DILEMMAS IN DAY-TO-DAY CARE
Industrial accident leads to extrication by amputation
By Calvin Yang, DO; William Ross, MD & L. Michael Peterson, DO
Your aeromedical team responds to a 29-year-old female whose right hand has been entrapped between the inside of a hopper wall and industrial auger for five hours.
She’s found in a semi-erect position on top of a platform. Although
she’s in pain, she expresses that she’s losing sensation to her hand.
Upon physical examination, you find that her right hand is entrapped
proximal to the metacarpophalangeal joints, excluding the patient’s thumb.
Multiple attempts at freeing the hand are made to no avail.
Upon arrival of a second aeromedical team with an emergency
medicine physician and hand surgeon on board, the circumstances are
explained to her and it’s recommended that she undergo endotracheal
intubation and a complete amputation of the hand.
Nerve blocks of the hand are performed by anesthetizing the median,
ulnar and radial nerves at the level of the wrist.
The patient, still in a semi-erect position, undergoes rapid sequence
intubation with etomidate and succinylcholine. Sedation is maintained
by administering push doses of ketamine, versed and fentanyl.
Hemodynamic monitoring and wakefulness are conducted with
field telemetry and serial physical exams. To prepare for significant
hemorrhage, the patient is administered fresh frozen plasma and Type
O-negative blood through an inline warmer. Furthermore, although the
patient had a single peripheral IV line, an intraosseous line is also placed.
With the patient intubated and sedated, a final attempt to liberate
the hand fails, and the hand surgeon uses rib cutters to amputate the
hand at the level of the distal metacarpals while preserving the thumb.
After the amputation, hemostasis is achieved with hemostatic dressings. The patient is extricated and flown to the Level 1 trauma center
40 minutes away for further evaluation.
The patient is discharged from the hospital six days later. After
stable soft tissue coverage is achieved, she’s fitted with a bioelectric
prosthesis. (See video, p. 20.)
Based on the literature search that was conducted, field amputations
are uncommon, and have been conducted by a variety of personnel. There appears to be no yearly prevalence data. A 1992 survey
of attendees to the mid-year meeting of the National Association
of EMS Physicians (NAEMSP), between 1986 and 1992, indicates
that 26 were conducted. 1, 2 The majority of cases involving amputation in the prehospital setting are described as case reports in large-scale natural disasters and industrial accidents. 3–5
In the emergency and disaster medicine literature, it’s generally
accepted to amputate the limb as distally as possible. 4, 6, 7 This is consistent with the steering committee recommendations set forth in 2011
by the International Search and Rescue Advisory Group (INSARAG). 4
One report describes a field paramedic amputating a lower leg in a
motor vehicle accident. 8 A three-case series involving upper and lower
extremity entrapments describe trauma surgeons attending all cases
to complete amputations. 4 Even more rare are cases where subspecialist surgeons were on scene to conduct the amputation. The 1992
NAEMSP survey indicates a small majority of the cases, 53.2%, were
conducted by trauma surgeons. 1, 2
In this particular case, a hand surgeon completed the amputation,
which limited significant morbidity due to the decision to spare the
thumb. The decision to conduct a thumb-sparing amputation was made
with trepidation, taking into account that the surgeon had to maneuver his body inside the hopper with the blades above and below him.
After assessing the risks and benefits of amputation at the level of
the wrist outside the hopper or at the level of the distal metacarpals, it
was decided that the patient would benefit the most from amputation
within the hopper in order to limit disability of the entire limb. The
patient was intubated in the semi-erect position with rapid sequence
intubation. The monitoring of the patient’s pain and wakefulness was
conducted by with the physical exam, telemetry, and end-tidal carbon dioxide (EtCO2).
With regard to pain control and sedation, this case seems to be
commensurate with current literature. The most common procedural sedation agents in the ED used in isolation or combination
Postoperative photo of hand. Photo courtesy William Ross, MD