Amputation:

Definition/Etiology:

A traumatic amputation is the loss of part of or the entire extremity. This is usually caused by external sharp or blunt forces. You can have something sliced right off, or crushed to the point of separation. The most affected areas are the fingers, toes, arms and legs.

Pathophysiology:

Patho usually applies to a disease process and our discussion here is about trauma as opposed to disease, sooooo the patho of amputations would be the separation of skin, muscle, and bone from itself due to an external force.

Clinical Presentation:

The clinical presentation for these is usually fairly obvious, you know, something is missing. When they arrive, depending on the severity and location of the amputation, we definitely need to assess for shock related to hypovolemia. We need to determine the amount of soft tissue injury and the degree of wound contamination. This is directly proportional to the mechanism of injury and timeline. If the part was removed with a clean guillotine cut from a sushi knife, you are going to have much less complications then if they were crushed under a vehicle in a motor vehicle collision.

There are also some definite factors that will inhibit good outcomes:

• Crush wounds
• Long period of time since amputation (>6 hours)
• Proximal amputations
• Nerve injuries
• Systemic hypotension
• Severe contamination
• Concurrent medical conditions
• Age
• Poor nutritional status

Collaborative Management:

If they come in with a tourniquet…do not remove it. Let the doc make that assessment. If you can determine the mechanism of injury, it will put your mindset on looking for any other issues. As with any trauma, ABC’s are first and foremost. Actually, with major trauma, and especially with amputations, i like to use the MARCH PAWS mnemonic:
M-Massive bleeding
A – Airway
R – Respirations
C – Circulation
H – Hypothermia / head (LOC)

P – Pain
A – Antibiotics (lifesaving Ancef)
W – Wounds
S – Splinting

You use what you like, but just understand that many nurses can get tunnel vision when a major injury like an amputation comes in. What i mean here is that if we get the guy who had his leg torn off above the knee, we wind up focusing on that, and forget to check if he is breathing or has a pulse.

OK….what do we do with the amputated part? Come one guys, say it with me. Cover the part with dry sterile gauze. Place the part in a bag, then place the bag on ice. NEVER PUT AN AMPUTATED PART DIRECTLY ON ICE!

You will want to get X-rays of the amputated part as well as the stump to assess the amount of bone damage. Please do not lose the body part going back and forth to radiology!

Evaluation | Patient Monitoring | Education:

Clearly, we need to monitor for shock. Cardiac monitoring is a must. These patients can have a change in their hemodynamic stability very quickly. We need to assess for continued bleeding, so watch your dressings for saturation. Most severe traumatic amputations are going to the OR so education is not something we are going to be terribly concerned about. Perhaps some education to the family member about chainsaw safety or letting go of the firework before it goes off, you know that sort of thing.

Linchpins: (Key Points)

• Life and Limb
• Tunnel Vision
• Wrap, bag, Ice