Replantation in Emergency Medicine Treatment & Management

Updated: Sep 12, 2017
  • Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD  more...
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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. An amputated digit, for example, can withstand up to 30 hours of cold ischemia.

For cooling, wrap the part in saline-soaked gauze and then 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. [11]

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. [12, 13]

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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 the bleeding may be near a neurovascular bundle containing ischemia-sensitive nerves. 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. [14]

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 (250 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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