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INTRODUCTION

An amputation is an old procedure. Early amputations were crude: amputations were performed without anesthesia, hemostasis was achieved by dipping the amputated extremity in hot oil, and the mortality was high. The first reference to an amputation was found in the ancient Babylonian code of Hammurabi in 1700 BC. Hippocrates described the amputation for vascular gangrene in 385 BC. William Cloves performed the first successful above-the-knee amputation in 1588. The tourniquet was described in the 16th century by Botallus and Holdani. The development of anesthesia in the 16th century made the procedure easier for all involved. Jean Domnique performed 200 limb amputations and 11 shoulder disarticulations. Norman Kick used the guillotine amputation during World War II. This procedure has undergone many advancements since the first amputations. It is a common procedure, with approximately 65,000 amputations occurring annually usually due to peripheral vascular disease of the lower extremities. An amputation is often performed in a hospital but the acceptance by the patient is still low.

Relatively common situations in which rescuers may find victims entrapped include machinery limb entanglement (e.g., agricultural, construction, or industrial), motor vehicle collisions, confined space rescues, and structural collapses. Rescuers have been able to achieve success in situations that were previously futile as extrication technology has progressed. The methods of safe extrication may be exhausted or the patient’s clinical course may not be stable enough to endure prolonged extrication attempts. The actions of extrication can sometimes put rescuers or other victims at risk. This is particularly true in structural collapse situations. A prehospital field amputation of entrapped or entangled limbs may be the only way to save the patient.

Prehospital field amputation is performed infrequently. Very little is published on the overall incidence of the procedure except in case reports.1-10 It is a lifesaving procedure with several indications to be performed in the prehospital environment. Training in limb amputations is not standardized and is infrequently available in Emergency Medical Services (EMS) agencies for their providers. An interview occurred with Medical Directors at the National Association of EMS Physicians (NAEMSP) meeting in 1992.5 The number of prehospital extremity amputations in the prior 5 years was reported to be 26 by the 143 Medical Directors. Almost all (96%) reported there was no formal training in the procedure or its indications.5 This highlights the issue of lack of standardization.

Formal training, protocols, and preformed teams are rare.5 It is conceivable that a local Emergency Physician or Surgeon may be called upon to assist in a prehospital amputation with no prior formal training or equipment preparation.

The amputation may be achieved with the cutting of a long bone or with a disarticulation at a joint. The joint capsule, tendons, and ligaments are transected in a disarticulation as opposed to cutting the bone in an amputation. Severely mutilated limb injuries may only have minimal connective tissue remaining (e.g., ...

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