Field Amputations...sort of

[FCWood]

Originally Posted by swatsurgeon

How to get through the bone is another question to ponder....saw, gigli or otherwise is a great option if available. A leatherman tool has a saw.....ss

Yes, as SS stated, the gigli would be great for bone. If necessary it could be used to cut entire leg (skin and all, not that I’d say do it) in an emergency, but would definitely leave the surgeon to trim up tissue later. I have done this to several types of large animal, (calves & foals), during troubled still-born/dead deliveries (my dad was an older veterinarian so I helped a lot/did most of the manual labor) so lighter human bones would be even easier.

FCW

[Red Flag 1]

Thanks SS!

A word to the wise.

Application of a tourniquet ("T") is a simple life saving measure that is frought with complications, as SS pointed out. Once the "T" is applied, all tissue below dies. Should the "T" be relaxed, any metabolic toxins from the dying tissue below enter systemic circulation and place the patient at risk of dying, 18 D's and medics know this. So why would anyone loosen or relax a "T"?

A "T" stops blood flow and after a time kills the nerves below, providing surgical anesthesia. In the process, it hurts like hell!! It is very compelling to respond to the patient's pleas to loosen the "T" just a bit. Bad move!!

My time in anesthesia practice has given me a respect for the amount of pain a "T" brings to the patient. From time to time, surgery on limbs have taken longer than thought. Limb surgey generally requires a "T". Long before there is any pain to the surgical site, "T" pain becomes an issue dictating a change from regional anesthesia to general anesthesia. A "T" hurts that much.

Think before using a "T".

My $.02.

RF 1

[cdwmedic03]

Cool stuff SS!



Red Flag,

Sir, I do not mean to speak out of turn here. But the education we (68Ws, TC3, etc.) are receiving on TQ application includes guidlines for removal, as soon as tactically feasible (but not removed if left in place for more than 6 hours). It is also being put out that ischemic damage is rare in instances where TQ's are in place less than 2 hours. This is all applied in the tactical setting, so if I took your statement out of context sir I apologize in advance.


Q: What can be done to mitigate/manage the effects of reperfusion injury in either the tactical or non-tactical setting?
(I don't mean to hijack the thread or get to far off topic)

[Red Flag 1]

Originally Posted by cdwmedic03

Cool stuff SS!



Red Flag,

Sir, I do not mean to speak out of turn here. But the education we (68Ws, TC3, etc.) are receiving on TQ application includes guidlines for removal, as soon as tactically feasible (but not removed if left in place for more than 6 hours). It is also being put out that ischemic damage is rare in instances where TQ's are in place less than 2 hours. This is all applied in the tactical setting, so if I took your statement out of context sir I apologize in advance.


Q: What can be done to mitigate/manage the effects of reperfusion injury in either the tactical or non-tactical setting?
(I don't mean to hijack the thread or get to far off topic)

We liked to keep "T" times at or below two hours in surgery.

My point was to be prepared for physical pain one must deal with once a "T" is placed. As Brush Okie pointed out, there are other things that may be of value.

I do think we are getting a bit off topic here but probably worthy of discussuion, IMHO.

My $.02.

RF 1

[cdwmedic03]

Originally Posted by Red Flag 1

We liked to keep "T" times at or below two hours in surgery.

My point was to be prepared for physical pain one must deal with once a "T" is placed. As Brush Okie pointed out, there are other things that may be of value.

I do think we are getting a bit off topic here but probably worthy of discussuion, IMHO.

My $.02.

RF 1

Ah, gotcha RF 1.... I was secretly trying to incite a discussion.

I did find an interesting study on TQ's and their use both in the civilian sector and military, while looking for some info on reperfusion injury. Here's the link.....http://www.americanheart.org/downloa...Dec04Final.pdf (note: the interesting stuff starts on Pg. 6)...

[swatsurgeon]

A few things.....
You are taught to place the tourniquet because of the circumstances under which you applied it.....need both of your hands to do other things and you saw a wound that had the POTENTIAL to have the patient bleed out....so apply the tourniquet (SOP). When things have calmed down you can loosen it to see if the a) bleeding wasn't really too bad and can be controlled by some other means, b) the wound wasn't as nasty as you originally thought and a tourniquet wasn't needed at all. But if you see the limb is gone/almost gone, do NOT loosen the tourniquet...blood is life and every red cell lost in the field is one closer to shock.

The reperfusion injury can only be attenuated/reduced with the reversal of the ischemia sooner. If you mis-apply a tourniquet for 30 minutes, the reperfusion injury is less than if were on an hour...etc., but what had been discussed in the medical literature is given IV and po.....antioxidants, vit A, C, E, mannitol, antiinflammatories. If you can give an oral form of mega vitamin, allopurinol, celebrex (doesn't ruin your platelet function) than you are attenuating the reperfusion injury. If the limb is not going to be amputated, we would do fasciotomies to release the pressure of the referfused muscles which SWELL like hell after a prolonged ischemic period. These can be closed later...I'll post pics when I find a few.

Moral of the story, apply the tourniquet when needed, keep it on to prevent loss of blood (life), LOOSEN ONLY WHEN OTHER APPROPRIATE MEDICAL TREATMENTS ARE AVAILABLE or unless it was put on and not really needed.

ss

[sofmed]

Wow! I can't believe I missed this thread. Great stuff!! Going back to sitting back and reading now.

[whocares175]

just curious....any photos of the cutless amputation? i really learn better from pictures.....

[swatsurgeon]

Value of Preoperative Physiologic Amputation *
WILLIAM H. MoRE-rz, M.D., WALTER R. VOYLES, M.D., CHARLES B. THOMAS, M.D.
From the Department of Surgery, Medical College of Georgia, Eugene Talmadge
Memorial Hospital, Augusta, Georgia
Annals of Surgery
November 1961

Physiologic amputation, afforded by local
hypothermia and tourniquet application
above the affected tissue, grants this interval,
free of the harmful effects of the involved
part, in which to prepare the patient
for operative amputation.