British trauma surgeon and pre-hospital pioneer Professor Keith Porter describes how to do a pre-hospital amputation in this months EMJ. Thankfully the procedure is only rarely necessary and often only requires cutting remaining skin bridges with scissors. The indications are:

• 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

The recommended procedure is:

1. Ketamine anaesthesia
2. Apply an effective proximal tourniquet
3. Amputate as distally as possible
4. Perform a guillotine amputation
5. Apply haemostats to large blood vessels
6. Leave the tourniquet in situ
7. Apply a padded dressing and transport to hospital

Remember: the requirement for prehospital amputation other than cutting minimal soft tissue bridges is rare. However pre-hospital critical care physicians should be trained and equipped to amputate limbs in order to save life. Probably good to have a Gigli saw in your pack and to familiarise yourself with its use, as shown here:

Prehospital amputation
Emerg Med J 2010 27: 940-942