ER: A Shift in the Night

each post gonna contain a bunch of cases i visited on ER or Clinic a week before

Wednesday, March 4, 2009

Digital Amputations

a 18 year-old boy who cut 4 fingers white a industrial blade 1 hour before he came to ER, unfortunately he put the amputated fingers in ice, so they almost macerated.. (i don't know were the people get this!)
he went to OR immediately, I'm still looking for follow up...

If a case is accepted for replantation by the hand surgeon, the next step is to initiate the protocol for transfer. This involves step-by-step instructions for the care of the patient, the amputated part, and transportation of both. These instructions are as follows.

The Patient

Check the patient's general condition to rule out life-threatening injuries. On arrival at the emergency room, a large-bore intravenous line should be started with Normal Saline solution at a maintenance rate. If there are signs and symptoms of shock, the patient must be stabilized before transportation. To begin antibiotic coverage, administer cephazolin (Keflin), 1 g IV (except when prohibited by history of allergy). Tetanus toxoid, 0.5 cc IM, is necessary if it has not been administered within the last 5 years. Evaluate and medicate the patient for pain as needed with IM or IV analgesia of choice. Keep the patient nil by mouth to facilitate later anaesthesia, and do not allow them to smoke or chew tobacco. Send X-rays (both part and stump), emergency records, and all laboratory studies (especially haematocrit and urinalysis), including a clot of blood for further miscellaneous tests. An ECG and chest X-ray should be sent if the patient is over 35, or if indicated by injury. Transport the patient supine. Apply saline-moistened sponges to the injured hand or extremity wound and cover with a sterile, bulky dressing. If extensive bleeding is noted, apply a pressure dressing rather than a tourniquet. Truly uncontrollable bleeding must be treated surgically before transport. Splint and elevate the injured part for comfort.                               

NOTE: Do not delay transport. If necessary, the above steps can be carried out at the hospital if the patient is stable.

Amputated Part

Instruct the referring doctor or emergency room to send all parts. Although all tissues may not be replantable, various portions may be used to reconstruct missing elements. No minimal cleansing is necessary at this time. More extensive debridement (removal of damaged tissue or foreign objects from a wound) is done in the operating room by the hand surgery team while they examine the part:

  1. Rinse part(s) with normal saline to remove gross contamination
  2. then wrap in DRY gauze and place in DRY plastic bag (zip-close).
  3. Then place the plastic bag in another bag with ice mixed with water to prevent frostbite of the amputated part.The gauze and plastic prevent the tissue from coming into direct contact with the ice. This method is preferred to immersion or wrapping in a moist dressing to avoid maceration.

Do not bury in ice because immersion may cause cold injury to the part. Do not use dry ice because it is too cold and causes tissue damage.

In cases of partial amputation:

  1. Apply saline-moistened sponges to wound and cover with sterile, bulky dressing. Again, avoid extensive cleansing; this will be accomplished under anaesthesia.
  2. Splint and elevate the injured part for comfort.

NOTE: Do not inject the site with local anaesthesia. Local injection may cause vasoconstriction (vessel spasm), vessel compression, or direct vessel injury.

Transportation Arrangements

Transportation can be arranged by the referring or receiving party. This may involve dispatching a helicopter for air or an ambulance for ground transportation. The hand surgeon at the hospital is responsible for the final transport decision, aided by the information gathered by the transport staff. Current weather patterns, road conditions, accessibility, and convenience must all be considered. Medical considerations include the severity of the injury, the ischaemia (lack of blood supply) time already elapsed, and the status of amputation. Complete amputation can be cooled, whereas icing a partial amputation may decrease residual blood flow and cause undue discomfort.

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