1. SPECIAL PATIENTS IN TRAUMA
PREGNANT, CHILD AND GERIATRICS
WAEL- ALHALABI

2. TRAUMA IN PREGNANCY

3. TYPES OF TRAUMA IN PREGNANCY
Motor vehicle accidents.
Falls and slips.
Burns.
Domestic Violence.
Penetrating Injuries.
Toxic Poisoning.
Sexual Assault.
Suicide and homicide

4. Right Posture and fastened
Seat belt with side lock
system is safe while driving

8. TRAUMA IN PREGNANCY
 Trauma complicates approximately 1 in 12 pregnancies
 It is the leading non-obstetrical cause of maternal death
 Trauma has foetal complications as well, and has been reported
to increase the incidence of
- Spontaneous abortion (SAB)
- Preterm premature rupture of membranes
- Preterm birth (PTB)
- Uterine rupture
- Cesarean delivery
- Placental abruption
- Stillbirth
 Placental abruption is major contributing factor in foetal death
 Usually 1 in 3 pregnant women admitted to the hospital for trauma
will deliver during her hospitalization

9. UNINTENTIONAL TRAUMA : MOTOR VEHICLE CRASH (MVC)
 Most common cause of trauma in pregnancy
Incidence
 207 cases per 100,000 pregnancies
 It is one of the leading causes of both maternal and foetal
mortality.
 Risk factors
 The major risk factor for adverse Trauma are improper/ No seat
belt use: in both front and rear collisions , Steering ,Dash board
injury.
 The use of intoxicants while driving

10. UNINTENTIONAL TRAUMA : MOTOR VEHICLE CRASH (MVC)
Obstetrical complications
 The major obstetrical concern with MVC is the strain placed on the
uterus, which may result in placental abruption
 Pregnant women involved in MVC appear to be at increased risk
for
- Emergency Caesarean delivery
- Preterm Birth
- Perinatal death
Mechanism
Shear force (strain) Tensile force (“countercoup”
mechanism)

11. SLIPS & FALLS DURING PREGNANCY
 It is known that pregnancy increases joint laxity and weight gain;
can affect gait and predispose pregnant women to slips and to falls
Types of Injuries
 The fracture of the lower extremity/ pelvis. spine are the most
commonly associated injuries.
 Blunt injury to abdomen and pregnant uterus.
Obstetrical complication
 A 4.4-fold increase in preterm labor
 An 8-fold increase in placental abruption
 A 2.1-fold increase in foetal distress
 A 2.9-fold increase in foetal hypoxia

12. BURNS IN PREGNANCY
 The impact of burns depends greatly on the burn depth and the
total body surface area affected
Risk factors
 Sepsis is a major contributor to mortality
 Maternal and foetal mortality are significantly increased in cases
when smoke inhalation has occurred leading to maternal hypoxia
/ Hyper carbon di oxymea / CO Poisoning.
Obstetric complications
 Burns during the first trimester have been associated with
spontaneous abortion; Thermal injury also appears to increase
the risk of Preterm birth

13. INTENTIONAL TRAUMA DURING PREGNANCY
 The most common form of intentional trauma is domestic violence
(DV) or intimate partner violence (IPV)
Incidence
 This wide range is due to inclusion of emotional, verbal, and/or
physical violence within the definition of DV/IPV
Risk factors
 Maternal or intimate partner---- substance abuse
 Low maternal educational level & low socioeconomic status
 Unintended pregnancy
 History of DV prior to pregnancy
 Unmarried status

14. TYPES OF DOMESTIC VIOLENCE
 Beating --- hurt on abdomen—with leg. Stick.
 Pushing down from stairs.
 Pushing her out of door
 Torched with burning objects –wood , candle , Hot Iron ,hot
iron rod ,intentional Kerosene stove burn/ cooking gas
stove accident s
 Sharp objects like kitchen knife,
 NO food / drink even water for whole day and night.
 Abasement.
 Electric shock.
 Pushing the head against pillar / wall.

15. PENETRATING TRAUMA IN PREGNANCY
 In one study, penetrating trauma accounted for 9% of all pregnant
trauma admissions
 Of those, 73% were handgun-, 23% knife-, and 4% shotgun related.
 Fall on sharp object and bull horn injury are common in rural Indian
women
 Penetrating trauma in pregnancy is associated with
- Increased foetal mortality (as high as 73%)
- Increased hospital stay,
- Complications such as intestinal perforation . Haemo peritoneum
due to intra abdominal organs like liver .spleen. Pregnant uterus. Big
vessels etc.

16. SUICIDE & HOMICIDE IN PREGNANCY
Risk factor
 Substance abuse appears to be the best identifier for detecting
women at risk for suicide
 Often associated with / precipitated by DV/IPV
 Unsuccessful suicide attempts have also been associated with
adverse pregnancy outcomes
Obstetric outcome
 Women who attempted unsuccessful suicide had increased risk of
- Premature labor
- Cesarean delivery
- Need for Blood transfusion
- Increased respiratory distress syndrome in new born
- Low birthweight

17. MODALITIES FOR EVALUATING TRAUMA
 Plain Films – X-rays
 Ultrasound
 CT & MRI
 Cardiotocographic Monitoring
 DPL(Diagnostic Peritoneal Lavage)
 Laparotomy

18. When fetus is viable, Start fetal monitoring along with management

20. PEDIATRIC TRAUMA
 Epidemiology
 25% of traumatic injuries occur in children
 Trauma is the leading cause of death after infancy (age 1-
14y)

21.  Most common causes of injury-related deaths:
 Traumatic brain injury
 Motor vehicle crashes
 Submersion injury
 Homicide
 Suicide
 Fires

22. HEAD TRAUMA
 Head trauma is the leading cause of death & disability
in childhood
 Mortality rate 20-30%

23.  Epidemiological/Environmental factors:
 Infancy: NAT, falls
 Childhood: MVA, pedestrian, bicycle
 Adolescence: MVA, pedestrian, bikes/boards, violence
 Sex:
 M = F ~ 5 yo
 M > F > 5 yo (2-5:1)

24. HEAD INJURY
 Definitive management dependant on lesion and
examination
 Early involvement of neurosurgery recommended
 Admission for observation and closely monitoring for
deterioration a must
 Consider need for IV Mannitol early for raised intracranial
pressure

25. CHEST/THORACIC TRAUMA
 Accounts for 4.5 – 8% pediatric trauma
 2nd most common cause of mortality in pediatric trauma
 Most common causes:
 Motor vehicle accidents (MVA’s)
 Pedestrians
 Unrestrained passengers
 Bicycle riders
 Falls

26. Pediatric thoracic trauma higher risk:
 More compliant chest wall
 Increased mediastinal mobility
Tension pneumothorax
 Children more prone to hypoxia
 Less ability to compensate for
hypovolemia

27.  Blunt versus penetrating
 Blunt:
 High energy trauma affects internal organs
 Deceleration mechanisms affect mediastinal structures
 Penetrating:
 Disrupts underlying structures
 Do not remove penetrating objects! Must remove in a controlled
setting (Operating Room

28.  Consider:
 Hemothorax
 Pneumothorax (+/- Tension Pneumothorax)
 Diaphragmatic ruptures
 Bronchial/Tracheal tears
 Esophageal ruptures
 Pulmonary contusions
 Cardiac tamponade

29. ABDOMINAL TRAUMA
 3rd leading cause of traumatic death
 Often unrecognized in children
 Consider abdominal injury in the following:
Sign Possible Injuries
Seatbelt Injury Small bowel injury
Chance fracture
Handlebar injury Duodenal hematoma
Pancreatic injury
Sport related injury Spleen, kidney, bowel

30. BURNS/THERMAL INJURY
 70% pediatric burns secondary to hot liquid
 Up to 20% burns in younger children secondary to abuse or
neglect
 Consider inhalational injury and need for EARLY intubation
if not secondary to liquid
 Hoarseness
 Black sputum
 Facial burn
 Accident in closed area

31. SUBMERSION INJURIES
 >50% drowning victims <5yo
 Fatality is highest in children <5yo
 M>F
 Most common cause of cardiac arrest in children

32.  Pathophysiology of drowning:
 Accidental submersion
 Loss of normal breathing pattern
 Possible laryngospasm
 Pulmonary aspiration/breath-holding/apnea
 Hypoxemia:
 Low O2, hypercarbia, acidosis
 End-organ damage – circulatory a

33. CONCLUSION
 Pediatric trauma and injury are preventable conditions
 Principles of management should always include a well
orchestrated primary and secondary survey
 Never hesitate to admit for observation, ask for help or
consult specialty services -the earlier the better.

34. GERIATRIC TRAUMA
 Older then 65 years
 Decline starts in late 20’s
 Leading causes of death:
 Heart disease
 Cancer
 Stroke
 Diabetes
 Trauma

35. TRAUMA
 Mechanisms of injury*
 Falls
 Motor vehicle trauma
 Assault and Domestic abuse
 Pedestrian accidents
 Burns

36. FALLS
 Risk Factors
 Dementia, visual impairments
 Lower extremity and foot diseases
 Gait and balance problems.
 Meds, med. problems, postural hypotension, neuro- muscular
disease

37. MVCS
Age 75+ - second highest crash rate
 MV vs pedestrians:
 Most severe of all elderly injuries

38. ELDERLY ABUSE
 Estimated 1 million cases / year.
 Physical violence
 May not be as apparent as child abuse.
 Emotional abuse
 Material exploitation.
 Neglect (may be unintentional)
 Dehydration / malnutrition, mental status changes.

39. ELDERLY ABUSE
 Risk Factors
 Physical frailty and cognitive impairment.
 Living with abuser
 Substance abusers, mental disease.
 Adult kids who are financially dependent.

40. MANAGEMENT
 Circulation-may have different normal blood pressure
 Airway
 Breathing-possibility of Chronic Lung Disease
 Protect the cervical spine
 Control their temperature
 Determine baseline/chronic medical conditions