What is the appropriate course of action for a 19-year-old male, involved in a road traffic accident (RTA), presenting with unconsciousness, trauma to one thigh with profuse continuous bleeding, and absent distal pulse, for whom amputation is planned, but whose father, the legal guardian, is not present to provide consent?

From the Guidelines

The correct answer is B. Amputate without consent as it is a life-saving procedure. In this emergency situation involving a 19-year-old male who is unconscious with profuse continuous bleeding from a traumatic thigh injury and absent distal pulse, immediate surgical intervention is necessary to prevent death from exsanguination. While obtaining informed consent is typically required for surgical procedures, emergency exceptions exist when a patient cannot provide consent, delay would result in death or serious harm, and no surrogate decision-maker is immediately available. The profuse bleeding and absent distal pulse indicate potential vascular compromise that could lead to rapid death if not addressed. Although the father is en route and relatives are present, waiting for the father's arrival could result in fatal blood loss, and selecting a relative without clear legal authority could delay critical care. The principle of implied consent applies in this scenario, as it is reasonable to assume the patient would consent to life-saving treatment if able to do so. After the emergency is addressed, full documentation of the circumstances and decision-making process should be completed, and the family should be informed about the procedure and rationale as soon as possible, as suggested by 1. Additionally, guidelines for the acute care of severe limb trauma patients, as outlined in 1, emphasize the importance of prompt intervention in cases of severe bleeding and hemodynamic instability, further supporting the decision to amputate without consent in this life-threatening situation. Moreover, the management of bleeding following major trauma, as updated in 1, recommends immediate bleeding control procedures for patients presenting with hemorrhagic shock and an identified source of bleeding, which aligns with the necessity of amputation in this scenario. Key considerations include:

• The patient's unstable clinical status, characterized by severe circulatory shock and potential coagulopathy, as described in 1
• The need for immediate action to prevent death from exsanguination, as emphasized in 1
• The application of implied consent in emergency situations where delay would result in serious harm or death, as discussed in 1

From the Research

Assessment of the Situation

• The patient is a 19-year-old male involved in a road traffic accident (RTA) with trauma to one thigh and profuse continuous bleeding.
• The patient is unconscious, and distal pulse is not palpable, indicating potential severe vascular injury.
• Amputation is being considered due to the severity of the injury.

Consideration of Consent

• The patient's father is on his way to the hospital, but there are many relatives present.
• The decision to amputate without consent is a critical one, as it is a life-saving procedure 2, 3.
• However, it is essential to consider the ethical and legal implications of performing such a procedure without proper consent.

Evaluation of Options

• Option A: Waiting for the father to arrive may delay the procedure and potentially put the patient's life at risk.
• Option B: Amputating without consent may be necessary to save the patient's life, but it is crucial to ensure that all other options have been exhausted.
• Option C: Choosing the most senior relative to provide consent may be a viable option, but it is essential to ensure that they are fully informed and capable of making such a decision.

Medical Evidence

• Studies have shown that prompt treatment of severe posttraumatic bleeding is critical to prevent mortality and limb loss 2, 3, 4.
• The presence of multiple arterial injuries, fractures, and soft tissue disruption can increase the risk of limb loss 3, 4.
• The use of scoring systems, such as the mangled extremity severity score (MESS), limb salvage index (LSI), and predictive salvage index (PSI), can help assess the prognosis and guide treatment decisions 4.