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The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review

Published online by Cambridge University Press:  27 May 2020

Eric Weinstein
Research Center in Emergency and Disaster Medicine (CRIMEDIM), Università degli Studi del Piemonte Orientale, Novara, Italy
James E. Gosney
Department of Physical Medicine and Rehabilitation, Geisinger Health System, Bloomsburg, PA
Luca Ragazzoni
Research Center in Emergency and Disaster Medicine (CRIMEDIM), Università degli Studi del Piemonte Orientale, Novara, Italy
Jeffrey Franc
Research Center in Emergency and Disaster Medicine (CRIMEDIM), Università degli Studi del Piemonte Orientale, Novara, Italy University of Alberta, Edmonton, AB
TeriLynn Herbert
Library, Medical University of South Carolina, Charleston, SC
Brielle Weinstein
PGY4 Plastic and Reconstructive Surgery, University of South Florida, Health Morsani College of Medicine, Tampa, FL
Manuela Verde
Research Center in Emergency and Disaster Medicine (CRIMEDIM), Università degli Studi del Piemonte Orientale, Novara, Italy
Johannes Zeller
Department of Anesthesiology, Bundeswehr Central Hospital, Koblenz, Germany
Nikolaj Wolfson
Department of Orthopedics, California Pacific Medical Center, Saint Francis Memorial Hospital, San Francisco, CA
Will Boyce
MS4 Geisel School of Medicine, Dartmouth College, Hanover, NH
Jordan Cramer
MS3 Medical University of South Carolina, Charleston, SC
E-mail address:



A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs).


A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis.


Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3.


This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.

Systematic Review
Copyright © 2020 Society for Disaster Medicine and Public Health, Inc.

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