Trauma In Women

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Trauma in Women

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Trauma In Women

  1. 1. Chapter 11 Trauma in Women <ul><li>A: Anatomic </li></ul><ul><ul><li>12 weeks - rise out of pelvis </li></ul></ul><ul><ul><li>20 weeks - at umbilicus </li></ul></ul><ul><ul><li>34-36 weeks - at the costal margin </li></ul></ul><ul><ul><li>2nd trimester - amniotic fluid embolism </li></ul></ul><ul><ul><li>3rd trimester - abruptio placentae </li></ul></ul>
  2. 2. <ul><ul><li>B. Blood Volume and Composition </li></ul></ul><ul><ul><li>1.Volume: 1200-1500 ml -signs of hypovolemia </li></ul></ul><ul><ul><li>2. Increased in WBC, fibrinogen , clotting factors </li></ul></ul><ul><ul><li>3. Decreased in Hb, PT, aPTT, albumin </li></ul></ul><ul><ul><li>4. Blood pressure falls 5-15 mmHg </li></ul></ul><ul><ul><li>in 2nd trimester </li></ul></ul><ul><ul><li>5. CVP is variable </li></ul></ul><ul><ul><li>6. ECG: flattened or inverted T waves </li></ul></ul><ul><ul><li>in leads II, III, AVF </li></ul></ul>
  3. 3. <ul><ul><li>C. respiratory </li></ul></ul><ul><ul><li>Increased in tidal volume </li></ul></ul><ul><ul><li>Decreased in residual volume </li></ul></ul><ul><ul><li>Hypocapnea ( Pco2 of 30 mmHG) </li></ul></ul><ul><ul><li>in late pregnancy </li></ul></ul><ul><ul><li>D. Musculoskeletal </li></ul></ul><ul><ul><li>7th months: the symphysis pubis widens (4-8mm) </li></ul></ul><ul><ul><li>The sacroiliac-joint space increased </li></ul></ul>
  4. 4. <ul><ul><li>Mechanism of Injury </li></ul></ul><ul><ul><li>A. Blunt Injury </li></ul></ul><ul><ul><li>1. Direct Injury </li></ul></ul><ul><ul><li>2. Indirect Injury </li></ul></ul><ul><ul><li>Abrutio Placentae & Uterine Rupture </li></ul></ul><ul><ul><li>Seat belt: forward flexion and uterine compression </li></ul></ul><ul><ul><li>B. Penetrating Injury </li></ul></ul><ul><ul><li>Dense uterine musculature & Amnion </li></ul></ul><ul><ul><li>Low incidence of maternal visceral injury </li></ul></ul>
  5. 5. <ul><li>Assessment and Management </li></ul><ul><ul><li>A: Primary Survey and Resuscitation </li></ul></ul><ul><ul><li>1. Maternal: Hyperventilation </li></ul></ul><ul><ul><li>4 - 6 inches elevation of right buttock </li></ul></ul><ul><ul><li>Fetus may be in shock before </li></ul></ul><ul><ul><li>maternal hypovolemia shock signs </li></ul></ul><ul><ul><li>Vasopressors - fetal hypoxia </li></ul></ul><ul><ul><li>B: Fetus: Uterine rupture </li></ul></ul><ul><ul><li>Abruptio placentae </li></ul></ul><ul><ul><li>Continued fetal heart tones </li></ul></ul><ul><ul><li>20 -24 wks of gestation </li></ul></ul>
  6. 6. <ul><li>B. Adjuncts to primary survey </li></ul><ul><ul><li>Maternal: </li></ul></ul><ul><ul><li>Monitor on her left side after physical examination </li></ul></ul><ul><ul><li>Monitor of the CVP response to fluid </li></ul></ul><ul><ul><li>Maternal bicarbonate is usually low </li></ul></ul><ul><ul><li>Fetus: </li></ul></ul><ul><ul><li>20-24 wks heart tones: 120- 160 beats / min </li></ul></ul><ul><ul><li>Continous monitor with cardiotocodynamometry </li></ul></ul><ul><ul><li>Consultation if abnormal fetal heart rates </li></ul></ul>
  7. 7. <ul><li>C. Secondary Assessment </li></ul><ul><ul><li>1. DPL: perform above the umbilicus </li></ul></ul><ul><ul><li>Presence of uterine contractions </li></ul></ul><ul><ul><li>2.Vaginal Examination : </li></ul></ul><ul><ul><li>Amniotic fluid with PH of 7 - 7.5 : </li></ul></ul><ul><ul><li>ruptured of chorioamniotic membrane </li></ul></ul><ul><ul><li>Bleeding in 3rd trimester: </li></ul></ul><ul><ul><li>disruption of placenta </li></ul></ul><ul><ul><li>impending fetal death </li></ul></ul><ul><ul><li>The fetus may be in jeopardy even with apparent, minor maternal injury </li></ul></ul>
  8. 8. <ul><li>D. Definite Care </li></ul><ul><ul><li>Uterine rupture: shock or no s/s </li></ul></ul><ul><ul><li>Placental abruptio: leading cause of fetal death </li></ul></ul><ul><ul><li>30% no vaginal bleeding </li></ul></ul><ul><ul><li>All pregnant Rh-negative trauma patient should considered for RH immunoglobulin therapy . </li></ul></ul><ul><ul><li>Initial management is directed at resuscitation and stabilization of the pregnant patient. </li></ul></ul><ul><ul><li>Perimortem c/s may be successful if it is done within 4-5 mins arrest. </li></ul></ul>
  9. 9. <ul><li>Radiography in Pregnant Women </li></ul><ul><ul><li>No fetus risk: 5 - 10 rad. </li></ul></ul><ul><ul><li>The maximum risk attributable to 10 rad of exposure is approx. 0.1 % </li></ul></ul><ul><ul><li>After 20th weeks of gestation: cause no fetal abnormalities. </li></ul></ul><ul><ul><li>Routine C-spine, CXR, Pelvis obtained with shielding: negligible fetal exposure </li></ul></ul><ul><ul><li>CT beam in direct line to fetus: 3 - 9 rad. </li></ul></ul><ul><ul><li>CT scan above uterus: < 3 rad to fetus. </li></ul></ul>
  10. 10. <ul><li>Radiography to fetus varies: </li></ul><ul><ul><li>1. The type of study </li></ul></ul><ul><ul><li>2. The size of patient </li></ul></ul><ul><ul><li>3. Position of the fetus </li></ul></ul><ul><ul><li>4. Type of machine </li></ul></ul><ul><ul><li>5. Method of shielding </li></ul></ul><ul><ul><li>6. The number of section obtained </li></ul></ul><ul><ul><li>7. Fetal/uterine size </li></ul></ul><ul><ul><li>8. Coned x-ray beam aimed > 10 cm away from </li></ul></ul><ul><ul><li>fetus are not dangerous. </li></ul></ul>
  11. 11. Estimated Radiation Dose to the Pelvic Uterus/ Radiography <ul><ul><ul><li>Type of examination Dose (mrad) </li></ul></ul></ul><ul><ul><ul><li>Low dose group </li></ul></ul></ul><ul><ul><ul><li>Head < 1 </li></ul></ul></ul><ul><ul><ul><li>C- spine < 1 </li></ul></ul></ul><ul><ul><ul><li>T-Spine < 1 </li></ul></ul></ul><ul><ul><ul><li>CXR < 1 </li></ul></ul></ul><ul><ul><ul><li>Extremities < 1 </li></ul></ul></ul><ul><ul><ul><li>High Dose Group </li></ul></ul></ul><ul><ul><ul><li>L-spine 204 - 1260 </li></ul></ul></ul><ul><ul><ul><li>Pelvis 190 - 357 </li></ul></ul></ul><ul><ul><ul><li>Hip and Femoral ( proximal) 124 - 450 </li></ul></ul></ul><ul><ul><ul><li>IVP 503 - 880 </li></ul></ul></ul><ul><ul><ul><li>Urethrocystography 1500 </li></ul></ul></ul><ul><ul><ul><li>Abdomen ( KUB) 200 - 503 </li></ul></ul></ul>
  12. 12. Upper-Limit Fetal Dose From Angiography and CT Scan Studies <ul><li>Type of examination Dose (mrad) </li></ul><ul><li>Angiography </li></ul><ul><li>Cerebral < 100 </li></ul><ul><li>Cardiac Cath < 500 </li></ul><ul><li>Aortography < 100 </li></ul><ul><li>CT scanning </li></ul><ul><li>Head ( 1 cm slices) < 50 </li></ul><ul><li>Chest ( 1 cm slices) < 1000 </li></ul><ul><li>Upper abdomen( 20 1-cm slices < 3000 </li></ul><ul><li>> 2.5 cm from uterus) </li></ul><ul><li>Lower Abdomen ( 10 1-cm slices 3000 - 9000 </li></ul><ul><li>directly over the uterus/fetus </li></ul>

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