eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Replantation: Treatment & Medication
Updated: Sep 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
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.
- 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.7
- 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.8,9
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.
Consultations
Consult a microvascular hand surgeon.
Medication
Prophylactic antibiotics are indicated with amputation, crush, or degloving injuries. Devitalized tissue is a good culture medium for bacterial contaminants. Common pathogens are Staphylococcus aureus (most likely organism) and group A streptococci, whereas clostridia species and organisms from the Enterobacteriaceae family are less common. Gram-negative and anaerobic bacteria are more commonly found with extensive tissue damage or with wounds grossly contaminated with soil, saliva, or feces. In these cases, perform Gram staining and cultures before initiating antibiotic therapy.
If the amputation is from a human bite, antibiotic coverage should include streptococci, Eikenella corrodens, anaerobic bacteria, and staphylococci. Use oral amoxicillin and clavulanate for human bites without amputation. Use intravenous ampicillin and sulbactam or ticarcillin and clavulanate for amputations or established infections caused by human bites. A combination of penicillin G and an antistaphylococcal antibiotic is also acceptable for minor bite wounds.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens.
Cefazolin (Ancef, Kefzol)
First-generation semisynthetic cephalosporin; binds one or more penicillin-binding proteins; arrests bacterial cell-wall synthesis and inhibits bacterial growth; primarily active against skin flora, including S aureus.
Adult
500-1500 mg IV/IM q6-8h; not to exceed 100 mg/kg/d
Pediatric
25-50 mg/kg/d IV/IM divided tid/qid
Probenecid decreases renal clearance and prolongs effect; concurrent use with aminoglycosides may increase renal toxicity; may yield a false-positive result for glucose with urine dipstick testing
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal impairment
Ampicillin and sulbactam (Unasyn)
Drug combination that involves a beta-lactamase inhibitor with ampicillin; covers skin organisms, enteric flora, and anaerobes; not ideal for nosocomial pathogens.
Adult
1.5 g (1 g ampicillin with 0.5 g sulbactam) to 3 g (2 g ampicillin with 1 g sulbactam) IV/IM q6h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: ampicillin 100-200 mg/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults
Probenecid and disulfiram decrease renal excretion of ampicillin and sulbactam and increase levels of the antibiotics; allopurinol increases ampicillin excretion; may potentiate ampicillin rash and decrease the effect of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal failure; evaluate rash and differentiate from hypersensitivity reaction
Ticarcillin and clavulanic acid (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth; antipseudomonal penicillin and a beta-lactamase inhibitor covers most gram-positive and gram-negative organisms, as well as anaerobes.
Adult
3.1 g IV q4-6h; not to exceed 18-24 g/d
Pediatric
100 mg/kg/dose IV q8h
Tetracyclines may decrease the effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if they are administered in same IV line; effects when administered with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; do not treat severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Obtain complete blood count before therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring aspartate transaminase (AST) and alanine transaminase (ALT) during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and determine blood urea nitrogen and creatinine levels during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Analgesics
Pain control is essential to quality patient care, ensuring patient comfort and promoting pulmonary toilet. Most analgesics have sedating properties, which are beneficial for patients with painful skin lesions.
Fentanyl (Duragesic)
More potent narcotic analgesic with a much shorter half-life than morphine sulfate; drug of choice for conscious sedation analgesia; ideal for analgesic action of short duration during anesthesia and in immediate postoperative period. For patient needing long-term pain control, sustained-release fentanyl transdermal patch (Duragesic) may control pain with 72-h dosing intervals; some patients require dosing intervals of 48 h. Onset of transdermal fentanyl patch analgesia is delayed for 8-12 hours, so acute pain control must be provided prior to full effect of patch. Overdose has been reported, so start with lowest dose/hour patch (25 mcg/h).
Adult
1 mcg (0.001 mg)/kg IV/IM q30min to q2h prn
(50-100 mcg IV q1-2h prn; alternatively 0.5-1.5 mcg/kg/h IV infusion)
Pediatric
1-3 years:
Dose: 2-3 mcg/kg IV q1-4h prn; alternatively 1-2 mcg/kg IV X 1, then 0.5-1 mcg/kg/h infusion; titrate upward
3-12 years:
Dose: 1-2 mcg/kg IV q1-4h prn; alternatively 1-2 mcg/kg IV X 1, then 0.5-1 mcg/kg/h infusion; titrate upward
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects when both drugs are used concurrently
Documented hypersensitivity; respiratory depression; constipation; nausea; emesis; urinary retention; hypotension; potentially compromised airway that would make it difficult to establish airway control rapidly
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, or urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation
Morphine (Astramorph, MS Contin, Duramorph, Oramorph)
Drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used and are commonly titrated until desired effect is obtained.
Adult
4-10 mg bolus slow IV; may repeat to maximum of 30 mg for severe pain
Pediatric
0.1-0.2 mg/kg slow IV/IM
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; respiratory depression; nausea; emesis; constipation; urinary retention; hypotension; potentially compromised airway that would make it difficult establish airway control rapidly
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in atrial flutter and other supraventricular tachycardias; vagolytic action may increase the ventricular response rate
Black Box Warning
Abuse potential: Opioid agonist schedule II controlled substance
More on Replantation |
| Overview: Replantation |
| Differential Diagnoses & Workup: Replantation |
 Treatment & Medication: Replantation |
| Follow-up: Replantation |
| Multimedia: Replantation |
| References |
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Further Reading
Keywords
replantation, amputated digits, amputated finger, amputated toe, amputation injury, amputation, amputated, digital replantation, severed finger, severed limb, severed toe, red-line sign, ribbon sign, avulsion, crush avulsion, toe-to-thumb transfer
