The scenario
We have the will to outlast everything!
Proper pre-hospital care for an amputation victim saves the
life of the patient and provides the best chance of reattachment of the lost
limb. However, you must know what you are doing before lending a helping hand.
Otherwise, you could cause more harm than good.
You are visiting relatives in a rural area of another state.
You hear shouts for help originating in an adjacent field. As you near the
source of the shouts, a worker runs over and says he’s going for an ambulance,
“old Jake” got his hand caught in the belt. After traveling a few
yards further you find a middle-aged male with his right arm wedged between the
belt and drive roller of a conveyor system.
About half of the lower arm, from the elbow down, is intact.
From there, muscle protrudes around a jagged bone end. The crushed hand, with
flaps of skin hanging where the wrist and lower arm used to be, is lying on the
ground where it was thrown by the belt.
You attempt to reassure the farmer while applying digital
(finger) pressure to a proximal arterial pressure point (between the wound and
the heart). A short time later, the local “rescue squad” arrives.
After assessing the patient, they apply a tourniquet to the stump. You refrain
from pointing out that digital pressure was working effectively. As they load
the patient into the ambulance, you ask what they are going to do with the
hand. One of the attendants says, “Nothing, you want it?” amid laughs
from the rest of the crew, the doors are shut, and the ambulance speeds off
through the field, its siren wailing.
As we all know, before anesthesia and aseptic techniques
were developed, a victim of traumatic amputation would probably die. If he did
not bleed to death infection would claim him eventually. As refinements were
made in surgical techniques amputees had a better chance of living, albeit
without a limb, at worst, or with a crude prosthetic appliance, at best. Most
work at this time was directed toward developing more functional and more lifelike
prosthetics.
In the past 40 years, replantation surgery has progressed to
the point where success is measured not by whether or not the limb survives,
but rather by how much of the limb’s pre-amputation function returns.
Obviously, not every traumatic amputation victim is a
candidate for reattachment surgery. As time goes on, the option will be
available to more and more patients, as long as they and the amputated pan have
received proper pre-hospital care, care aimed at providing the surgeon with the
best possible candidate for such surgery.
Basically, there are three types of amputations.
Complete or total amputation occurs when a limb or
protrudance is completely severed from the body. Partial amputation describes
those injuries where a limb or protrudance is more than 50 percent severed but remains attached to the
proximal portion by a relatively small amount of soft tissue. Third, there are
“degloving” injuries (complete avulsion). These are basically
injuries in which the skin and adipose (fatty) tissue are removed from a
region, leaving the underlying tissue essentially intact.
While some may disagree with this being considered a type of
amputation, treatment of the recovered skin is identical to that of an
amputated limb and is included for that reason. In most cases, a degloving
injury alone will involve minimal blood loss. Peripheral vasoconstriction
(closing of the blood vessels) will speed hemostasis (cessation of bleeding).
When a limb is completely severed several things occur which
act to reduce blood loss. After the loss of about one liter of blood, affected
arteries begin to spasm, partially occluding the vessel. The veinous and
lymphatic vessels contain valves which prevent backflow of their respective
fluids.
The elasticity of the vessels tend to draw them back into
the surrounding tissue of the proximal aspect of the limb. The pressure exerted
on these vessels by the surrounding tissue tends to force them closed. This
effect, coupled with the veinous and lymphatic valves and the arterial spasms,
tends to greatly reduce blood and fluid loss from a complete amputation.
In a partial
amputation the vessels, unless completely severed, will not be able to withdraw
into the proximal aspect of the limb. It’s obvious that should an artery be
lacerated but not severed, the risk of exsanguination (bleeding to death) is
much greater than with the other two types of amputations.
No clamps (Kellys, hemostats, etc.) of any type should ever
be used on a blood vessel. Clamps are great for shutting off an intravenous
(IV) line to administer medication, or for similar uses, but they are
emphatically contraindicated for use on blood vessels in the field.
When the patient arrives in surgery, the width of the clamp
must be removed from the vessel before anastomosis (end-to-end attachment of
transected vessels) can proceed. By using a clamp, you have provided the
surgeon with an even shorter vessel to work with, needlessly.
As with any extremity wound, elevation and direct pressure should first be tried. This should be applied with a sterile surgical sponge or compress moistened with sterile isotonic saline solution. A bandage should then be applied to hold the dressing in place, and an elastic bandage (“Ace Wrap”) applied on top of this. The elastic bandage should be tight enough to constrict the vessels sufficiently to slow the bleeding.
Pneumatic appliances such as MAST (Military Anti Shock Trousers), air splints or even an extra sphygmomanometer (blood pressure cuff) can be used to provide the necessary constriction. If this proves ineffective, digital pressure should be applied to an arterial pressure point proximal to the wound. As a very last resort, a tourniquet can be applied. A wide band is practical and it should be used. Be certain to mark the time of application somewhere obvious on the patient, on the limb beside the tourniquet, or on the patient’s forehead with ink or an indelible marker. The tourniquet should only be loosened or removed by a physician, preferably within an hour after it was applied.
When treating a degloving injury, a saline dressing should
be used to cover the area and held in place with an appropriate bandage. Ice
should never be applied to the proximal portion of the injured limb. The questionable
benefits are far outweighed by the potential damage to the tissue from this
practice.
The amputated part should be located and debris rinsed off
using isotonic saline solution. It should then be dried using sterile sponges.
The open end should then be covered with surgical sponges moistened with saline
solution. These should be held in place, and the remainder of the limb wrapped,
using a dry sterile bandage. The part should then be enclosed with a tightly
tied plastic bag. This package should then be similarly sealed within a second
plastic bag. The double bagging effectively seals out moisture. This package is
then placed in a container of ice and completely covered with ice.
In the case of a partial amputation, the same basic
procedure should be followed, with the exception, of course, that the bags
should not be tied tightly, but rather closed around the intact tissue
“bridge.”
When dealing with a degloving injury, the surface of the
skin normally in contact with underlying tissue should be covered with saline-moistened
sponges and the “outer” surface covered with dry dressings. It should
then be transported like any other amputated body part.
The departure from the previously recommended procedure of covering the entire limb with moistened dressings is designed to alleviate the maceration caused by prolonged contact with moisture. Maceration is the destructive softening of the skin by exposure to water. This effect occurs when you soak in the bathtub. The skin on your fingers becomes wrinkled and easily torn. This revision not only makes the surgeon’s job a little easier, but it may mean the difference to the patient of having a functional limb or a stump.
It is important that the amputated part be recovered and
treated as outlined above —no matter what its condition. Even if it is damaged
beyond the point of replantation, it can still supply skin for grafting onto
the stump. The amputated part should have a label affixed to the outside bag,
indicating the patient’s name, body part enclosed, and the time of amputation.
Avoid getting preoccupied with the search for the amputated
part. You are still dealing with a trauma patient and still fighting time. Even
though the patient appears stable, he must still receive definitive treatment
within that “golden hour.”
The catchphrase here is “life before limb.” It is
of little value to save the limb but lose the patient. A suggestion to deal with
the problem of the hard-to-find limb is to print the packaging requirements on
a 3 x 5 card. If the difficulty is encountered in retrieving the limb, the
card, a bottle of saline, sponges and bandage material can be left with another
rescuer or even a family member and the limb transported separately from the
patient. While not ideal, this is still a functional alternative.
The importance of time should be stressed to those personnel
conducting the search. Once at the hospital the patient must be prepared for
surgery. Once in surgery, the bone ends are aligned, then anastomosis of the
arteries, then veins, is performed. This all takes time. To maintain the viability
of the limb for replantation, cold ischemic (interference with blood flow in
tissue) time cannot exceed six hours. This means six hours from amputation to
revascularization if the amputated part is treated as outlined above. Again,
time is of the essence.
In the recent past, a replantation was considered successful
if the patient did not ultimately lose the limb. Today success is measured by
the ultimate return of the function to the limb after replantation.
Many things enter into whether or not a patient represents a likely candidate for such surgery. It is up to those of us in the field to provide the best possible, most modern care to our patients before they get to the hospital, and to provide the hospitals with the most likely candidates for successful replantation.
This article has been written by James H. Redford MD for Prepper’s Will.
Knowledge to survive any medical crisis situation
A DIY Project to Generate Clean Water Anywhere
Find Out What’s the Closest Nuclear Bunker to Your HomeA
The vital self-sufficiency lessons our great grand-fathers left us
SURVIVAL LESSONS FROM OUR ANCESTORS
BEST ITEMS TO HOARD FOR SURVIVAL
The scenario
Research & References of The scenario|A&C Accounting And Tax Services
Source
0 Comments