Hand Case 8 ED Management

To preserve an amputated digit, it should immediately be covered in saline-soaked gauze and placed in watertight bag. This bag should then be immersed in a 50/50 mix of ice and water to provide an icy slurry with an ideal temperature of 4 degrees Celsius.

Do not use vascular clamps to obtain hemostasis. Pressure dressings, elevation, and tourniquets will control bleeding in most cases. Amputations are similar to open fractures, so antibiotics should be initiated early in ED course. Analgesia and tetanus immunization should be given as needed.

Amputations distal to the DIP joint are usually left to heal by secondary intention if no bone is exposed and the defect is small. The tip can even be sutured on to provide some temporary cosmetic benefit and a physiologic dressing while healing. If there is a small amount of phalangeal bone protruding from stump (less than 0.5cm), a bone rongeur should be used to trim it to below level of skin. Amputations proximal to the DIP, particularly for the thumb and index fingers, require hand surgery consultation.

Reimplantation decisions are made by experienced microvascular specialists. Ideal candidates are clean cut "guillotine" injuries affecting the thumb or multiple digits. Poor candidates include injuries with longer than 12 hours of warm or 24 hours of cold ischemia time, and crush or avulsion injuries.