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

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ESSENTIAL WORKUP

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.

DIAGNOSIS TESTS & NTERPRETATION
Lab

Preoperative lab studies, cultures from wounded area

Imaging

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

Diagnostic Procedures/Surgery

Determined by surgical consultant for replantation

DIFFERENTIAL DIAGNOSIS
  • Involves neurologic, vascular, and soft tissue integrity and potential for replantation/revascularization
  • Do not miss other major injuries with concurrent trauma.
TREATMENT
PRE HOSPITAL
  • 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.
INITIAL STABILIZATION/THERAPY
  • 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.
ED TREATMENT/PROCEDURES
  • 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.
Pediatric Considerations
  • 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).
Geriatric Considerations

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

MEDICATION
  • 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
DISPOSITION
Admission Criteria

Hospitalization is required for all patients undergoing replantation or revascularization.

Discharge Criteria
  • Mild fingertip amputations or mild degloving injuries with adequate repair and stable vasculature
  • Close surgical or orthopedic follow-up is required.
Issues for Referral
  • Know exact mechanism and time of injury
  • Refer as early as possible
  • Transfer imaging and amputated parts with patient, stored in appropriate medium
FOLLOW-UP RECOMMENDATIONS

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

PEARLS AND PITFALLS
  • 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
ADDITIONAL READING
  • 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
ICD9
  • 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

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