|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| If the case is accepted for replantation by the microsurgeon, the next step is to initiate the protocol for transfer. The replant center is responsible for providing this information. Here at Davies Medical Center, we undertook this task by mailing laminated posters to all emergency rooms in our referral area, and by offering lectures to regional medical centers, ambulance teams, and professional associations. Each poster clearly lists step-by-step instructions for care of the patient, the amputated part, and transportation of both. These instructions are as follows.
Check the patient's general condition to rule out life-threatening injuries. On arrival at the emergency room, a large-bore intravenous line should be started with lactated Ringer's solution at a maintenance rate. If there are signs and symptoms of shock, the patient must be stabilized before transportation. To begin antibiotic coverage, administer cephazolin (Ancef or Kefzol), 1 g IV (except when prohibited by history of allergy). Diphtheria/tetanus toxoid, 0.5 cc IM, is necessary if it has not been administered within the last 5 years. Insert a 10 grain (600 mg) aspirin rectal suppository (if not contraindicated by history of coagulopathy) for anticoagulation. Evaluate and medicate the patient for pain as needed with IM or IV analgesia of choice. Keep the patient NPO to facilitate later anesthesia, and do not allow him or her to smoke or chew tobacco. Send x rays (both part and stump), emergency records, and all laboratory studies (especially hematocrit and urinalysis), including a clot of blood for further miscellaneous tests. An ECG and chest x ray should be sent if the patient is over 35, or if indicated by injury. Transport the patient supine.
REMEMBER: DO NOT DELAY TRANSPORT. IF NECESSARY, THE ABOVE STEPS CAN BE CARRIED OUT AT THE REPLANT CENTER IF THE PATIENT IS STABLE.
Injured Hand or Extremity
Apply saline-moistened sponges to the wound and cover with a sterile, bulky dressing. If extensive bleeding is noted, apply a pressure dressing rather than a tourniquet. Truly uncontrollable bleeding must be treated surgically before transport. Splint and elevate the injured part for comfort.
Instruct the referring emergency room to send all parts. Although all tissues may not be replantable, various portions may be used to reconstruct missing elements. No minimal cleansing is necessary at this time. More extensive debridement is done in the operating room by the microsurgical team while they examine the part. Rinse parts with normal saline to remove gross contamination, then wrap in DRY gauze, place in DRY plastic bag (zip-close), and place on ice. (Do not bury in ice because immersion may cause cold injury to the part. Do not use dry ice because it is too cold and causes tissue damage.
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