Auckland HEMS has recently added a Gigli saw to the medical pack in case a patient requires prehospital amputation. Fortunately the team has not yet been required to perform this procedure. Anecdotally, prehospital amputations that have been performed by paramedic staffed EMS in the Auckland area in recent years have involved near-total amputation due to injury itself, with limbs attached with minimal skin or soft tissue.
EMJ published an excellent review article of the procedure in 2010, which covers indications, contraindications, and technique. Click HERE for the full pdf (secure area limited to ADHB staff, who have access to this journal via the Philson Library at the University of Auckland School of Medicine)
The Medical College of Wisconsin has produced 3 educational videos, and made available a field manual for physicians who provide assistance to fire crews and EMS in the field.
Click HERE for a brief case report of a prehospital amputation performed by an anaesthetist and a urologist using a torch, some ketamine, and a Leatherman tool following the 2013 Christchurch earthquake.
Sydney HEMS has also produced a video, complete with a maudlin French musical accompaniment (!) demonstrating use of the Gigli saw on a deer limb:
A recent concept that has been widely discussed on FOAM sites, as well as at the SMACC conference, is The Vortex(pdf)
Who needs an algorithm? Here is The Vortex!
The Vortex is a simple cognitive aid that can be used in the setting of an unanticipated difficult airway. Conceived by Nicholas Chrimes (Melbourne anaesthetist) and Peter Fritz (Melbourne emergency physician), it aims to simply concepts, move away from complex algorithims, and be applicable in multiple settings.
Key to the concept is that the key goal in an unexpected difficult airway situation is alveolar oxygen delivery. Techniques to deliver oxygen (LMA, ETT, face mask) are regarded as equivalent, as any of these, if successful, will move a desaturating patient out of the Vortex into the ‘green zone’ where oxygenation is adequate for a ‘time out’ and alternative planning to occur. At the centre of the vortex is a surgical airway.