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The Pregnant Trauma PatientRebecca A. Bavolek, MD FACEP

Barnes Jewish HospitalWashington University in St. Louis School of Medicine

Objectives

1. Review physiologic and anatomic changes in pregnancy and how that alters stabilization and management of the pregnant patient

2. Discuss the primary and secondary survey with respect to evaluating the pregnant patient

3. Discuss adjuncts to the trauma resuscitation such as radiologic imaging

4. Described when and how to perform a peri-mortem c-section

Caesarian_section_-_Pull_out.jpg

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ERTraumaRoomGhostsPict_lg04.jpg

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6a00d83483b8fc53ef013488a2189e970c-800wi

About those A’s and B’s

http://crashingpatient.com/resuscitation/airway/airway.htm/

About those A’s and B’sTiny,

Squished Stomach

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About those A’s and B’s

About those A’s and B’s

http://en.wikipedia.org/wiki/Reinke's_edema

Moving on to C...

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Hypotension in Pregnancy

Is it normal, or is it shock?

HR by5-15 bpm

MAP by10-15 mmHg

Blood volby 1L

Hgb by1-3 mg/dL

Patient Positioning

Does Pelvic Position Matter?

Where is the Max IVC diameter?

Supine 24%LLT 48% RLT 28%

No correlation to patient age, BMI, EGA

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Primary Survey

• No different than for the non pregnant patient

• Keep in mind positioning as discussed

Adjuncts

• Use chest and pelvis radiographs as needed for major trauma

• Ultrasound - use early and often

• FAST has the same sensitivity and specificity as the non pregnant patient

• Depending on the stability of the patient, use ultrasound to quickly assess fetal well being and gestational age

Secondary Survey

• Same as for the non pregnant patient

• Again, assess fetal well being. Consider external fetal monitoring.

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Radiologic Imaging

• Plain radiographs should be used as needed for traumatic workup

• CT can and must be used in the severely injured pregnant trauma patient that is stable enough to go to the scanner

• Don’t forget ultrasound!

Traumatic Injury

https://drhem.wordpress.com/tag/fast-exam/

Perimortem C-section

“There are few data to support perimortem cesarean section in pregnant trauma patients who experience hypovolemic cardiac arrest… At the time of maternal hypovolemic cardiac arrest, the fetus already has suffered prolonged hypoxia. For other causes of maternal cardiac arrest, perimortem cesarean section occasionally may be successful if performed within 4 to 5 minutes of the arrest.”

“Based on isolated case reports, cesarean delivery should be considered for both maternal and fetal benefit 4 minutes after a woman has experience cardiopulmonary arrest in the third trimester.”

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Indications for Perimortem C-Section

Indications for Perimortem C-Section

Maternal Considerations Fetal Considerations

• No pulse by 4 min with CPR

• Potential reversible cause of arrest

• Deliver fetus of 20 weeks to assist with hemodynamics

• No pulse by 4 min with CPR

• Do not delay if there is nonreversible cause of arrest

• Deliver fetus of 24 weeks to improve survival

Contraindications

• ROSC within 5 minutes of cardiac arrest

• Potentially reversible maternal cardiac arrest with fetal age < 20 weeks

• Nonreversible cause of maternal arrest with fetus below age of viability

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Are Medical and Trauma Resuscitations the Same?

Morris ja, et al. “Infant Survival After Cesarean Section for Trauma.” Annals of Surgery May 1996

114,952 441

Are Medical and Trauma Resuscitations the Same?

Morris ja, et al. “Infant Survival After Cesarean Section for Trauma.” Annals of Surgery May 1996

441 32 3

Infants who meet criteriaand are delivered by

Perimortem C-Section areExtremely rare.

In appropriate patients,the procedure should be Carried out without delay.

The Key Question - How Old is the Fetus?

• Measurement of Fundal Height. How good is it?

• EP measured Fundal Height

• r = 0.808 (0.733-0.833) to OB measurements

• r = 0.712 (0.615-0.809) to True Gestational age

• Determination of >24 weeks was 88.5% sensitive, 63.6% specific

• Overestimated GA by avg 8.07 daysFrom “Military Obstetrics and Gynecology”

The Brookside Assoc Medical Education Divisionc. 2009

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What about Ultrasound?

51 secr = 0.995 (0.937-0.973)

Underestimated GA by 0.32 d

59 secr = 0.973 (0.962-0.984)

Underestimated GA by 2.096 d

Cardiac Arrest in Gravid Female

Cardiac Arrest in Gravid Female

Optimal PositioningET Intubation

IV Access (Upper Torso)ACLS

Prepare for Perimortem C-Section

Optimal PositioningET Intubation

IV Access (Upper Torso)ACLS

Prepare for Perimortem C-Section

GA > 20 wks?GA > 20 wks? YesYesNoNo

Continue Maternal Resuscitation

Continue Maternal Resuscitation

Continue Maternal Resuscitation

Continue Maternal Resuscitation

Fetal Resuscitation

Fetal Resuscitation

Obstetrics NICU

Adult ICUInfant Warmer

Instruments

Obstetrics NICU

Adult ICUInfant Warmer

Instruments

Perform C-SectionPerform C-Section

0 Min

4 Min

The Perimortem C-Section

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What to do afterwards?

http://www.harmonieii.co.uk/east.html http://www.nytimes.com/2012/09/05/health/research/doctors-may-be-ending-cpr-efforts-too-soon-study-says.html?_r=0

Success, Now What?

Post Procedural Considerations

• Bleeding• Infection• Post-resuscitative Care

Thank You!

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