Trauma in Pregnancy & Paediatric Trauma
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Dr .Patibandla SowjanyaDept. Accident & Emergency Medicine
Vinakaya Mission Research Foundation (D.U)Salem, Tamilnadu, India.
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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
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Some alterations mimic shock
supine hypotensive syndrome
Some alterations hide shock
Increased blood volume
Some alterations can aggravate
traumatic bleeding
uterus
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(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984
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Respiratory alkalosisReduce oxygen reserve Residual volume decreased by 40%Respiratory rate increasedImpaired buffering capacityDiaphragm elevation
Respiratory system
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Decrease GI motilityDecrease peritoneal irritation
Upward position of abdominal viscera
Gastrointestinal system
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Bladder is displaced upward >10 wks
Dilatation of renal pelvis and ureters
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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.
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Different elastic properties in uterus & placenta “shearing”
3 % of minor trauma and up to 50 % in severe trauma
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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
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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
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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.
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Every women in the
Reproductive age group must
be tested for pregnancy
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Plain x-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy
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Best modality to assess both fetus and mother
Not sensitive:Colonic lesionsSub-placental hematoma Safe procedure
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If < 24 weeks, intermittent fetal
doppler
If > 24 weeks, then continuous
cardiotocographic monitoring to
assess FHR and uterine activity
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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
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A Normal ABG Report in a Pregnant
Patient Is ABNORMAL
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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.
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Pre-hospital Pre-hospital ConsiderationConsideration
Prevention of maternal hypoxia and
hypotension.
Airway patency with adequate O2.
Left lateral tilt.
Volume replacement.
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AirwayAssess & control
Pre oxygenate and sellick’s maneuver
BreathingAssess and manage
CirculationAssess maternal circulation
IV accessTilt to left if > 20 wks
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Unstable Mother
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Stable mother
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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.
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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.
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~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
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4 Minute Rule:
Maternal CPR for 4 minutes,
Infant should be delivered by
the 5th minute.
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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
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Anatomic and physiologic changes
Vigorous fluid and blood
replacement
Treat the mother first and treat her
just like any other trauma patient
Remember
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EARLY !
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What is Best for the Mother is Best for the Fetus!
Remember
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The priorities are same as that of
the adult.
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Size & shape : smaller body mass-greater force applied per unit body areaSkeleton: more pliable – internal organ damage -without overlying bony #Equipment : appropriate size
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Smaller in diameter,shorter in length Epiglottis – long, floppy,narrow Large occiput-flexion Narrowest portion –below vocal cords Larynx – Anterior & caudal Large tongue
Airway
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OxygenationOral airwayIntubation
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Sellick’s maneuver
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Uncuffed tube
Short trachea
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Respiratory rate
Volume
Hypoventilation-res.acidosis
Caution – bicarbonate
Tube thorocostomy
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Recognize heamodynamic changes
Tachycardia and poor skin perfusion are
early signs of shock
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Normal hemodynamics Abnormal hemodynamics
Further evaluation 10 ml/kg PC
Observe Operate Normal
Abnormal
Further evaluation
Operate Observe Operate
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Packed RBC’s
Type specific / O-negative
Warmed
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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
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Peripheral venous access
Avoid femoral venous access
Intraosseous - < 6 yrs of age
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Refractory to treatment
Prolongs coagulation times
Affect CNS
Overhead heat lamps or
heaters or thermal blankets
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Rib # - severe injury force Compliant chest wall
Lung & Cardiac contusion
Aortic transection
Diaphragmatic rupture
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Gastric distention
‘FAST’
Don‘t delay for CT
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Open Fontanelle, Suture lines
Don’t allow hypotension
GCS =?
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Appropriate words/ smiles = 5Cries but consolable = 4Persistently irritable = 3Restless, agitated = 2None = 1
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Full Fontanel
Split sutures
Altered state of Consciousness
Paradoxical Irritability
Persistent Emesis
Setting Sun Sign
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Head End Elevation
Hyperventilation
Mannitol 0.25-2 gm/Kg
Pentobarbital 1-3 mg/Kg or
Phenobarbitone
Hypothermia (27-310 C)
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Flexible interspinous ligamentsAnteriorly wedged vertebraeFlat facetLarger head greater flexion extension injuriesLigamentous injuries more common
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Pseudo subluxation‘SCIWORA’Take normal sideTreat when in doubt
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History
Blood loss
Early splinting
Child abuse
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Same priority like an adult
Unique anatomic& physiologic
changes
Early surgical intervention
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