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Polytrauma bei schwangern

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Ein Fortbildungsvortrag zum Thema "Trauma in der Schwangerschaft' als teil der Abteilungsfortbildung in der Klinik für Anästhesie und Internsivmedizin in Klinikum Braunschweig

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Polytrauma bei schwangern

  1. 1. Polytrauma bei Schwangeren Ahmad Al Halabi, Assistenzarzt, Klinik für Anästhesie Städtisches Klinikum Braunschweig 1
  2. 2. Inhalts 1. Statistiken 2. Physiologische Veränderungen während der Schwangerschaft. 3. Versorgung der polytraumasierten Schwangeren. 4. Fazit 5. Fragen 2
  3. 3. Statistik 3
  4. 4. Statistiken- Deutschland Es gibt keine aktuelle Statistiken zum Thema “Trauma in Schwangerschaft“ in Deutschland. 4
  5. 5. Statisken - USA Häufigkeit: 6-7% 2 Primigravid: 43% der Betroffenen. Mittleres Gestationsalter: 25.9 Wochen. 5
  6. 6. Ursachen: Verkhersunfälle: 54.6% Uniforme Verteilung. Meiste Mortalität. Missbrauch und Gewalt 22.3% Meiste vor 18 Wochen. Fallen 21.8% Sonstige 1.3%. 6
  7. 7. Komplikationen: Perinatale Mortalität 5.67% Mütterliche Mortalität 2.94% Frühgeburt 25% Plazenta Ablation 1.58% 7
  8. 8. Physiologie1 8
  9. 9. Herz-Kreislaufsystem Herzfrequenz ↑ 10-12 Schläge/Min  Herzminutvolum: ↑ 50% Blutvolum: ↑ 30-50% Verdunnungseffekt  leichte Anämie Cave: Kavakompressionssyndrom 9
  10. 10. Atmung Residualkapazität Atemfrequenz 40-50% Steigerung der alveolären Ventilation  Leichte Hyperventilation. 10
  11. 11. Magen-Darm Trakt Kompression des Magens + Störung des Verschlussmechanismus des Ösophagus + Abnehmende Magenaktivität bzw. Entleerung = höhe Aspirationsgefahr Jede Schwangere > 14 Wochen = nicht nüchtern 11
  12. 12. Versorgung der Mutter 12
  13. 13. Konzepte 1.Hilfe abholen (OA) und ruhig bleiben. 2.Lebens der Mutter kommt in erste Stelle. 3.ABCDE (primary survey) Schema folgen. 4.Multidisplinäre Behandlung. 5.Optimale Lage: 15-30 Grads linkseitg, mit gleichseitige WS Stabilisierung. 6.Frühzeitige Erkennung der Art des Traumas (Strumpfes vs. Penetriendes). 13
  14. 14. 14
  15. 15. Primary Survey A: Frühzeitige Sicherung des Atemswegs B: Frühzeitige ausreichende Beatmung C: Kreislaufstabilisierung Frühzeitige Flüßigkeiten Zuführ und Bluttransfusion (Bei Bedarf). Optimierung der Lage. ZVD Messung mittels eines ZVK. D: neurologische Defizit E: Exposure (uterine Blutung?). 15
  16. 16. Don’ts Vasopressors Eingabe (Vasokonstriktion in der Plazenta). Flußigkeiten Zuführ verspäten (falsche Zeichen der Kreislaufstabilität, Kristalloid vs Kolloid) Gefahr zu dem Fetus unterschätzen (Auch bei minimaler mütterlichen Verletzung). 16
  17. 17. Besondere Komplikationen3 DIC aufgrund Fruchtwasser Embolien (Thrombozyten + Fibrinogen Werte) Iso-immunisation (RH –ve Mutter) 5 (8-30% vs. 2-8%) Jede Rh- Schwangere soll RH Immunoglobulin Therapie bekommen. Eklampsie und Präeklampsie 17
  18. 18. Versorgung des Fötus 18
  19. 19. Risikofaktoren zur fetalen Mortalität4 Ejection from vehicle Pedestrian injury Lack of restraints Maternal tachycardia Maternal hypotension Maternal hypoxia Maternal contractions Abnormal fetal heart rate Injury severity score > 9 19
  20. 20. Ursachen4 Mütterliche Kreislauf Instabilität (80%). Plazenta Ablation (54% ( Vaginale Blutung (70%) Gebärmutter Zärtlichkeit. Wehe Gebärtsmutter Ruptur: Akut Abdomen Schock 20
  21. 21. Optimale Versorgung 1. Optimale Überwachung: Sonographie Doppler Cardio-Tokograph 2. Optimale Versorgung Geburtshilfe ärztliche Teilnahme Optimierung und Stabilisierung des mütterlichen Kreislaufs. 21
  22. 22. Notsektio? Nur bei: Schwangerschaftsalter > 24 Wochen (Gebärmütter überschreit Bauchnabel). Positive fetale Herzaktivität. Mütterliche Reanimation <10 Min. Peri- aber nicht Postmortem 22
  23. 23. ErlaubteVerbotene Medis2 23 Depolarisierende sowie nicht Depolarisierende Muskelrelaxans. Lokaleanästhetika: Bupivacain und Ropivacain. X Opoid (nür bei Bedarf, vorsichtlich, und bei bedarf mit 0,01 mg/Kg Naloxon antagonisieren).
  24. 24. Fazit 24 Atemwegssicherung Kreislaufstabilisierung durch Flüßikeiten und optimale Lagerung. Katecholamine vermeiden. Multidisciplinäre Behandlung. Lebens der Mutter zu erst!
  25. 25. Fragen? 25
  26. 26. Vielen Dank für Ihre Aufmerksamkeit! 26
  27. 27. Quellen 1.Trauma and pregnancy, Connolly AM, Katz VL, Bash KL, McMahon MJ, Hansen WF, American Journal of Perinatology. 1997 Jul;14(6):331-6. 2.Hans Walter Striebel. Anästhesie, Intensivmedizin, Notfallmedizin. 7e Auflage. Schattauer; 2009. Sektion 5.3, Anästhesie in der Geburtshilfe; Seite 250. 3.Advanced Trauma Life Support for Doctors, Student Course Manual. 8th Edition; American College of Surgeons; 2004. Chapter 12; Page 259. 4.Dr Michael E Sugrue, Commander Michael C O’Connor, Dr Scott K D’Amours. Trauma during pregnancy. ADF Health 2004; 5: 24-28. 5.Pearlman MD, Tintinelli JE, Lorenz PR. A prospective study of the outcome after trauma during pregnancy. Am J Obstet Gynecol 1990; 162: 1502-1510. 27

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