What's the most appropriate action for a patient who has severed their thumb after controlling bleeding?

Management of Severed Thumb After Bleeding Control

The patient should be immediately transported to a specialized trauma center with microsurgical capabilities while preserving the amputated part in proper conditions, as replantation is the primary and optimal treatment for thumb amputation that offers the best functional outcomes. 1

Immediate On-Scene Actions

Wound and Stump Management

• Apply a pressure dressing to the stump if bleeding has been controlled but reassess continuously for any recurrence 1
• Maintain the tourniquet if one was applied for initial hemorrhage control, but this should be re-evaluated as soon as possible to minimize ischemic time 1
• Administer high-flow oxygen to optimize tissue perfusion 1

Amputated Part Preservation

• Wrap the severed thumb in saline-moistened gauze, place it in a sealed plastic bag, and then place that bag in ice water (not directly on ice to avoid freezing injury) 2
• Never place the amputated part directly on ice or in any solution as this causes tissue damage that compromises replantation success 2

Transport and Triage Priorities

Immediate Transfer Criteria

This patient meets criteria for immediate admission to a specialized trauma center because proximal amputation above the wrist is specifically identified as a severity criterion requiring specialized care 1

• Thumb amputations are absolute indications for replantation attempts at any level, unlike other single digit amputations 2
• Transport should not be delayed for imaging or other investigations in the field 1

En Route Management

• Establish large-bore IV access (ideally 8-Fr central access in adults) during transport 1
• Obtain baseline laboratory studies including complete blood count, coagulation parameters (PT, aPTT, fibrinogen), and cross-match 1
• Begin active warming measures to prevent hypothermia, which impairs coagulation and surgical outcomes 1

Hospital-Level Immediate Actions

Surgical Team Activation

• Alert the microsurgical team immediately upon patient arrival as replantation is time-sensitive, with optimal outcomes when performed within 6-12 hours for digits 2
• Prepare the operating room for microsurgical replantation, which is the gold standard treatment for thumb amputation 3, 4, 5

Clinical Assessment

• Assess the patient's hemodynamic stability by checking for consciousness, ability to speak, and presence of peripheral pulses—if present, blood pressure is adequate 1
• Evaluate for associated injuries that might require damage control surgery before replantation 1
• Document the mechanism of injury, level of amputation, and degree of tissue crushing or contamination, as these factors affect replantation success 2

Critical Decision Points

Replantation Viability Assessment

Replantation should be attempted for virtually all thumb amputations unless contraindicated by:

• Severe crushing or mangling injuries with extensive tissue destruction 2
• Prolonged warm ischemia time (>12 hours for digits) 2
• Patient hemodynamic instability requiring life-saving interventions 1
• Severe medical comorbidities precluding prolonged anesthesia 2

If Replantation is Not Feasible

Secondary reconstruction options should be discussed early (within days to weeks, not months) to optimize psychological adaptation and functional outcomes 6, 4:

• Microsurgical toe transfer (second toe or wrap-around great toe flap) is the preferred option for non-replantable cases, used in 85.7% of reconstructions with only 3.6% failure rate 6, 5
• The level of amputation determines the reconstructive approach: distal third injuries may only require soft tissue coverage, while more proximal amputations require length restoration 3, 4

Common Pitfalls to Avoid

• Do not delay transport for field imaging or prolonged stabilization unless the patient is hemodynamically unstable 1
• Do not repeatedly release and reapply tourniquets as this aggravates local muscle injury and systemic rhabdomyolysis 1
• Do not allow the patient to "mourn" the lost thumb for weeks before planning reconstruction, as delayed intervention compromises body image incorporation and functional outcomes 6
• Do not freeze the amputated part or place it in any solution other than saline-moistened gauze 2
• Do not assume the patient is stable based solely on initial blood pressure, as patients can compensate well despite significant blood loss 1