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• Amputation, can it wait for CPR: authors' response
  J Nigel Rawlinson
  Published on: 29 April 2016
• Physiologic amputation for crush syndrome induced cardiac arrest
  Bruce D. Adams
  Published on: 29 April 2016
• Amputation, can it wait for CPR
  Sreenadh Gella
  Published on: 29 April 2016

• Published on: 29 April 2016

  Amputation, can it wait for CPR: authors' response

  • J Nigel Rawlinson, Consultant in Emergency Medicine
  • Other Contributors:
    • Rob Wise, Jonathan Benger and Ian Higginson.

  Dear Editor

  Mr Gella raises some interesting questions. Before responding to the specifics we wish to make two general observations.

  Firstly, this case illustrates real-time emergency decision-making. We had a patient in cardiac arrest due to hyperkalaemia. Seconds counted. We had to restore circulation as quickly as possible.

  Second, such decisions are always made collaboratively. The rol...

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  Dear Editor

  Mr Gella raises some interesting questions. Before responding to the specifics we wish to make two general observations.

  Firstly, this case illustrates real-time emergency decision-making. We had a patient in cardiac arrest due to hyperkalaemia. Seconds counted. We had to restore circulation as quickly as possible.

  Second, such decisions are always made collaboratively. The role of the Emergency Medicine consultant (NR) was to initiate and enable rapid decision-making. This was achieved by consensus between emergency medicine, critical care and the vascular surgeons who had already assessed the patient. Such clinical scenarios are thankfully rare. We believe that good teamwork and decisive leadership were essential to the success achieved.

  In response to Mr Gella’s questions:

  1. It is true that there are many causes of hyperkalaemia. However, in healthy young individuals the list of acute causes is much smaller. He had no apparent cause of decreased potassium excretion and no reason to believe he had taken a potassium overdose, thus leaving potassium shifts and laboratory errors as the only possible reasons. He had a normal pH prior to his arrest (ruling out metabolic acidosis), had received no medication that could alter his potassium, and had no internal bleeding or signs of infection. He did, however, have an ischaemic leg – clearly the most likely cause.

  2. The patient received the correct medical treatment for hyperkalaemia and the variety of arrhythmias encountered. Despite this, he remained unstable. Dialysis could not occur until circulation was restored. This was unlikely until the continuing hyperkalaemia was reversed. The source of potassium had to be isolated, and we observed a dramatic clinical improvement once the amputation had been completed.

  3. We included the results available at the time of the arrest.

  4. A tourniquet was suggested at the time, but no suitable device was immediately available. It would have taken as much time to fetch a tourniquet from the orthopaedic theatre in our large hospital as to perform a below knee amputation (which took a matter of minutes once started).

  5. The final level of amputation was not determined in the resuscitation room. Our approach was to remove the clearly non-viable tissue. The stump was then bandaged and later revised in an operating theatre.

  We hope this addresses all the points raised.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Physiologic amputation for crush syndrome induced cardiac arrest

  • Bruce D. Adams, Associate Clinical Professor of Emergency Medicine
  • Other Contributors:
    • Jill A. Grant, Michael L. Hawkins

  Dear Editor,

  Wise et al are to be commended for an excellent “save” as we like to say in the USA.1 I wonder, however, if the very midst of CPR is the best timing for a surgical amputation. Surgery, even the life saving maneuver described, invariably stresses the body. If at all possible, it should be delayed until medical resuscitation is complete because surgical mortality in cases such as the authors describe...

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  Dear Editor,

  Wise et al are to be commended for an excellent “save” as we like to say in the USA.1 I wonder, however, if the very midst of CPR is the best timing for a surgical amputation. Surgery, even the life saving maneuver described, invariably stresses the body. If at all possible, it should be delayed until medical resuscitation is complete because surgical mortality in cases such as the authors describe can exceed 40%.2

  We wholeheartedly agree that the only way to control the massive rhabdomyolysis and hyperkalemia in their patient was to quickly eliminate the intracellular toxin leak from the leg. The authors briefly mention tourniquet application, but they do not state whether they considered it at the time. There is some fairly good experience with “physiologic amputation” or “cryoamputation” and we believe that the strategy deserves some elaboration for the readers.2-4

  To perform, firmly apply 1-2 tourniquets to the extremity above the level of injury or entrapment and then apply dry ice distal to the tourniquet. Combat surgery hospitals from World War II through current conflicts have performed the procedure not infrequently.5 Physiologic amputation rapidly reduces myoglobin and other intracellular toxins due to crushed, ischemic or septic extremities.2, 3 One center reported a dramatic reduction in myoglobinuria within 24 hours of tourniquet application and the physiologic tourniquets have allowed definitive surgery to be delayed for up to 32 days.3

  Physiologic amputation of the nonviable extremity should be considered for similar clinical scenarios as described by the authors.

  References

  1. Wise R, Higginson I, Benger J, Rawlinson N. Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest. Emergency Medicine Journal 2006;23(3):e20.

  2. Hunsaker RH, Schwartz JA, Keagy BA, Kotb M, Burnham SJ, Johnson G, Jr. Dry ice cryoamputation: a twelve-year experience. Journal of Vascular Surgery 1985;2(6):812-6.

  3. Winburn GB, Hawkins ML, Wood MC. Physiologic amputation prevents myoglobinuria from lower extremity myonecrosis. Southern Medical Journal 1993;86(10):1101-5.

  4. Winburn GB, Wood MC, Hawkins ML, Wynn JJ, Nesbit RR, Wray CH, et al. Current role of cryoamputation. American Journal of Surgery 1991;162(6):647-50; discussion 650-1.

  5. First United States Army Report of Operations: 1 August 1944-22 February 1945. Medical Section Report Annex 11. Government Printing Office 1946:131-196.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Amputation, can it wait for CPR

  • Sreenadh Gella, SPR Orthopaedics

  Dear Editor,

  Article named Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest(Ref1) is very interesting as well as thought provoking. Such clinical scenario is not only rare but needs a good team effort to come to a clinical judgement. Amputation in acute scenario in the absence of obvious vascular injury is definitely a brave decision.

  I would be grateful for the...

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  Dear Editor,

  Article named Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest(Ref1) is very interesting as well as thought provoking. Such clinical scenario is not only rare but needs a good team effort to come to a clinical judgement. Amputation in acute scenario in the absence of obvious vascular injury is definitely a brave decision.

  I would be grateful for the authors if my doubts can be clarified

  1) There are many causes of hyperkalemia and how the team treating could come to a conclusion that the hyperkalemia was caused by the rhabdomyolysis of foot.

  2) Drugs like cocaine, heroine can cause rhabdomyolysis (of any muscle), disseminated intra vascular coagulation, hyperkalemia and arrythmias which can be made worse by naloxone (Ref2). In the presented clinical situation these possibilities cannot be ruled out.

  3) Arterial blood gas values of this patient would be very interesting to see as well, with particular emphasis on acidosis and anion gap.

  4) If limb ischaemia and reprfusion of the ischaemic limb are considered as the cause of hyperkalemia, application of tourniquet or clamping of the vessels can act as diagnostic test rather than going for an amputation.

  5) What are the parameters that the teams used to determine the level of initial amputation and what was the initial level of amputation.

  Thanking you

  Yours sincerely

  Mr Sreenadh Gella
  SPR Orthopaedics
  Calderdale Royal Hospital

  Reference

  1. R Wise1, I Higginson2, J Benger2 and N Rawlinson1 Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest, Emergency Medicine Journal 2006;23:e20; doi:10.1136/emj.2005.

  2. McCann B, Hunter R, McCann J. Cocaine/heroin induced rhabdomyolysis and ventricular fibrillation.Emerg Med J. 2002 May;19(3):264-5.

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  Conflict of Interest:
  None declared.

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