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ChapterChapter

XIXXIX TRAUMA IN TRAUMA IN PREGNANCYPREGNANCY

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OverviewOverview

Anatomy and physiology Pathophysiology Evaluation and management

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The Pregnant Trauma The Pregnant Trauma PatientPatient

Two patients with separate needs

» Mother » Fetus

Twin goals of management» Support mother» Identify needs of the fetus

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Physiologic Changes Physiologic Changes of Pregnancyof Pregnancy

Changes related to gestational age Major shift of circulatory system

to provide blood flow to uterus Mother at more risk

» Increased risk of injury» Less able to compensate for shock

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Cardiopulmonary Cardiopulmonary ChangesChanges

Cardiac output increases by 20-30%. Pulse increases by 10-15 beats/minute. BP decreases by 10-15mmHg. Increased resting respiratory rate. Elevation of diaphragm by uterus

decreases thoracic volume.

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Systemic Blood Systemic Blood VolumeVolume

Increased plasma volume. Increased red cell volume. Blood volume increases 45-50%. “Anemia of pregnancy”

» Rise in plasma volume is greater than the rise in red cell volume.

» Results in a “relative” anemia.

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AbdomenAbdomen Delayed gastric emptying.

» Increased risk of vomiting and aspiration

Uterus becomes the largest abdominal organ.

» More likely to be injured from either blunt or penetrating trauma

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Urinary System Urinary System ChangesChanges

Bladder is displaced upward and forward by enlarging uterus.

Increased risk of bladder injury from blunt or penetrating trauma.

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Changes in the UterusChanges in the Uterus Uterine blood flow increases.

» Nonpregnant = 2% cardiac output» Pregnant = 20% cardiac output

Uterine vessels constrict in response to catecholamine release in early shock.

» 20-30% decrease in uterine blood flow» Risk fetal hypoxia and death

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Causes of Traumatic Causes of Traumatic Fetal DeathFetal Death

#1 - Maternal death

#2 - Maternal shock

#3 - Abruptio placenta

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Fetal DevelopmentFetal Development

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Supine Hypotension Supine Hypotension SyndromeSyndrome

The enlarging uterus can compress the inferior vena cava when the mother is in the supine position.

» Reduces venous return and cardiac output by up to 30%

» More likely after the 20th week of pregnancy

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Compression of the Compression of the vena cava can cause:vena cava can cause:

Maternal hypotension

Syncope Fetal

bradycardia

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Packaging of Pregnant Packaging of Pregnant Trauma PatientsTrauma Patients

Spinal motion restriction. Tilt backboard 20-30 degrees to

the left. May manually displace the uterus

to the left but not as effective. Short backboards and similar

devices are not useful because of difficulty attaching straps.

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Packaging of Pregnant Packaging of Pregnant Trauma PatientsTrauma Patients

The vacuum backboard is the most secure (and comfortable) device to restrict spinal movement in the pregnant patient.

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AssessmentAssessment Assessment sequence same as for

nonpregnant patients» BTLS Primary Survey

Initial Assessment Rapid Trauma Survey or Focused Exam

» Ongoing Exam Use Doppler (if available) to monitor fetal heart

tones» Detailed Exam

Priorities same as for nonpregnant patients

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Do not confuse normal Do not confuse normal vital signs in pregnancy vital signs in pregnancy for signs of shock.for signs of shock.

Pulse is 10-15 beats/min faster. BP is 10-15mmHg lower.

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Shock in PregnancyShock in Pregnancy Can lose 30% of blood volume

before having significant change in BP.

Can have significant occult intrauterine or abdominal bleeding.

» Uterus is very vascular.» May not have abdominal tenderness early

even with significant bleeding.

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ManagementManagement 100% oxygen.

» Very important.» You are treating the fetus also.

Transport with full spinal packaging.

» Tilt backboard to the left if uterus is to the umbilicus. Secure backboard so it does not flip over

onto the floor. Treat specific injuries.

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Management of ShockManagement of Shock IV access:

» Two large bore IVs of NS or RL. May require larger volume of

fluids for resuscitation.» Blood should be given early.

If PASG is indicated, inflate leg compartments only.

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Maternal Cardiac ArrestMaternal Cardiac Arrest Manage same as the

nonpregnant patient. Perform CPR. Notify hospital to be prepared

for possible emergency c-section.

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SummarySummary Treating two patients. Physiologic changes increase the

risk of injury and shock. Treat shock early. Prevent and treat hypoxia. Prevent supine hypotension

syndrome. Frequent reassessment.

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Questions?Questions?