Extremity trauma algorithm

A: Manual pressure or pressure dressing. A tourniquet is an option for life-threatening hemorrhage that cannot be controlled with other means, but removed as soon as possible. An operative pneumatic type tourniquet is preferred to field type.
B: For suspected concomitant intra-cavitary hemorrhage (abdominal or thoracic), two operative teams are an advantage. If only a single team is available, extremity tourniquet may temporarily control hemorrhage until intra-cavitary bleeding can be managed using damage control techniques. Damage control allows the ischemic extremity to be addressed as soon as possible.
C: Restoration of alignment alleviates kinking of vasculature and may improve perfusion.
D: In patients with multiple injuries, competing priorities for treatment may delay diagnosis of extremity vascular injury. Early vascular assessment minimizes ischemic time.
E: Peripheral nerve deficits are not sensitive predictors for failure of functional limb salvage, but it is important to document neurologic findings and factor their presence into decision making.
F: Assess factors associated with poor outcome for the mangled extremity, particularly in the context of other injuries or ongoing hemorrhage from the extremity or other sources.
G: For hemodynamically stable patients, CTA characterizes the location and extent of vascular injury. If CTA is not available, standard contrast arteriography may be needed, but can often be performed in the operating room, particularly if a hybrid operating suite is available.
H: Intraluminal shunts temporarily restore distal perfusion and allow ongoing patient evaluation or restoration of bony alignment. Once the shunt is placed, distal pulses should be documented.
I: Assessment of systemic, and extremity skeletal, soft tissue, nerve and vascular factors are weighed against the overall patient injury burden. Limb salvage efforts should not be counter to efforts to sustain life and a good overall patient outcome.
J:It is important to include the patients and their family in the decision for limb salvage versus amputation at the earliest possible moment, whenever possible. If they desire to do so, consider bringing family into operating room to view the extremity, if the patient is stable.
K:Document the injury with photos placed into the medical record prior to undertaking amputation. The photos may also help the patient and his/her family understand the need for amputation.​