ATLS Trauma in WOMAN
Introduction
Any female patient between ages of 10 and 50 years
can be pregnant.
In a pregnant patient, there are 2 patient :
Mother and fetus
The best initial treatment is optimal resuscitation of
the mother and early assessment of the fetus.
A qualified surgeon and an obstetrician should be
consulted early in the evaluation of pregnant trauma patient.
Anatomic alteration of pregnancy
Fundal height
Anatomic alteration of pregnancy
Blunt trauma
The uterus and its
contents(fetus and placenta) are more vulnerable for trauma than bowel
Penetrating trauma
Penetrating trauma to upper
abdomen result in complex intestinal injury
Anatomic alteration of pregnancy
Increased plasma volume : decreased Hct
(31-35% in late pregnancy)
Anatomic alteration of pregnancy
Increased WBC (up to 15,000-25,000) Mildly elevated serum fibrinogen and other clotting factors Shorted PT & aPTT Unchanged bleeding time Decreased serum albumin
Anatomic alteration of pregnancy
Cardiac output : increase plasma volume and decrease PVR of the uterus and
placenta
HR : Consider when interpreting tachycardia response to hypovolemia BP during second trimester Supine hypotension syndrome : compression of IVC Variable CVP, response to volume is the same as in the nonpregnant state
Anatomic alteration of pregnancy
Axis may shift leftward ~ 15o Flattened or invert T wave in leads III & aVF &
precordial leads may be normal
Increase ectopic beats
Anatomic alteration of pregnancy
Progesterone : hypocapnia is common in late
pregnancy
PaCO2 35-40 mmHg may indicate impending respiratory failure
Diaphragm elevate : reduce residual volume Increase inspiratory capacity FVC slightly change Increase O2 consumption
Anatomic alteration of pregnancy
Prolong gastric emptying time RBF GFR BUN & Cr Glycosuria Physiologic renal calices & renal pelvis & ureter
dilatation (Rt>LT)
Anatomic alteration of pregnancy
Pituitary gland increases in size and weight
by 30% to 50% : pituitary insufficiency
Anatomic alteration of pregnancy
Pubic symphysis widening 4-8 mm SI-joint space
Anatomic alteration of pregnancy
Eclampsia : mimic head injury
Seizure occur with associated
hypertension, hyperreflexia, proteinuria, and peripheral edema
Mechanism of Injury
abdominal wall, uterine myometrium,
amniotic fluid buffer
Blunt Injury
Enlarged and engorged pelvic vessels
in gravid uterus massive retroperitoneal hemorrhage after blunt trauma
Incidence
Motor vehicle accidents/pedestrians
59.6% Falls Direct assaults Other 22.3% 16.7% 0.1%
Mechanism of Injury
Collisions
Unrestrained pregnant women
higher risk of premature delivery and fetal
death
Blunt Injury
Restrain
Lap belt alone
forward flexion and uterine compression Uterine rupture or abruptio placentae
Lap belt + shoulder restraints
greater surface area for dissipating the
deceleration force
Prevent forward flexion over the gravid uterus
Mechanism of Injury
Blunt Injury
Mechanism of Injury
enetrating Injury
Enlarged gravid uterus
other viscera injury uterine injury
Severity of Injury
Determine
Maternal and fetal outcome Treatment method
Major injury typically associated with fetal injury admit to facility with trauma + obstetric
capability Minor trauma
Severity of Injury
Determine
Maternal and fetal outcome Treatment method
Major injury Minor trauma occasionally associated with abruptio
placentae and fetal loss closely observed
Assessment and treatment
1. Primary survey & resuscitation of mother 2. Primary survey & resuscitation of fetus 3. Adjunct to primary survey for the mother 4. Adjunct to primary survey for the fetus 5. Secondary survey of mother 6. Definitive care
Assessment and treatment
Primary survey & resuscitation of mother
ABCDE assessment Manually place uterus to the left side
pressure on IVC VR CO
Assessment and treatment
Primary survey & resuscitation of mother
Proper immobilization in pregnant patient Log roll 4-6 inches or 15 to the left
Assessment and treatment
Primary survey & resuscitation of mother
Fluid resuscitation
Physiologic hypervolemia
Significant blood loss before
hypovolemic signs occur Fetal and placenta deprived of blood while maternal condition and V/S stable Crystalloid and early type-specific blood are indicated
Do not use vasopressors
Vasopressors reduce uterine blood flow
fetal hypoxia
Assessment and treatment
Primary survey and resuscitation of the FETUS
Fetal death
Most common : Maternal shock & death Second most common : Abruptio
placentae Abruptio placentae Vaginal bleeding (70%) Uterine tenderness Frequent uterine contractions Uterine tetany Uterine iritability
Investigation : U/S
Assessment and treatment
Primary survey and resuscitation of the FETUS
Fetal death
Rare cause : Uterine rupture
Uterine rupture Abdominal tenderness, guarding, rigidity, or rebound tenderness Profound shock Abnormal fetal lie; transverse or oblique Easy palpation of fetal part Inability to readily palpate the uterine fundus Investigation : X-ray extended fetal extremities, abnormal fetal position, and free
Assessment and treatment
Primary survey & resuscitation of the FETUS
Risk factor for fetal loss Maternal HR > 110/min Injury severity score > 9 Evidence of placental
abruption Fetal HR > 160 or < 120 Ejection during a motor vehicle accident Motorcycle or pedestrian collisions
Assessment and treatment
Adjunct to primary survey and resuscitation for the MOTHER
CVP monitoring
uesful in maintaining the relative
hypervolemia required in pregnancy
Pulse oximetry ABG
HCO3 is normally low in pregnant
patient
Assessment and treatment
Adjunct to primary survey and resuscitation for the MOTHER
Consult OB
Fetal distress can occur any time
Fetal heart rate : 120-160/min
Mater blood volume status and fetal well-being
Fetal heart tone
Intermittent doppler u/s after GA 10 wk
Cardiac tocodynamometer
Useful after GA 20-24 wk
Radiographic study should be perform as
necessary benefit > risk
Assessment and treatment
Adjunct to primary survey and resuscitation for the MOTHER
Assessment and treatment
Secondary assessment
Hx & PE and I/C for CT scan, FAST, DPL
same as non-pregnant patient
DPL
Catheter should be placed above the umbilicus with open technique
Assessment and treatment
Secondary assessment
Pay attention to uterine contractions regular contractions suggesting early
labor tetanic contraction suggesting abruptio placentae
Perform pelvic examination by OB doctor decision for emergency cesarean
section
Admission to hospital Vaginal bleeding Uterine irritability Abdominal tenderness, pain, or
cramping Evidence f hypovolemia Change or absence of fetal heart tones
Assessment and treatment
Definitive care
OB consultation Extensive placental separation or amniotic
fluid embolization Widespread intravascular clotting DIC
fibrinogen (<250 mg/dl), other clotting
factors and platelets
Mg : Urgent uterine evacuation and replacement of clotting & platelets as necessary
Assessment and treatment
Definitive care
Fetomaternal hemorrhage
Fetal anemia and death Isoimmunization in Rh-negative mother Mg : Rh immunoglobuin therapy within 72 hr of injury in all pregnant Rh negative trauma patient unless the injury is remote from uterus
The Battered, Abused Child
A discrepancy exists between the history and the
degree of physical injury
A prolonged interval has passed between the
time of injury and presentation for medical care same or different EDs.
The history includes repeated trauma, treated in
The Battered, Abused Child
The history of injury changes or different
between parents or guardians.
Shopping of hospitals or doctors Parents respond inappropriately to or do not
comply the medical advice
The Battered, Abused Child
Multicolored (multi-stage ) bruises Evidence of frequent previous injuries, typified by old
scars or healed fractures on x-ray examination
Perioral injury Injury to the genital or perianal area Fracture of long bones in children younger than 3
years of age
The Battered, Abused Child
Ruptured internal viscera without antecedent major blunt trauma Multiple subdural hematoma, especially without a fresh skull fracture Retinal hemorrhages Bizarre injuries : bite, cigarette burns, rope marks Sharply demarcated second-third degree burn in unusual area
