Episode 5: Amputation

02/02/16 • 38 min

https://phemcast.co.uk/wp-content/uploads/2016/02/amputation.mp3

Welcome to PHEMCAST episode 5: Amputation

One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done.

This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements.

This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy.

Which patients / scenarios:

An immediate and real risk to the patient’s life due to a scene safety emergency.
A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation.
The patient is dead and their limbs are blocking access to potentially live casualties.

Which kit:

CAT x 2
Scalpel
Gigli saw (and spare)
Arterial forceps x 4
Tuff Cut scissors
Appropriate dressing (e.g. Israeli combat bandage)

Preparation:

Sedation or anaesthesia
Brief team
Plan next phase

Stages of amputation process:

Apply an effective proximal tourniquet.
Amputate as distally as possible.
Perform a guillotine amputation.
Apply haemostats to large blood vessels.
Leave the tourniquet in situ.

(consider IV antibiotics if can be delivered as concurrent activity)

Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure.

References:

Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2.

Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. .

Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–

Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3.

Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466.

McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

https://phemcast.co.uk/wp-content/uploads/2016/02/amputation.mp3

Welcome to PHEMCAST episode 5: Amputation

One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done.

This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements.

This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy.

Which patients / scenarios:

An immediate and real risk to the patient’s life due to a scene safety emergency.
A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation.
The patient is dead and their limbs are blocking access to potentially live casualties.

Which kit:

CAT x 2
Scalpel
Gigli saw (and spare)
Arterial forceps x 4
Tuff Cut scissors
Appropriate dressing (e.g. Israeli combat bandage)

Preparation:

Sedation or anaesthesia
Brief team
Plan next phase

Stages of amputation process:

Apply an effective proximal tourniquet.
Amputate as distally as possible.
Perform a guillotine amputation.
Apply haemostats to large blood vessels.
Leave the tourniquet in situ.

(consider IV antibiotics if can be delivered as concurrent activity)

Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure.

References:

Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2.

Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. .

Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–

Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3.

Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466.

McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

Previous Episode

Episode 4: Chemical incidents

https://phemcast.co.uk/wp-content/uploads/2016/01/chemical-incidents.mp3

We hope you enjoyed this PHEMCast. Please feedback your comments via the blog, twitter or email us on [email protected].

The NARU video we mention in the podcast can be accessed here:

http://naru.org.uk/videos/ior-nhs/

And the paper we discuss is:

Chilcott RP. Managing mass casualties and decontamination. Environmental International. 2014; 72: 37-45.

This is the Step 1,2,3 tool described:

For more information on the toxidromes associated with various chemicals, biological agents and radiation sources have a look at this document (admittedly it’s a few years old but the content is still good, especially the flow chart which is pasted below):

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340709/Chemical_biological_radiological_and_nuclear_incidents_management.pdf

What is an anti-muscarinic chemical?

Anti-muscarinic = blocking the muscarinic receptors, ie blocking the effect of acetylcholine, hence also called anti-cholinergic. Impacts on parasympathetic stimulation. Antimuscarinic effects include dilated pupils (leading to blurred vision), reduced secretion of saliva (hence dry mouth), sweat and digestive juices. Relaxation of smooth muscle causing urinary retention, ileus. Also tachycardia, confusion progressing to delirum/coma.
Nerve agents inhibit anticholinesterase therefore there is an excess of acetylcholine resulting in opposite features: diarrhoea, urination, miosis, increased bronchial secretions, bronchoconstriction, vomiting, lacrimation, salivation.

Always ahead of the curve... St Emlyns have recently published a blog post on this very topic! It’s great, so have a read:

http://stemlynsblog.org/cbrn-an-introduction/

Next Episode

Episode 6: Oxygenation

To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful!

https://phemcast.co.uk/wp-content/uploads/2016/03/oxygenation-16032016-15-25.mp3

Some of the stuff we talked about:

Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here.

But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible.

Taken from: http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices

A water’s circuit looks like this:

This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart & Levitan 2012.

Here are some other great resources which demonstrate some of the principles we have discussed:

Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation:

http://www.heftemcast.co.uk/apnoeic-oxygenation/

There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here:

http://emcrit.org/preoxygenation

A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team:

http://lifeinthefastlane.com/ccc/bag-mask/

This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation.

References

Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376.

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175.

Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355.

Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010;

Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72.

Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67.

Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial)

How to cite this podcast:

Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk