dr.patibandla sowjanya dept. accident & emergency medicine vinakaya mission research foundation...

Dr .Patibandla SowjanyaDept. Accident & Emergency Medicine

Vinakaya Mission Research Foundation (D.U)Salem, Tamilnadu, India.

The Leading cause of non-obstetrical

mortality

Causes of Trauma (1)

Motor vehicle accident

Domestic abuse & assault

Falls

Penetrating injury

(1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14:331-336, 1997  

Some alterations mimic shock

supine hypotensive syndrome

Some alterations hide shock

Increased blood volume

Some alterations can aggravate

traumatic bleeding

uterus

(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984

Respiratory alkalosisReduce oxygen reserve Residual volume decreased by 40%Respiratory rate increasedImpaired buffering capacityDiaphragm elevation

Respiratory system

Decrease GI motilityDecrease peritoneal irritation

Upward position of abdominal viscera

Gastrointestinal system

Bladder is displaced upward >10 wks

Dilatation of renal pelvis and ureters

Premature ContractionsRarely progress to preterm delivery

Tocolysis is not proven in trauma.(1)

(1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: 665-671, 1990.

Different elastic properties in uterus & placenta “shearing”

3 % of minor trauma and up to 50 % in severe trauma

Rare, 0.6 % of severe abdominal

trauma (1)

Direct trauma after 12 wks of

gestation

Prior Surgery (C/S ) the risk

1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

Uterine Rupture

4 to 5 X more common in injured pregnant

women

Causes isoimmunization & fetal death

? Kleihauer-Betke test - volume of fetal blood

To determine amount of Rhogam needed

Gravid uterus alter injury pattern to the mother.

If missile enter upper abdomen; increased probability of harm

If enters below uterine fundus visceral injury less likely

(1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

Every women in the

Reproductive age group must

be tested for pregnancy

Plain x-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy

Best modality to assess both fetus and mother

Not sensitive:Colonic lesionsSub-placental hematoma Safe procedure

If < 24 weeks, intermittent fetal

doppler

If > 24 weeks, then continuous

cardiotocographic monitoring to

assess FHR and uterine activity

A 28 yrs female with 29 weeks pregnancy

brought to ER after RTA with the

suspected abdominal injury .

HR – 110, BP – 110 / 70, Spo2 –

98% on RA , RR – 28/min , GCS – 15/15

C/O – diffuse pain in chest & abdomen

A Normal ABG Report in a Pregnant

Patient Is ABNORMAL

Avoid distractions and avoid focus on the fetus. Be aggressive! But temper with common sense. An apparently stable mother may be compensating at expense of the fetus.

Pre-hospital Pre-hospital ConsiderationConsideration

Prevention of maternal hypoxia and

hypotension.

Airway patency with adequate O2.

Left lateral tilt.

Volume replacement.

AirwayAssess & control

Pre oxygenate and sellick’s maneuver

BreathingAssess and manage

CirculationAssess maternal circulation

IV accessTilt to left if > 20 wks

Unstable Mother

Stable mother

Place the patient in the left lateral position or manually and gently displace the uterus to the left.

Give 100% oxygen.

Give a fluid bolus.Immediately reevaluate.

Relieve aortocaval compression by manually

displacing the gravid uterus.

Generally perform chest compression higher on

the sternum to adjust for the shifting of pelvic

and abdominal contents toward the head.

~200 successful cases reported in the literature Maternal CPR <5 minutes, fetal survival excellent23 weeks gestation survival chance is 0% Maternal CPR >20 minutes, fetal survival unlikely

4 Minute Rule:

Maternal CPR for 4 minutes,

Infant should be delivered by

the 5th minute.

Vertical incision from xyphoid to

pubis

Continue straight down through

abdominal wall and peritoneum

Cut through uterus and placenta

Bluntly open uterus and remove fetus

Cut and clamp cord

Anatomic and physiologic changes

Vigorous fluid and blood

replacement

Treat the mother first and treat her

just like any other trauma patient

Remember

EARLY !

What is Best for the Mother is Best for the Fetus!

Remember

The priorities are same as that of

the adult.

Size & shape : smaller body mass-greater force applied per unit body areaSkeleton: more pliable – internal organ damage -without overlying bony #Equipment : appropriate size

Smaller in diameter,shorter in length Epiglottis – long, floppy,narrow Large occiput-flexion Narrowest portion –below vocal cords Larynx – Anterior & caudal Large tongue

Airway

OxygenationOral airwayIntubation

Sellick’s maneuver

Uncuffed tube

Short trachea

Respiratory rate

Volume

Hypoventilation-res.acidosis

Caution – bicarbonate

Tube thorocostomy

Recognize heamodynamic changes

Tachycardia and poor skin perfusion are

early signs of shock

Normal hemodynamics Abnormal hemodynamics

Further evaluation 10 ml/kg PC

Observe Operate Normal

Abnormal

Further evaluation

Operate Observe Operate

Packed RBC’s

Type specific / O-negative

Warmed

Slowing of the HR ( 130/mt )Return of normal skin colourIncreased warmth of extremitiesImproving GCS Increasing sys. BP (>80 mm Hg )Urinary output of 1-2 ml/Kg/hour

Peripheral venous access

Avoid femoral venous access

Intraosseous - < 6 yrs of age

Refractory to treatment

Prolongs coagulation times

Affect CNS

Overhead heat lamps or

heaters or thermal blankets

Rib # - severe injury force Compliant chest wall

Lung & Cardiac contusion

Aortic transection

Diaphragmatic rupture

Gastric distention

‘FAST’

Don‘t delay for CT

Open Fontanelle, Suture lines

Don’t allow hypotension

GCS =?

Appropriate words/ smiles = 5Cries but consolable = 4Persistently irritable = 3Restless, agitated = 2None = 1

Full Fontanel

Split sutures

Altered state of Consciousness

Paradoxical Irritability

Persistent Emesis

Setting Sun Sign

Head End Elevation

Hyperventilation

Mannitol 0.25-2 gm/Kg

Pentobarbital 1-3 mg/Kg or

Phenobarbitone

Hypothermia (27-310 C)

Flexible interspinous ligamentsAnteriorly wedged vertebraeFlat facetLarger head greater flexion extension injuriesLigamentous injuries more common

Pseudo subluxation‘SCIWORA’Take normal sideTreat when in doubt

History

Blood loss

Early splinting

Child abuse

Same priority like an adult

Unique anatomic& physiologic

changes

Early surgical intervention