Traumatic Amputation: Hemorrhage Control and Wound Care

Hemorrhage Control: The First Two Minutes

Tourniquet Application

A tourniquet is the definitive field treatment for life-threatening extremity hemorrhage. Apply it without hesitation.

When to apply:

• Amputation (partial or complete) of any extremity
• Traumatic wound with arterial bleeding (bright red, pulsatile) that does not stop with direct pressure
• Hemorrhage from extremity wound that would cause death without intervention

Application technique (commercial tourniquet — CAT, SOFTT-W, or similar):

1. Apply 2-3 inches above the wound, as high on the extremity as possible — high and tight
2. For amputations: apply at the highest possible position on the remaining limb (high thigh or high arm) — this minimizes the risk of tourniquet being bypassed by bleeding from small collateral vessels
3. Thread the free-running tail through the buckle and pull tight — as tight as you can
4. Wind the windlass until bleeding stops
5. Lock the windlass in place
6. Write the time of application in marker on the patient's forehead (or on the tourniquet if it has a time slot) — "TK 14:35"

Effective tourniquet: Bleeding stops. Pulse distal to tourniquet disappears. The patient will have significant pain from the tourniquet — this is expected and not a sign that the tourniquet is incorrectly placed.

Ineffective tourniquet: If bleeding does not stop and pulse persists distally after maximum tightening, the tourniquet may be venous-only compression (preventing venous return but not arterial inflow, which actually worsens hemorrhage). Apply a second tourniquet proximal to the first.

Improvised Tourniquet

If no commercial tourniquet is available:

• A belt, fabric strip, or similar material at least 2 inches wide
• Narrow cordage or shoelaces concentrate pressure and cause nerve/tissue injury — use wider material
• Apply and tie around the extremity
• Place a stick, pen, or similar object under the knot as a windlass
• Twist the windlass until bleeding stops
• Secure the windlass so it cannot unwind (tie with remaining cloth)

Improvised tourniquets are less reliable than commercial ones. Use a commercial tourniquet if available.

Junctional wounds (groin, axilla, neck) cannot be controlled with a limb tourniquet. Use wound packing with hemostatic gauze and direct pressure, or a junctional tourniquet device if available.

Wound Management After Hemorrhage Control

Stump Assessment

After tourniquet placement and hemorrhage control:

1. Cut away clothing to expose the injury
2. Assess the amputation level and wound characteristics
3. Look for secondary hemorrhage sites not covered by the tourniquet
4. Assess distal circulation if partial amputation (is the distal part viable?)

Wound Packing for Partial Amputation or Stump Hemorrhage

If the amputation is incomplete or there is additional wound bleeding beyond tourniquet control:

1. Pack the wound cavity firmly with hemostatic gauze (Combat Gauze, Celox, ChitoGauze) or standard gauze
2. Direct all gauze packing into the depth of the wound, not across the surface
3. Apply firm direct pressure over the packed wound for minimum 3 minutes
4. Once packed, apply a pressure dressing over the top
5. Do not remove packing in the field — removal risks dislodging clots

Pain Management

Amputations are excruciatingly painful. Pain management in the field:

• If trained and authorized: IV morphine 2-4mg or intranasal ketamine 0.5mg/kg
• Oral opioids if available: codeine 30-60mg, tramadol 100mg
• Ibuprofen 800mg plus acetaminophen 1000mg (best available non-opioid combination)
• Keep the patient warm — cold pain is amplified by hypothermia
• Address shock first — pain management given in the context of hemorrhagic shock requires careful monitoring

Psychological support is as important as pharmacological. A reassuring, calm voice, physical presence, and explicit communication ("We have stopped the bleeding. You are going to get help.") reduces the pain experience and prevents panic that worsens physiological outcomes.

Hypothermia Prevention

Amputees lose body heat rapidly from exposed tissue, blood loss, and shock. Hypothermia worsens coagulopathy (clotting ability), creates a deadly cycle:

• Wrap the patient in all available insulating material
• Protect from ground contact (significant heat loss)
• Keep the stump covered and protected
• Warm the IV fluids if possible (hand-warm bags before infusing)

Handling the Amputated Part

If the Part Is Recoverable

Replantation of amputated parts is possible for some injuries, particularly digits and distal limb segments, when:

• Ischemia time is short
• The patient is otherwise stable
• A microsurgical facility can be reached

Preservation protocol:

1. Wrap the part in a clean, moist (not saturated) saline-dampened gauze or cloth
2. Place in a sealed plastic bag
3. Place the sealed bag in a container of ice water — the ice water keeps it cool without freezing
4. Label with the patient's name and the time of injury
5. Transport with the patient to the receiving facility

What NOT to do:

• Do not place the part directly on ice (freezing destroys tissue)
• Do not immerse the part in water
• Do not use dry ice
• Do not delay patient transport to search for the part — patient stabilization first, part recovery second

Realistic expectation for field settings: Replantation requires microsurgery not available in most grid-down scenarios. Preservation of the part is valuable if there is any chance of reaching a surgical facility, but it is a secondary priority to patient survival.

Tourniquet-to-Pressure Conversion (If Extended Field Time)

If evacuation is delayed beyond 1.5-2 hours after tourniquet application and hemorrhage assessment suggests it may be controllable without tourniquet:

1. Expose and reassess the wound
2. Apply hemostatic gauze packing directly into the wound
3. Apply firm pressure dressing
4. Slowly loosen the tourniquet while observing for return of bleeding
5. If bleeding restarts: immediately retighten the tourniquet
6. If bleeding remains controlled: keep tourniquet in place but fully released, in case it needs to be rapidly re-applied

Note: this conversion is only appropriate if the wound is accessible and capable of being packed, and only by providers trained in wound packing technique. An uncertain attempt that results in re-hemorrhage is worse than leaving the tourniquet in place.

Evacuation

Traumatic amputation requires surgical care:

• Wound debridement and stump management
• Vascular injury assessment
• Infection prevention
• Possible replantation or revision amputation

Evacuation priority: High. Hemorrhagic shock, infection risk, and pain are all active threats. Do not delay evacuation for secondary wound management.

Handoff information:

• Time of amputation (mechanism and time)
• Time of tourniquet application
• All interventions performed and times
• Estimated blood loss
• Vital signs trend
• Pain medications given
• Location and preservation status of the amputated part