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Okay, now we got a situation where this worker was working in a sheet metal shop, they were using something to cut the sheet metal, and got their thumb in the way, and it was amputated. Now, there's a point to make here. It's easy to get distracted as a rescuer in trying to retrieve the amputated part, but we have to remember that patient is the primary focus first. It isn't that we're not concerned about the part, in fact we may send volunteers with gloves to go and locate the part. If it's in close proximity, great, but remember spinning and cutting devices could actually throw the part or the partial amputation quite some distance from the accident site. So could be a little difficult. It may also be covered in sawdust or in shavings and a little hard to find. So, have other people do that, if at all possible or if they're capable of doing that while you attend to the patient. It's easy to get really focused on the primary injury, but what we might not realize is that they also passed out and hit their head on a heavy piece of equipment, meaning they may have been knocked unconscious, and they've got a serious concussion. So don't forget to access the patient for life-threatening emergencies as well as the bleeding issue. The next point I wanna make about amputations is that in all my experience as a paramedic, not to say that an amputated part, or especially a partially amputated part or a crushing injury can bleed a lot. But most of my clean-cut amputations have not bled all that much. Some of it is because of this phenomenon where the arteries actually contract up into a stump and the veins and sort of clamp themselves down for at least the first few minutes that gives us a little bit of time so that we can control that injury and the bleeding that's associated with it. So, you may not see a ton of blood, but let's still address it all the same. The person is awake, they respond to me normally, they are helping me hold pressure over the remaining stump, and they seem to have no other life-threatening injuries. So let's control this bleeding. I can see that it's beginning to leak through. I'm not gonna remove the gauze bandage to look at it, because that will pull the first beginning clots off. Now I'm going to simply replace his fingers with the gauge bandage, and ask him to continue to press while I do other things. If he can't do that or if he's starting to suffer from like some emotional shock, that's understandable, so I may have to control it or get another bystander to give me a hand and make sure they have protection on their hands with gloves. But a special note here. When there's been an amputation, though it could be a clean-cut, sometimes you'll have bone fragments actually sticking, out and I think you need to be really careful if you apply that direct pressure that you don't become victim number two by poking that bone end into your skin. Not only do we not wanna damage that bone fragment any more or cause unnecessary pain and bacteria to get in there. But it's like a needle. I mean some of those bone fragments are really sharp. So just be very careful as you are covering that bone end that you actually poke yourself with that bone end. But now he's holding it just fine, he's doing a great job, and I don't see it leaking through the second bandage. Now I'm gonna take my roller gauze and I'm gonna hold that dressing in place. Let me just go and take your hand here a moment, and now I'm wrapping it as a pressure bandage, but I'm certainly not trying to cause a tourniquet effect. I'm really just tried to hold that pressure bandage in place. And as long as it's controlling the bleeding, it's certainly tight enough. If it begins to leak through again, I'll put more bandage on there and continue to wrap. A little special trick of the trade, sometimes if I need a little extra pressure when I come on top over the wound, I'll twist the bandage and then just bring it around, it just adds a slight bit more torque over the actual wound site and can help control that with a little extra pressure. Now if the person can hold the bandage, or I can cut it, tape it or I can actually tuck it underneath the other bandage. That bleeding is controlled, the patient is stable. Now let me address the next piece which is the amputated part. Hopefully, the bystanders were able to locate it and bring it to me. Once we actually have the amputated part with us, there's a few things we need to do. The first thing that I want to do is keep it just as clean as possible. I'm also going to wrap it in a sterile gauze or bandage if I can. Now, I'm using an abdominal dressing here and I'll tell you why. I like the insulation that that offers. If I'm going to put it between ice or cold packs. Cold packs aren't such a big concern, because they're not really up to that freezing level, but I do want them, the tissue to be protected from getting damaged through frostbite. Think about frostbite with an attached limb that has warm blood flowing through it. This little piece does not have blood flowing through it and so its ability to freeze is actually much faster than if it was still attached to the patient. So I'm insulating it from cold damage and if I don't keep it cool between cold packs, I have another method. The first thing I wanna do before I use the submerging into an ice water slurry, is I wanna stick it in an airtight bag. So this is a sealable bag. I'm going to go ahead and seal it. Fold it over, and now using some ice and some water, it does not have to be sterile water because it's not touching the water. I'm gonna now submerge the sealed part into this ice water slurry. And I'm gonna seal the outside of this bag. This helps keep the part cold but not frozen. Now. you might say, what's the big deal about keeping that part dry? Well, have you ever been in a hot tub swimming pool or bathtub too long, what happens to your skin? It tends to get pruney, doesn't it? That is because it kind of breaks down the tissues. It will do that to this part as well and can make it a nightmare when it comes time for an attempt to reattach it. Not that reattachments are guarantees anyways, but it does certainly help if the part, skin is not damaged because of water contact. Now, last but not least, we wanna make sure this amputated part stays with its owner. We need it to ride along with the patient. This is probably not a good idea to have it in front of the patient. They know they just had a serious injury, they know that's their thumb and that alone could start to develop some psychosomatic or psychogenic shock. I like to hide it kind of behind the patient, keep it out of their view, but if you're not gonna have it on the stretcher or with the patient directly, it's important that you vitally keep an eye on where it's at and remain diligent, really about keeping the part with the patient so that when they arrive to the hospital, the surgeons can get it as fast as possible and reattach it or at least attempt to reattach it as fast as possible. Some tips, and how to do that, and in the meantime always be watching with your secondary survey for those signs of life-threatening emergencies and be sure to treat them if you see them arise.
An amputation from trauma involves the loss of an extremity like a finger or toe but could also include an arm or a leg. It's important to not get too distracted looking for the amputated part and focus on the wellbeing of the victim.
As amputation injuries often occur in machine accidents, the amputated part can get thrown quite a distance from the scene of the accident. It may also be covered in saw dust or shavings of some kind, which could make finding it more problematic. If there are other people on the scene, you may want to consider asking for help to locate the missing part.
Amputation injuries are quite serious. It’s important to assess the patient beyond the amputation, including:
- Did the victim lose consciousness?
- If so, did they hit their head and are now suffering from a concussion?
- Is the victim showing signs of being in shock?
How to Provide Care
Clean-cut amputations bleed less than you might expect and often less than crushed extremities or partial amputations. The reason for this is that the arteries contract up into the stump and clamp down, which helps to control the bleeding for at least the first few minutes following the amputation.
After you make sure the scene is safe, proceed with the following steps.
- Put on latex-free gloves if available or wash your hands thoroughly using soap and water or a sanitizer of some kind, preferably with alcohol.
- If the victim is conscious and not in shock or showing signs of other life-threatening injuries, ask him or her to help apply pressure to the wound.
- If there is already a cloth or dressing pad covering the stump, don’t remove it, as this will pull off some of the clotting blood.
- Apply a second piece of gauze padding and, if necessary, subsequent pieces until bleeding is controlled and apply pressure.
- If the victim can't help apply pressure, you'll need to manage it yourself or ask someone to assist you.
Pro Tip 1: With amputation injuries, there will sometimes be a protruding bone fragment. These can be very sharp and may cut you while you attend to the victim. Therefore, it's important to be careful when dressing the wound. If you're not, you could easily:
- Damage the bone further
- Cause more pain to the victim
- Introduce bacteria into the wound
Once you've controlled the bleeding, meaning it is no longer leaking through the dressing pads, it's time to wrap the wound with a roller gauze bandage.
Pro Tip 2: Your goal in wrapping the wound is to apply enough pressure to hold the dressing pads in place and control the bleeding. Be careful not to wrap so tight that you cut off circulation. Remember to use the pinch test on finger and toe nails if appropriate and you are able to.
If blood begins to leak through while you're wrapping the wound, simply insert another dressing pad and continue wrapping. If you need extra pressure at that point, twist the bandage over the wound area. This will apply a bit more torque and should help control the bleeding. When you're done wrapping, tuck or tape the end of the bandage.
By this point, the bleeding should be controlled, and the patient should be stable. Continue assessing the victim for signs of shock or other health concerns.
How to Handle the Amputated Extremity
If you or someone at the scene were able to find the amputated part, it’s important that you handle it properly using the following steps.
- Make sure it's clean.
- Wrap it in a sterile gauze pad, preferably an abdominal dressing pad if you have one. This will offer much more insulation than regular pads and help protect the part from cold damage.
- Place the part into a sealable plastic bag.
- Put the bag with the part between two cold packs or into a bag filled with ice water and seal that bag.
Warning: The amputated part has no blood flowing through it, which makes it much more susceptible to frost bite and tissue damage. You want to keep it cold, not frozen. It's also important to keep it dry.
When skin becomes water logged and gets pruney, this is actually the onset of that tissue breaking down and will make reattachment more difficult.
Pro Tip 3: It's important to keep the amputated part with the victim and, if possible, out of sight from the victim. You don't want to encourage psychosomatic shock, but you want the surgeons at the hospital to have access to both victim and part immediately.
As amputations are serious injuries, you should be continually assessing the victim for signs of shock or other life-threatening conditions.
A Word About Early Signs of Shock
We will be discussing shock in great detail in the next lesson, but it's important to know that it's a progressive condition. Symptoms may seem minor at first, but the situation can quickly get worse. Your rapid response is vital.
Early symptoms of shock include:
- The victim expresses anxious or apprehensive feelings
- The victim's body temperature is lower than normal
- The victim's breathing is quicker than normal
- The victim's pulse has increased
- The victim's blood pressure has decreased
- The victim's skin appears pale or clammy
If you suspect that the victim is in shock, it's important to call 911 immediately. It's impossible to know when an individual will go into shock, but with amputation injuries you may want to consider the threat more elevated. And knowing the warning signs and being able to spot them early on could make a big difference.