1. Perform surgical preparation of the entire limb, including the extent of the full zone of injury and the need for proximal vascular control.
Tourniquet control is mandatory. If a tourniquet was placed in the prehospital setting for hemorrhage control, it is prepped entirely within the surgical field.
2. Cut off nonviable tissue.
- Necrotic skin and subcutaneous tissue or skin without vascular support.
- Muscle that is shredded, contaminated, or non-contractile. (This muscle is usually at the level of the retracted skin.)
- Bone that is contaminated or missing soft-tissue attachment for blood supply.  Cut across bone at its lowest viable level, regardless of the residual soft-tissue coverage.
3. Identify and securely ligate major arteries and veins to prevent hemorrhage in transport.
4. Identify nerves and cut across them at the level of available muscular coverage to minimize patient pain due to dressing changes. 

5. Ligate the major nerves if they are bleeding (eg, sciatic)
Preserved muscle flaps should not be sutured, but should be held in their intended position by the dressing.Flaps should not be constructed at the initial surgery to facilitate closure.
 

In blast injuries, particularly landmine injuries, the blast forces drive debris proximally along fascial planes. It may be necessary to extend incisions proximally parallel to the axis of the extremity to ensure adequate surgical debridement of the wound. Each successive debridement should explore all intermuscular and fascial planes to avoid missing areas of pus, without devascularizing the remaining skin flaps.

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Dressings: 

Because amputations must be left open, skin retraction most likely to occur. This may cause the loss of usable limb length and making definitive closure difficult. This is especially true if a patient is in the evacuation chain for a prolonged period.
Negative pressure wound therapy (NPWT) dressings may be placed prior to evacuation only if reliable maintenance of suction can be expected during transport and on arrival at the next level of care. If an NPWT wound dressing is used, skin traction and counter-traction can be achieved using a running vessel loop in a laced fashion, secured to the skin edges over the reticulated foam and held in place with staples. Monitor output on NPWT device for excess output that could indicate ongoing bleeding.
After initial completion of amputation a temporary dressing can be fashioned by applying gauze sponges to the end of the stump and loosely approximating the flaps over the gauze. This aids with hemostasis and prevents skin retraction and folding of loose flaps and compromising their blood supply. This is intended as a short-term dressing to facilitate transport.

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