Index operative procedures should be prioritized with the surgical team leader; these surgeries require a team approach with constant communication.20 Hemorrhage control of traumatic amputations and peri-pelvic sources is the main priority along with restoration of blood volume and keeping the patient warm. Pelvic and perineal packing with hemostatic dressings such as Combat Gauze may be helpful for small-vessel hemorrhage control and cases with continued oozing due to coagulopathy.

Revision or completion amputations should occur at the most distal viable level with suture ligation or double ligation of all named vessels in an open, length-preserving fashion. Limb length is inversely proportional to later energy expenditure (i.e. life expectancy) so preserving as much bony length as possible is preferable. Any viable skin and soft tissue should be preserved; guillotine-style or open circular amputations are contraindicated. Care should be given to salvaging healthy tissue for flap coverage, even if it is an atypical rotational flap in the face of destroyed or missing conventional flap tissue. If the pelvic ring is unstable, a pelvic external fixator should be used instead of a binder, to facilitate access to the groins, debridement of proximal wounds and other procedures. Pin placement in the iliac crest or anterior inferior iliac spine are both appropriate, with the latter offering greater reduction control but requiring fluoroscopy and surgeon experience. If the patient requires a colostomy and/or suprapubic (SP) catheter, these procedures must be coordinated with orthopedic surgery to determine optimal placement, so they do not interfere with future pelvic approaches necessary for fixation. External fixation of long bone fractures should be accomplished as soon as possible depending upon the acuity of the patient. Smaller bone and joint fractures can be addressed if the patient remains stable, otherwise they are deferred until after the initial operative resuscitation.

Refer to JTS Amputation: Evaluation and Treatment CPG for further guidance. 21