Synopsis
Prioritise survival and haemorrhage control, protect the residual limb without blind clamping, package an amputated part correctly, minimise warm ischaemia through direct specialist transfer, and integrate replantation, revision amputation and lifelong rehabilitation decisions.
- Control catastrophic haemorrhage first with direct pressure, packing or a commercial tourniquet placed as distally as effectively possible; record the exact application time and never use blind vascular clamps.
- Do not shorten, complete or repeatedly debride the stump in the emergency department. Cover with a sterile saline-moistened dressing and protect bone, nerves and vessels for specialist revision or replantation.
- Handle the part gently, remove only gross loose contamination, wrap it in sterile gauze moistened with saline and place it inside a sealed, labelled plastic bag.
- Place the sealed bag in a second container containing iced water. Do not let tissue touch ice, freeze it, immerse it directly or place it loose in a refrigerator.
- Label identity, side, anatomical level, injury time, cooling time and contamination and keep the part with the patient during direct trauma or replantation-centre transfer.
- Contact the receiving specialist immediately with age, hand dominance, occupation, level, mechanism, contamination, warm and cold times, associated injuries and physiological status; do not await all imaging.
- Replantation decisions consider life threat, level, muscle mass, ischaemia, crush or avulsion zone, contamination, comorbidity and likely useful function; a severity score cannot make the decision alone.
- Begin antibiotics, tetanus care, pain and psychological support, then plan stump or replanted-limb monitoring, rehabilitation, prosthetics and return-to-life goals from admission.
Key red flags
Uncontrolled stump bleeding, shock, coagulopathy, hypothermia or associated torso and pelvic injury requires simultaneous resuscitation and operative haemorrhage control; replantation discussion must not delay survival care.
A partial amputation with a narrow tissue bridge, absent distal perfusion, venous congestion or progressive neurological loss is a dysvascular limb and must not be completed in the emergency department.
Direct ice or freezer contact, immersion in water, dry storage or failure to cool the sealed part accelerates tissue injury and can destroy otherwise viable replantation options.
Crush, avulsion, farm or water contamination and prolonged ischaemia reduce replantation feasibility and increase compartment, infection and systemic rhabdomyolysis risk, but specialist teams rather than a bedside score make the final decision.
Investigation priorities
Identify haemorrhage, hypothermia, coagulopathy and associated life threat.
Management branches
A complete or near-complete traumatic amputation arrives with potential major haemorrhage.
- Run catastrophic haemorrhage and ABCDE care, using pressure, packing or the most distal effective tourniquet and recording its time.
- Activate blood-component resuscitation, TXA when indicated, warming and immediate trauma, orthopaedic and plastic or vascular support.
- Cover the stump without blind clamps or bedside shortening, give network open-injury prophylaxis and assess tetanus risk.
- Splint a near-amputation in alignment, repeat its perfusion and nerve examination and do not divide the remaining bridge.