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