Lloyd et al developed a protocol for the preoperative management of an amputated limb. This is intended to optimize the chances for limb reattachment with minimum complications. The authors are from the Royal Free Hospital in London.



(1) Resuscitate the patient first and treat life-threatening injuries.

(2) Culture the amputation site.

(3) Administer intravenous antibiotics.

(4) Type and crossmatch for 4 or more units of blood depending on injury severity.

(5) Prepare the patient for rapid transport to the trauma center.


While the patient is being stabilized the limb should be immediately:

(1) placed gently on a sterile towel

(2) photographed (this allows the plastic surgeon to plan the reattachment while keeping the limb immersed).

(3) X-rayed

(4) wrapped in sterile gauze moistened with sterile normal saline

(5) placed in a clean plastic bag large enough for the limb

(6) place the bottom of the plastic bag into a slurry of crushed ice and water in an insulated transport chest. Do not place on ice alone since this can freeze the tissue. Do not immerse the limb directly into the water since this can introduce bacteria.

(7) Collect any loose fragments of tissue and place in sterile containers between sterile gauze moistened with sterile normal saline.


Once time allows, the most proximal artery should be found and cannulated with a flexible catheter. The catheter is anchored with a silk suture. An organ transplant transport fluid (like the University of Wisconsin cold storage solution) at 10°C and 120 cm hydrostatic pressure is infused into the cooled limb. The fluid runs slowly and continuously to washout any stagnant blood.


Data to collect and transmit to the trauma center:

(1) age of the patient

(2) limb affected and handedness

(3) time of injury

(4) ischemia time

(5) mechanism of injury (crush or guillotine)

(6) smoking

(7) diabetes mellitus

(8) other significant traumatic injuries

(9) medications

(10) other comorbid conditions

(11) tetanus status


Mnemonic to help remember the steps: "AMPUTATE:

A TLS (resuscitate the patient)

M echanism of injury

P hotography

U nderlying injury

T emperature control

A dvice

T issue perfusion fluid

E xport (expedite) to a plastic surgeon for replantation


To read more or access our algorithms and calculators, please log in or register.