MD, MHPE, FAAEM, FACEP, RDMS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

J Akiva Kahn, MA  University of California, Irvine, School of Medicine

J Akiva Kahn, MA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Student Association/Foundation, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Lacey King  University of California, Irvine School of Medicine

Lacey King is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Ziad N Kazzi, MD, and Akiva Kahn, MD, to the development and writing of this article.

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Complete amputation of two digits.
Radiologic appearance of a hand with two-digit amputation.
After two-digit replantation.
Complete thumb amputation.
Radiologic appearance of a complete thumb amputation.
Complete thumb amputation.
After thumb replantation.
Surgical amputation of a left big toe.
Toe-to-thumb transfer.
 
 
 
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