Trauma in pregnancy praneel

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trauma in pregancy -Emergency management

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  • Normal anatomic location and function of multiple structures are altered because of changing uterine size Tension pneumothorax develop more quickly in pregnancy– know where to put chest drains – 2intercostal higher than the ususalAltered pain location – The gravid uterus itself protect abdominal organ from trauma but subsequently increase the likihood of bowel injury to penetrating trauma to upper abdomen . Upper ward displacement of bowel makes it less susceptible to blunt trauma
  • 1. Bladder becomes more vulnerable to injury
  • BP = decline insignificant /relatively normal .if patient hypotensive first thing is to turn the patient to the Lt – releasing uterine pressure therfore increasing venous return . 2nd is to treat with aggressive fluid and blood resuscitation 2.HR- consider tachycardia of pregnacy in the C stage of primary survey 3. Blood volume – mother may lose upto 1.5l of blood without hemodynamic instability but fetus will be in sock
  • 1.Increased 02 consumption – 2person and 1set of fuctioning lung 2. Paco2 of pregnacy is 30 -35mmhg – normal ABG is abnormal in pregnacy .PaCo2 of 35-40 may indicate inadequate ventilation and impending respiratory decompensation3.
  • Consider early gastric decompression and intubation
  • A- additional fact that the paitent is in collar
  • Supplemental oxygen – due to increased O2 consumption in pregnancy
  • Maternal heart rate and blood pressure are not consistently reliable predictors of fetal and maternal well being Displace uterus manually upward and Lt ward Tilt should be approximately 30degress .
  • Ultrasound – presence of heart rate / rate – tachy or badyDeclearation –early vs late – late decelration suggest fetal hypoxia /variable decleration is cord compression Fetal hemodynamics are more sensitve to decrease in maternal blood flow and oxygenation than most measures of the mother
  • Only speculum examination and no bimanual examination Bimaunal should not be performed of the possibility of rupturing the membrane Vaginal ph of 5 and amniotic ph of 7
  • Concealed will show no vaginal bleeding / the most sensitive indicator of placental abruption is fetal distress Still birth Placental abrution – more likely to have DIC – injured placenta release thromboplastin into the maternal circulation
  • Uterine contraction- tocolytic use has not shown beneficial effect/ most are self limiting /contraction that are not self limiting are often induced by underlying pathological condition such as placenta abruptio- which is contra indication of tocolyic therapy
  • KleihauerBetke sensitive to detect 5mls of fetal mmaternalhemorrage and less than 5mls is required to sesitize the mother
  • Trauma in pregnancy praneel

    1. 1. Praneel Kumar Bundaberg Hospital Emergency Department
    2. 2.      Introduction Take home point A & P changes in pregnancy and clinical significance Emergency management Traumatic Complications Of Pregnancy
    3. 3.     7% of all pregnancies 8% of women age 15-40 admitted to trauma centre do not know they are pregnant Order of frequencies – MVA – Interpersonal Violence and falls Viable fetus – 24 to 26 weeks of gestation or extimated fetal weight of 500gram
    4. 4.     Maternal Life takes Priority The best chance of fetal survival is maternal survival Initial management – ATLS protocol with some caveats Imaging should not be withheld if it provides significant diagnostic information
    5. 5.     Uterus – 12 weeks intrapelvic / 20 weeks umbilicus and costal margin by 34 to 36weeks Diaphragm rises as pregnancy progress – significance Abdominal viscera are pushed upward by enlarging uterus Stretching abdominal wall modifies normal response to peritoneal irritation – guarding /rebound can be blunted despite significant bleeding and injury
    6. 6.    Bladder displaced into abdominal cavity after 12weeks Baseline diastasis of the pubic symphysis may exist – can be mistaken for pelvic disruption on a radiograph AND REMEMBER SUPINE HYPOTENSION SYNDROME
    7. 7.    BP – declines in the first trimester/ level out in 2nd trimester and return to no pregnant level in the 3rd Trimester ( Systolic decline of 2-4mg and diastolic decline of 5-15mg ) ?? Significance HR – does not rise by more than 10-15 beats per minute Blood volume – may increase to as much as 45% peaking at 32 -34weeks of gestation with 25% increase in RBC – physiological anemia
    8. 8.  Marked venous congestion in the pelvic and lower extremities in the 3rd trimester – increasing potentional of hemorrage from both bony and soft tissue pelvic injuries
    9. 9.   Reduced oxygen reserve – due to decrease FRC caused by Diaphragm and increase in O2 consumption Minute ventilation increases leading to hypocapnea
    10. 10.   Gastro esophageal sphincter response is reduced and GI motility is deceased Increased risk of aspiration
    11. 11. EMERGENCY MANAGEMENT
    12. 12. GET YOUR TEAM READY  Airway - Intervene as early as possible - Prolong bag mask ventilation increase risk of aspiration ( already increased abdominal pressure and decreased lower esophageal tone - Difficult airway – proportion of Mallampati class 4 increase by 34% from 12 to 38weeks - NG decompression – to be performed to minimize the risk of ongoing Aspiration
    13. 13. Breathing -Supplemental oxygen in all patient –Fetus vulnerable to hypoxia -Apnoeic oxygenation during RSI - Remember the diaphragm during thoracostomy – use ultrasound to confirm where diaphragm is 
    14. 14.  - - Circulation Significant blood loss before hypotension Displace uterus to the Lt after 20weeks of gestation – either manually or tilting the backboard with wedge or pillow RH Neagtive blood should be used AVOID VASSOPRESSORS – decrease uterine blood flow
    15. 15.  -  - Disability/Dextrose Same as non pregnant – GCS /Pupil and gross motor function and sensation Exposure and Environment Examine all areas of the body Log roll
    16. 16. F- FAST /FINGER / FOLEYS / FAMILY + FETUS - EFAST - Finger – check every orifice for bleeding - Foleys – IDC if indicated - Family 
    17. 17.  - FETUS Use bedside ultrasound –HR and movement CTG ideal –minimum observation is 4hours HR 120 -160 Be-aware Very Angry Doctor Coming Fetal distress can be sign of occult maternal distress
    18. 18.   - - Similar in general to non pregnant patient Specific emphasis on abdominal and Vaginal examination Abdomen : fundal height – age / decrease may suggest traumatic PPROM Vaginal: preferably by obstetric specialist / evaluate vaginal lac or bony fragment and fluid
    19. 19.     -   Use it if needed Radiation risk – teratogencity,birth defect and increase life time risk of malignancy Loss of viability – risk greatest in the first 2 weeks post conception /risk with failure to implant at 50rad Radiation induced malformation at 2-15weeks Small head size / mental retardation/ organ malformation Afer 25 weeks – lifetime increase in malignancy Risk negligible < 5 rads exposure Risk increases > 15 rads exposure
    20. 20. Study Dose (rads) Chest X-ray <0.001 Pelvis 0.04 CT Head <0.05 CT Chest CT Abdomen 0.01-0.2 0.8-3.0 CT Pelvis Spine series 9 month background dose 2.5-7.9 0.37 0.1
    21. 21.  - - Placental Abruption Most common cause of fetal death Vaginal bleeding / abdominal cramps / uterine tenderness/ fetal distress Ultrasound – 50% sensitive 3.9 fold increase in Preterm labour More likey to have DIC
    22. 22. Uterine Injury -Rare, but always consider in significant trauma -Associate with near 100% fetal death rae -Cause :Pelvic fractures striking uterus :Penetrating trauma :Inappropriate seatbelt placement, too high -can lead to uterine contractions 
    23. 23.  - Fetomaternal Hemorrage Rh –ve mum /Rh positive baby All RH –ve women sustaining abdo trauma should receive RH immune globulin
    24. 24.    Mother stable/Fetus stable Mother stable / Fetus Unstable Mother Unstable /Fetus Unstable
    25. 25.     Maternal Life takes Priority The best chance of fetal survival is maternal survival Initial management – ATLS protocol with some caveats Imaging should not be withheld if it provides significant diagnostic information

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