Preservation of Traumatic Complete Amputated or Avulsed Body Parts in the Prehospital Setting: FA 7391 TF Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.

The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable.

Task Force Synthesis Citation

Singletary EM, Laermans J, Berry D, Cassan P, Pek JH, Thilakasiri K, Djärv T, on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.

Preservation of traumatic complete amputated or avulsed body parts in the out-of-hospital setting Task Force Synthesis of a Scoping Review. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2024 October 27. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of prehospital preservation of complete amputated or avulsed external body parts conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence for adult and pediatric literature was sought and considered by the First Aid Task Force.

Scoping Review

Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.

(manuscript in preparation)

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children with a traumatic complete amputation or a complete avulsion of an external body part (e.g. digit, hand, arm) or soft tissue in the out-of-hospital setting
Excluded: Adults and children with a partial amputation or avulsion, an internal avulsion, a surgical amputation

Intervention: Any approach to preservation of the amputated body part or avulsed tissue for possible replantation/attachment

Comparators: Another approach to preservation of the amputated body part or avulsed tissue for possible replantation/attachment

Outcomes: Any clinical outcome. Attempted and successful replantation of amputated body parts or reattachment of avulsed tissue.

Study Designs: Randomized controlled trials (RCTs), non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), and experimental studies with animal models were eligible for inclusion. Case series and reports were included in the literature search. Narrative reviews (with no systematic search of the literature) were excluded. The gray literature search included relevant guidelines from ILCOR-member organizations. All relevant publications in any language were included as long as there is an English abstract.

Timeframe: All years.

Literature search completed 17 April 2024

Search Strategies

A search strategy was developed with assistance from the information specialist at the Centre for Evidence-based Practice, Belgian Red Cross (see Appendix 1: Search Strategies). Records for review were obtained by searching PubMed, EMBASE, Cochrane CENTRAL, Allied Health Literature (CINAHL), ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), for all entries from database inception to 17 April 2024.

Articles are using key terms “Amputation”, “Avulsion”, “Tissue Preservation”; including their MeSH terms and Embase exploded terms. Records from the database searches were downloaded and imported into Covidence for duplicate removal and screening.

A total of 9481 studies were retrieved from all databases. After removal of 3090 duplicates, 6391 studies underwent title and abstract screening. After initial screening, 93 full text studies were assessed for eligibility and 37 studies were ultimately included (See Figure 1 for PRISMA flow chart). Reasons for exclusion at the full text level included: no description of pre-arrival tissue preservation (n=26); full text not available (n=7); wrong study design (narrative reviews) (n=5); data not available (n=6), wrong outcome (n=4), no English abstract available (n=3); wrong intervention (n=4); and wrong population (n=2). Hand search of references from included studies yielded 2 additional studies; neither study met inclusion criteria.

The gray literature search was limited to a targeted website search of ILCOR-member organizations and other major organizations known to task force members to produce first aid guidelines. Guidelines related to care of complete, traumatic amputated or avulsed body parts were sought and reviewed for content.

Inclusion and Exclusion criteria

Population Inclusion Criteria:

• Adults and children with complete traumatic amputations of external body parts (e.g., fingers, toes, digits, hand, foot, arm, leg, nose, ears)
• Adults and children with complete avulsions of soft tissue (e.g. scalp, cheek, ear)
  
  

Population Exclusion Criteria:

• Surgical amputations
• Partial amputations
• Partial avulsions
• Degloving injuries*
• Crush injuries*
• “Mangled” extremities*
• Internal avulsions (e.g., nerves, tendons, bone, teeth)
• 
  *These injuries were excluded as they are typically not considered for replantation due to the degree of injury and may require surgical amputation.

Intervention Inclusion Criteria:

• Any type of preservation of the amputated/avulsed body part/tissue, such as but not limited to:
  • Rinsing or cleaning it
  • Wrapping it in a dry or moist dressing
  • Cooling it
• Time intervals from injury to hospital arrival, injury to replantation or revascularization, with and/or without cooling (“cold ischemia time” and “warm ischemia time” respectively)

Intervention Exclusion Criteria:

• Delayed (in-hospital) preservation techniques (artificial perfusion)
• Preservation techniques performed in-hospital prior to transfer to a high level of care for replantation
• Surgical-specific preservation (e.g., free flaps)
  
  

Outcome Inclusion Criteria:

• Any clinical outcome, including but not limited to
  • Attempted replantation
  • Successful replantation, including
    • survival of replanted part
    • functional outcomes or appearance
  • Successful use of avulsed tissue for covering the defect

Data tables

See Figure 1 (PRISMA Diagram), Appendix 2 (Case Report/Series) and 3 (Observational Studies).

Prisma: FA7391 A Traumatic amputation Scop Rev Figure 1 PRISMA

Appendix 1: FA7391 Traumatic amputation Scop Rev Appendix 1 SEARCH STRATEGY final

Appendix 2: FA7391 Traumatic amputation Scop Rev Appendix 2 Data Tables Case reports final

Appendix 3: FA7391 Traumatic amputation Scop Rev Appendix 3 Data Tables Obs Exp Studies 27 OCT2024 final

Task Force Insights

1. Why this topic was reviewed.

This topic was prioritized based on the global burden of traumatic amputations, awareness of ILCOR Task Force members of recent publications describing improper preservation of amputated/avulsed body parts, and the subsequent potential lost opportunity for replantation or reattachment of amputated or avulsed body parts. First aid for the patient’s wound is not included in this review and has been covered in other ILCOR reviews (FA530, Control of life-threatening bleeding with direct pressure; FA 1543 and 1549, Tourniquets for life-threatening bleeding from an extremity; FA 7334, Use of hemostatic dressings for life-threatening bleeding).(Singletary 2020 S284}

Complete amputation of extremities or digits is a physically and emotionally traumatic experience that can lead to long-term disability and disfigurement. Globally, the incidence and prevalence number of traumatic amputation increased from 11.37 million and 370.25 million in 1990, to 13.23 million and 552.45 million in 2019, with a raise of 16.4 and 49.2%, respectively.(Yuan 2023 1258853} In many cases and in countries with higher resources, it has become standard of care to replant amputated digits, extremities and other body parts when the amputated part or tissue is recovered, preserved and transported with the patient. Nonfreezing cold storage of an ischemic amputated limb or digit is considered by surgeons who perform replantation of amputated body parts to be essential to improve the potential for successful replantation and revascularization, particularly when transport times are prolonged.(Goldner 2011 1585} Successful replantation is determined by the initial survival of the replanted part, followed by subsequent return of neurovascular and motor function and, in some cases, by appearance.

Indications for replantation have increased over the past few decades. When replantation is not an option, skin from the amputated limb is sometimes used for grafting of the defect created by the avulsion or amputation. Preserved avulsed tissue can similarly be considered for reattachment or used as a biologic wound cover.

Numerous first aid and prehospital guidelines recommend wrapping the amputated/avulsed body part in saline-moistened gauze, placing the body part/tissue in a plastic bag or airtight container, and placing the bag or container in a second bag/container of ice and water.{International Federation of Red Cross and Red Crescent Societies 2020; Saint John Ambulance 2019} However, it has been reported that only 35% of patients with traumatic amputations present to the emergency department with properly preserved amputated body parts, making it difficult for surgeons to offer replantation when it would otherwise be an option.{Massand 2020; Sinatro 2022 155}

This scoping review sought to identify studies and reports of completely amputated/avulsed body parts in which replantation was performed, to describe the first aid strategies for storing and preserving the tissue, to identify factors related to care of the amputated or avulsed part, including delays in preserving the tissue or attempting replantation, and to document success of replantation surgery.

2. Narrative summary of evidence identified

After removal of duplicates, the database search yielded 6,391 unique records. Following title and abstract screening, 93 records underwent full text screening, with 56 being excluded for reasons listed in the PRISMA diagram (Figure 1). The most common reason for exclusion was failure to describe care provided to the amputated part prior to hospital arrival. A total of 37 studies were ultimately included in this review: 27 case reports,(Akyurek 2020 e749; Borenstein 1990 442; Braga-Silva 2016 419; de Lagausie 2008 e11; Dvořák 2020 e20068; Elsahy 1974 124; Facio 2015 77; Fernandez-Palacios 2009 14; Firdaus 2017; García-Murray 2009 824; Gunasagaran 2022 122; Henry 2020; Kyrmizakis 2006 45; Li 2020 427; Liang 2004 645; Makki 2020; May 1981 566; Musa 2016 786; Salem 2009 264; Selmi 2018 111; Szlosser 2015 67; Usui 1979 613; Wei 1988 346} 2 case series,{Berger 1977 59; O'Brien 1973 714} 2 experimental studies using animal models,{Hayhurst 1974 134; VanGiesen 1983 60} 1 prospective observational study,{Waikakul 1998 1024} 6 retrospective observational studies,{Chen 2017 5445; Li 2008 833; Okumuş 2020 123; Sinatro 2022 155; Tark 1989 17; The Hoang 2009 1167} and 3 systematic reviews with meta-analyses(Huawei 2015 265; Ma 2016 157; Shaterian 2018 66}. All studies included human subjects except for the two experimental studies. Studies originated in Austria (1), Australia (2), Brazil (2), Canada (1), China (6), Czech Republic (1), Denmark (1), Egypt (1), France (1), Greece (1), Israel (1), Japan (2), Malaysia (2), Mexico (1), Nigeria (1), Poland (1), Spain (1), Taiwan (1), Thailand (1), Turkey (2), United Kingdom (1), Vietnam (1) and the United States of America (5). Of the 37 included studies, 19 studies originated in 13 different high-income countries, while 18 studies originated in 9 different middle-income countries. No studies originated in low-income countries.

A complete overview of case report and series characteristics and key findings is presented in Appendix 2, while characteristics and key findings from experimental studies, observational studies and systematic reviews can be found in Appendix 3. A narrative summary of the included studies follows and is presented beginning with older experimental animal models that helped lead to some of the current techniques for preserving amputated and avulsed body parts or tissue. The remaining studies are presented beginning with lower certainty study designs and progressing to systematic reviews.

Experimental Studies

A 1974 experimental study{Hayhurst 1974 134} evaluated replantated amputated index fingers in 10 Macaque monkeys. Amputated fingers were wrapped in a saline-moistened gauze sponge and maintained at 4°C for 21 hours, then brought to room temperature for up to 2.5 hours before replantation. Necrosis occurred in the digits in the first 3 animals that did not receive daily SQ heparin, while one digit had bleeding and necrosis attributed to anticoagulant overdose or trauma. Of the remaining 5 finger replantations, all were successful with survival at a maximum follow up of 35 days.

A second experimental study{VanGiesen 1983 60} assessed survival of replanted rabbit ears after storage under 8 different conditions, including room temperature and minus 5°C. Rabbit ear structure is considered similar to the human digit for amputation studies as it contains skin, loose connective tissue, a central artery, vein, nerve, and distal arteriovenous networks similar to the digit. All replants that were stored for 24 hours at room temperature or - 5° C failed to survive. Two other failures were recorded: one stored at 4°C wrapped in a moistened normal saline surgical sponge, and one stored 2 hours at room temperature followed by 22 hours of storage at 4°C. Nineteen of 20 replants survived after immersion in saline or lactated Ringer’s at 4°C for 24 hours, or wrapping the part in gauze moistened with saline or lactated Ringer’s solution and storing at 4C for 24 hours. Results suggest that there is no significant difference between immersing an amputated part in the solution or wrapping an amputated part in a saline or lactated Ringer’s solution-moistened cloth during cooling for 24 hours at 4° C. The authors concluded that there is no difference among conventional methods of storage as long as the amputated part is not frozen or allowed to become normothermic for more than 2 hours.

Human case reports/series

The 27 case reports described complete:

• avulsions of the scalp with/without ears {Akyurek 2020 e749; Borenstein 1990 442}
• amputation/avulsions of the ear(s){Dvořák 2020 e20068; García-Murray 2009 824; Kyrmizakis 2006 45; Liang 2004 645}
• avulsion/amputations of the nose/alae{Elsahy 1974 124} and upper lip{Makki 2020}
• amputations of finger(s) at proximal and distal locations{Braga-Silva 2016 419; Gunasagaran 2022 122; May 1981 566; Szlosser 2015 67; Wei 1988 346}
• amputations of the penis {de Lagausie 2008; Facio 2015 77; Henry 2020; Musa 2016 286; Salem 2009 264} and testicle {Selmi 2018 111}
• amputation of the hand {Fernandez-Palacios 2009 14}, arm above the elbow {Firdaus 2017}, leg at knee level {Li 2020 427}, and leg at distal 1/3 level{Usui 1979 613}.
  
  

The identified case reports almost uniformly described varying degrees of successful replantation with revascularization when necessary or with reconstruction of amputated/avulsed parts that, prior to hospital arrival, received a wide variety and combination of interventions:

• Lost outdoors in snow for 4 hours
• Wrapped in wet gauze and placed in a plastic bag surrounded by ice
• Stored in a jar at 4°C for 15 days
• Placed on ice without direct contact
• Wrapped in moist gauze and stored on dry ice
• Left unpreserved outdoors for 2 hours, then immersed in saline and refrigerated for 2 hours
• Left unpreserved outdoors for 5 hours, then in a container with saline and ice for 1 hour
• Placed in a plastic bag on ice inside an isothermal box for 13 hours
• Preserved “on ice” directly
• Left unpreserved for 2 hours, then wrapped in moist gauze, placed in plastic bag and put inside bucket with ice water in a refrigerator for 52 hours
• Left unpreserved for an unknown period, then placed in plastic bag with ice cubes/melted ice for 2 hours
• Left unpreserved for 15 hours, then put on ice
• Placed in plastic bag with saline, then surrounded by ice
• Left unpreserved for 2 hours, then wrapped in saline soaked gauze and in a plastic bag with ice for 6 hours
• Left unpreserved for 5 hours, then preserved “in ice” for 5 hours
• Wrapped in saline-soaked gauze and placed on ice in a bag
• Placed in a bag inside another bag with ice and slush for 2 hours
• Placed in a jar of water for 2 hours
• “Cooled and stored appropriately” for 2 hours
• Placed in ice water for 5 hours

Many of the case reports documented a failure to preserve the amputated parts by any means for between 2 to 5 hours post injury, followed by cold preservation for several hours to (in the case of a distal fingertip) days later. The process for cooling described most often was wrapping the part in moist gauze, placing the part in a plastic bag and then placing the bag in another container with ice or an ice-water mix. In some cases, the details of how cooling was accomplished were not clearly described. When cooling was initiated immediately after the injury and before hospital arrival, it was in snow, ice water, a bag or other container with ice or ice-water mix or refrigerated dry or immersed in saline. For several case reports, it was unclear if cooling was initiated after arrival of emergency care providers or at a medical facility. For amputated digits, cooling for up to 94 hours was reported to precede successful replantation,{Wei 1988 346} while for more proximal limbs successful replantations (leg, arm),{Li 2020 427; Usui 1979 613} preservation in ice-water occurred for up to 5 - 6 hours. Only one case reported the inability to replant an amputated part (penis) due to lack of cold storage for 15 hours and a mummified appearance.{Musa 2016 786}

A case series {Berger 1977 59} of 33 patients with 68 amputated parts did not describe the specific pre-arrival method of care or preservation of amputated parts, except for 4 cases that were reported to have “improper” first aid contributing to failed replantation procedures. Lack of cooling in 2 cases, placing the amputated parts in a liquid-filled glass, and placing the part in ice water were considered inappropriate pre-arrival management. In 9 of 11 cases, a functional replantation was not achieved; both the storage technique of the amputated part and the injury mechanism were seen as the cause for failure of functional replantation.

A second case series{O'Brien 1973 714} of 8 patients with 14 amputated digits noted survival of 11/14 (83%) of digits with ischemia times ranging from 7 to 14 hours. Except for one case, all amputated digits were cooled as soon as possible after injury by placing them in a plastic bag and then inserting the digit(s) into another bag containing ice.

Observational human studies

In a Chinese retrospective cohort study of 211 patients with 211 complete fingertip amputations undergoing replantation surgery between 1990 and 2006{Li 2008 833}, different variables that may affect fingertip survival were studied. Multivariable analysis (adjusted for injury mechanism, use of a vein graft, smoking after the operation and platelet counts) showed that, compared to immersion in saline or ethanol, dry storage at room temperature was associated with increased survival rates in a non-statistically significant manner (adjusted odds ratio (aOR): 0.314, 95%CI [0.041-2.399], p=0.264), and that, again compared to immersion in saline or ethanol, dry storage at 2-6°C was associated with increased survival rates in a statistically significant manner (aOR: 0.028, 95%CI [0.003-0.270], p=0.002).

A Chinese retrospective cohort study{Chen 2017 5445} of consecutive patients with finger amputations seen between January 1, 2002, and December 31, 2013, assessed factors influencing survival of replanted digits using univariate and multivariate logistic regression analysis. The review included 896 severed fingers, and 851 (94.98%) fingers were successfully replanted. Univariate analysis demonstrated that many factors correlated with success, such as ischemic time, etiology of injury, age, plane of severed fingers, method of preservation (all p<0.05). Multivariate logistic regression analysis showed method of preservation, ischemic time, the etiology of injury, and the incidence of vascular crisis were the significant independent predictors for survival of the replanted digit. Preservation techniques used for amputated digits were not described in detail, and it is unclear if the preservation method was initiated before or after arrival at the hospital. Categories of preservation included: freeze-dried, room temperature dry, and soaking liquid. Of 851 replanted digits that survived, 518 (60.9%) were preserved by the “freeze-dried” technique, 257 (30.2%) were preserved dry and at room temperature, and 61 (7.2%) were preserved by soaking in an unspecified liquid. Of 45 replanted digits that did not survive, 18 (40%) were preserved with the “freeze-dried” technique, 16 (35.6%) were preserved dry at room temperature, and 11(24.4%) were preserved by soaking in an unspecified liquid.

A Korean retrospective cohort study{Tark 1989 17} assessed 176 replantations of complete finger and hand amputations between 1982 and 1986. An 80% successful replantation rate was reported. Survival of amputated parts was assessed based on a warm or cold ischemia time of ≤12 or ≥13 hours. There was no significant relationship between survival of the replant and length of ischemic time in the cold ischemia amputated parts group. Amputated parts that were replanted within 12 hours of warm ischemia had a higher success rate than those with a warm ischemia time of ≥13 hours. While hypothermic preservation of amputated parts was noted to improve odds of replantation and revascularization, this review does not describe the technique used to hypothermically preserve the amputated fingers and hands before or after arrival at the hospital.

A retrospective cohort study{Okumuş 2020 123} from Turkey identified 14 patients with major upper extremity amputations between 2007 and 2015 that were considered for replantation. Successful replantation was performed in all but 3 cases with multilevel crush injuries, with outcomes including measures of motor activity and sensation. All but one amputated part arrived at the hospital “in properly prepared cold ischemic conditions”. One without cooling had “appropriate” warm ischemic time. All other limbs had “appropriate” cold ischemic times. The author notes that properly prepared amputated parts should be wrapped in a saline-moistened gauze sponge, placed in a plastic bag, sealed and placed on ice. The amputated part should not be placed directly on ice. Recommended ischemia times for reliable success with replantation are 12 hours of warm and 24 hours of cold ischemia for digits, and 6 hours of warm and 12 hours of cold ischemia for major replants.

A Vietnamese retrospective cohort study{The Hoang 2009 1167} of 10 patients between 1999 and 2006 with complete forearm avulsion amputations reported survival of the replantation in all 10 replants despite a lack of pre-arrival storage/preservation efforts. Warm ischemia times ranged from 7 to 13 hours. All amputations underwent replantation 'shortly after arrival" at the hospital. Postoperative functional outcomes of replanted forearms were rated from “excellent” to “fair” in 70% of the patients with an average follow-up period of 20 months. One illustrative case described the amputated arm wrapped in a towel and transported with the patient 3 hours to the hospital. No prehospital storage/preservation of the amputated part was performed, beyond one case in which the arm was wrapped in a towel.

A retrospective cohort study{Sinatro 2022 155} from the USA of 91 patients seen between 2015 - 2019 with traumatic amputation and documented modality of preservation assessed the rate of “proper preservation” prior to hospital arrival and attempted replantation. Prearrival "proper preservation" was defined per Advanced Trauma Life Support guidelines as "wrapping the part in saline soaked gauze inside a watertight bag and placing it on ice". Most of the patients (60/91, 65.9%) arrived without proper preservation of their amputated parts. Of 74 patients transported by EMS, only 35.1% had proper preservation of their amputated part. Only 25.5% of patients presenting from home had proper preservation of their amputated part(s). Replantation was attempted at a significantly lower rate (n=14, 23.3%) in patients with improperly preserved parts than in those with properly preserved parts (n=18, 58.1%) (P=.001).

A prospective observational study{Waikakul 1998 1024} from Thailand of 186 patients seen between 1985 and 1994 with single-level isolated amputation or disarticulation of the upper extremity (shoulder to mid-palm), seen within 8 hours of injury, reported successful replantation in 167 patients (89.8%). Pre-arrival cooling of the amputated extremity was reported in 102/186 (54.8%) patients and was significantly associated with successful replantation. The methods for cooling the amputated extremity and other initial care were not provided in this study. The total time of ischemia after injury until arterial flow was established was not associated with successful replantation, although patients were only included in the study if seen within 8 hours of injury.

Systematic reviews of human studies

A systematic review{Huawei 2015 265} meta-analyzed data from 3 human studies (979 patients with 1,755 amputated digits) comparing replantation survival rates following storage of digits at low temperature (in an “ice bag”) with storage at “common” temperature. Replanted amputated digits stored at low temperature were more likely to survive than those stored at common temperature (OR 4.89, 95%CI 2.14-11.20, p=0.0002). There was no significant association between an ischemia time ≤12 h and ≥12 h and replantation survival rate, which the authors note may be related to lack of skeletal muscle in the finger.

A second systematic review {Shaterian 2018 66} of human studies with 6,000 digit amputations between 1985 and 2016 assessed factors potentially associated with successful replantation of the digits. Two studies were identified in this review that evaluated the method of preservation (cold vs warm){Heistein 2003 299; Li 2008 833}. The method of preservation was not statistically associated with replant survival (OR 0.94 (p>0.05)). Of note, one of the two studies included in this meta-analysis{Heistein 2003 299} was excluded from this scoping review, as it did not provide any description of how prehospital cooling was accomplished and it did not describe the time interval between injury/cooling and replantation.

A third systematic review{Ma 2016 157} of 22 observational human studies with 2,641 patients and 4,678 amputated digits included three studies that evaluated the method of preservation as a potential variable affecting digital survival after replantation. Meta-analysis of replanted digit survival rates suggested that cold preservation is associated with better survival rates than emergency compression bandaging (OR 4.89, 95% CI [2.14, 11.20], P = 0.0002).

Characteristics for equity according to Cochranes checklist Progress Plus{Karran 2023 70; O'Neill 2014 56} in most studies included place(country) of residence for patients, their ethnicity, sex, occupation, age and time-dependent relationships. Other characteristics for equity, such as education and socioeconomic status were commonly lacking.

Gray Literature

Because there was a known abundance of peer-reviewed literature on replantation of amputated body part and factors contributing to its success, the gray literature search focused on identification of current first aid guidelines from ILCOR member organizations and known prehospital trauma organizations that specifically mention care of completely amputated body parts.

The International First Aid, Resuscitation and Education Guidelines 2020{International Federation of Red Cross and Red Crescent Societies 2020} from the International Federation of Red Cross and Red Crescent Societies state:

• To prevent tissue damage, the amputated body part should be wrapped in a sterile compress or bandage and placed in a clean, watertight plastic bag, which is then sealed firmly.
• A second plastic bag containing water or ice can be used to preserve the body part. The first bag containing the part may be placed in the second bag containing water or ice. Do not immerse the body part directly in water or place it directly on ice as this may damage the tissue and make it more difficult or impossible to reattach it.
• The first aid provider should ensure the amputated body part is brought to a medical facility with the person.

The American Red Cross First Aid/CPR/AED guidelines{American Red Cross 2021} state:

After life-threatening bleeding is controlled, if present, try to locate any body part that is completely detached from the body because surgeons may be able to reattach it. Wrap the amputated body part in sterile gauze or other clean material. Put the wrapped body part in a plastic bag and seal the bag. Keep the bag containing the body part cool by placing it in a larger bag or container filled with a mixture of ice and water. Dο not place the bag containing the body part directly on ice or dry ice. Give the bag containing the body part to EMS personnel so that it can be taken to the hospital along with the person.

The European Resuscitation Council Guidelines 2021 for First Aid{Zideman 2021 270} do not address management of traumatic complete amputation/avulsion body parts but do address control of life-threatening bleeding.

The ANZCOR Guideline 9.1.1 – First Aid for Management of Bleeding{Australia and New Zealand Resuscitation Council 2024} does not address management of traumatic complete amputation/avulsion body parts but do address control of life-threatening bleeding.

The Indian Red Cross Society’s Indian First Aid Manual (7^th ed){Indian Red Cross Society 2016} defines amputation and addresses control of life-threatening bleeding. To preserve the amputate limb, fingers or toes they suggest to (1) place the amputated part in a clean plastic bag, (2) if possible, place the packed amputated part in a container of ice, (3) do not put ice directly on the amputated part – the amputated part should always be packed in a clean plastic bag, (4) do not put liquids or antiseptic products on the amputated part, and (5) mark the package clearly with the casualty’s name and the time the amputation occurred.{Indian Red Cross Society 2016}

St. John Ambulance’s First Aid Reference Guide{Saint John Ambulance 2019} defines amputation and addresses control of life-threatening bleeding. To preserve the amputate part they suggest to (1) put the amputated part in a clean, watertight plastic bag and seal it, (2) put this bag in a second plastic bag or container partly filled with crushed ice, and (3) attach a record of the date and time this was done and send this package with the casualty to medical help.

In summary, while some international organizations provide guidelines for management of amputated/avulsed body parts to include cold storage techniques, others do not include such advice.

3. Narrative Reporting of the Task Force Discussions

• This scoping review identified many case reports and observational studies that document various storage and preservation techniques for amputated and avulsed body parts that were applied before arrival at a hospital. Most preservation techniques involved some form of cooling of the amputated or avulsed part. The task force scoping review team notes that there were no randomized controlled studies that directly addressed this topic. However, the preponderance of evidence identified supports nonfreezing cold storage of amputated body parts as a preservation technique intended to prolong the interval between injury and successful replantation, and it would therefore likely be considered unethical to compare cold storage vs. warm storage techniques.

• Although this scoping review did not address care of the person with an amputated or avulsed body part, the first aid task force reiterates that this care, including control of life- threatening bleeding, has been addressed in past reviews and remains a priority for care of any person with such injury. Once care of the injured person has been addressed, attention should turn to locating and caring for the amputated or avulsed part.

• Older experimental studies{Hayhurst 1974 134; VanGiesen 1983 60} using animal models appear to be some of the first studies demonstrated that wrapping an amputated digit or ear in a gauze sponge moistened with saline or Ringers’ lactate and cooling the part to 4°C for 21-24 hours was associated with survival of the replanted part. Replanted parts that were stored at minus 5°C or at room temperature for 24 hours failed to survive, supporting the avoidance of freezing amputated or avulsed tissues, and the need for cooling of tissue to prolong the time that ischemic tissues can survive. Many of the studies included in this review describe “cooling”, “cold preservation” or “proper preservation” of amputated parts, but do not provide detail as to how the cooling process was achieved. In some cases, we speculate that case reports describing “proper preservation” of amputated body parts are referring to some form of nonfreezing cold preservation as described in early animal studies.

• We identified many case reports and series describing successful replantation of completely amputated or avulsed body parts that were preserved with or without cold storage, and with varying intervals between amputation, initiation of cooling and replantation. In some cases, the amputated part was lost or not immediately available for any first aid care, but once retrieved was cooled prior to or upon hospital arrival and successfully replanted. The task force notes that first aid education should stress the need to locate missing amputated or avulsed parts and to transport them to the hospital where the injured person is located.
• The scoping review team notes that the variety of successfully replanted amputated body parts in case reports was somewhat unexpected. Consequently, first aid providers may not consider amputated or avulsed ears, nasal tissue, lip, cheek, scalps and penis, to be tissues or body parts that would benefit from cold storage techniques and attempted replantation. This has implications for first aid education. The task force notes that storage of avulsed teeth is managed differently and was excluded from the search as it was considered an internal body part.

• Three retrospective observational studies evaluated storage of amputated fingertips,{Li 2008 833} fingers{Chen 2017 5445} and fingers and distal hands{Tark 1989 17} under conditions of ambient temperature vs cold temperature. Cold storage appeared to be associated with higher survival of replanted parts and to be successful after longer delays to surgery, although there was heterogeneity between studies in terms of the method and duration of cooling.

• The task force scoping review team noted that the identified cohort studies delivered more trustworthy evidence related to the effectiveness of the initial preservation of amputated and avulsed body parts. A prospective cohort study{Waikakul 1998 1024} reported a significant association between cold preservation and successful replantation of major upper extremity replantations, but failed to describe the techniques used to cool the amputated extremities. One retrospective observational study{The Hoang 2009 1167} reported survival of 10 forearm replantations that were not preserved under cold storage and with a warm ischemia time of 7-13 hours. Longer-term functional outcomes reported in this study appear to be less optimal than for case reports of extremity amputations preserved under cold conditions. A second retrospective observational study of 11 major arm amputations that underwent replantation reported survival of all replantations following storage/transportation of the part under cold conditions, with some residual motor limitations in 3 patients with elbow-level amputations and 1 patient with a crush-related hand-level amputation. The author commented that recommended ischemia time for reliable success with replantation is 12 hours of warm and 24 hours of cold ischemia for digits, and 6 hours of warm and 12 hours of cold ischemia for major replants, and the amputated part should be wrapped in a saline-moistened gauze sponge, placed in a sealed plastic bag and then placed on ice without direct contact with the ice. One retrospective cohort study{Sinatro 2022 155} of 91 patients noted that most patients, including those transported by EMS, arrived at a hospital without proper preservation of their amputated parts, defined as wrapping the part in saline-soaked gauze inside a watertight bag and placing it on ice. This latter study has important implications for first aid, prehospital provider and public health education.

• Three systematic reviews of human cohort studies{Huawei 2015 265; Ma 2016 157; Shaterian 2018 66} reported that for amputated digits, cold preservation is associated with better replantation survival compared with no cold storage. Techniques for performing cold preservation were not described in these reviews. We note that cold preservation is only one of several factors identified in these systematic reviews that were associated with successful replantation of amputated/avulsed body parts.
• The gray literature search identified guidelines from first aid organizations that describe care for amputated parts to include wrapping the part in moist gauze or clean cloth, placing it in a watertight bag or container, and then placing that contained inside another with ice or an ice-water mixture. This process avoids direct contact of any tissue with freezing temperatures, prevents desiccation of amputated tissues, and is consistent with experimental studies and observational studies demonstrating successful replantation following cold storage.

• The first aid task force agreed that the bulk of the identified evidence, while limited, supports the pre-hospital cold storage of amputated body parts, when feasible, especially when transport times may be delayed. Where details are provided for the technique of providing cold storage, most studies describe wrapping the amputated or avulsed part in a moistened gauze bandage or clean cloth, placing it in a watertight bag or container, and then placing that bag/container inside another container with ice or an ice-water mixture.
• We are aware of an experimental study not meeting inclusion criteria that compared different techniques for hypothermic preservation of chicken feet.{Partlin 2008 127} Specimens were wrapped in saline-soaked gauze, placed in a plastic bag or specimen jar, then paced in a fixed quantity of ice and water in either a plastic bag, kidney dish or sealed plastic container. Serial measurements were made of tissue temperature and the point at which ice in the solution was no longer visible. Placing the chicken foot into a specimen jar, then into a specimen bag with ice and water kept the amputated tissue within a target temperature rate (4C +/- 2 C) for their longest duration (225.8 minutes, 95% CI, 201.5-250.1. The bag in a kidney dish method performed the worst with slowest time to reach targe temperature and shortest duration at that temperature. The technique of wrapping tissue in saline moisten gauze, placing in a container and then placing that container in another sealed container with an ice/water mixture appears to conform with the technique described in most of our reviews describing successful replantation of amputated parts that were preserved hypothermically prior to hospital arrival.
  
  
• The Task Force notes that replantation surgery may not be an option in low- and middle-income countries (LMICs), although several included studies were conducted in LMICs. In addition, cold storage may not be possible, and transport times may be excessive. We discussed potential options for providing “cool” or cold, nonfreezing storage environment when ice is not available. In settings where ice is not available, Task Force members suggested wrapping the part in a moist, clean cloth or gauze and placing it inside a watertight bag, container or saran wrap, then placing the part in a cooler or other container filled with instant cold packs, freezer packs or snow. If these options are not available, cold (tap or natural source) water in many parts of the world will be cooler than body temperature and could be used to surround the amputated/avulsed part that is in a watertight container.
• It is unclear if direct immersion in water or saline solution would be harmful. Maceration of tissue may be a concern, especially with prolonged immersion. Direct immersion for short periods was described in some case reports and studies reporting successful replantation.

• Finally, there appears to be sufficient evidence to support transporting amputated body parts despite a lack of available cold storage processes, and to consider transporting any amputated body part even if the transport time will be 6 or more hours. This has important implications for first aid and prehospital care of amputated/avulsed body parts in countries or remote locations where cold storage is not feasible and transport times may be prolonged. Studies included in this scoping review demonstrate that more distal amputations such as fingertips and fingers appear to be more tolerant of warm/ambient temperature storage. In one case series from a LMIC, patients with major upper extremity amputations and warm ischemia times of up to 13 hours underwent successful replantation and revascularization but had limited functional outcomes. It was noted that some patients prefer to have a replanted extremity with limited function compared to an amputation or prosthesis (if available).

Considering the findings from the included studies the following Good Practice Statements are made:

• Replantation is time-dependent; completely amputated and avulsed external body parts such as fingers, hands, arms and legs should be retrieved and transported as soon as possible, preferably to the same healthcare facility as the injured person.
  
  
• Replantation outcomes may be improved by cooling without freezing the amputated or avulsed part as soon as possible and throughout transportation to a healthcare facility. If feasible, this can be accomplished by wrapping the part in a moist clean cloth or gauze and sealing it in a watertight bag or container prior to cooling.

Knowledge Gaps

• There were no randomized controlled studies identified that directly evaluated this question, including a comparison of different technique for the provision of cold storage, such as ice-water immersion vs dry cold storage.
• There are few studies or reports of amputation/replantation occurring in regions where ice is not available.
• There are no studies of alternatives to ice for pre-arrival cooling of amputated/avulsed tissue, such as with coolers and freezer packs, instant cold packs, cool water, battery powered coolers.
• There is a need for more and larger cohort studies; hospitals clearly have the data on this, they should publish them or make them accessible to researchers.
• Systematic collection and reporting of data on the methods of pre-hospital preservation by first aid providers and prehospital professionals specifically should be performed by both clinicians and researchers.

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