ATLS in Woman

7/31/2019 ATLS in Woman

1/37

ATLS

Trauma in WOMAN


2/37

Introduction Any female patient between ages of 10 and 50 years

can be pregnant.

In a pregnant patient, there are 2 patient :

Mother and fetus

The best initial treatment is optimal resuscitation of the mother and early assessment of the fetus.

A qualified surgeon and an obstetrician should beconsulted early in the evaluation of pregnant traumapatient.


3/37

Anatomic alteration of pregnancy

Fundal height


4/37

Blunt trauma The uterus and its

contents(fetus andplacenta) are morevulnerable for trauma thanbowel

Penetrating trauma Penetrating trauma to upper

abdomen result in complexintestinal injury



5/37

Increased plasma volume : decreased Hct(31-35% in late pregnancy)



6/37

Increased WBC (up to 15,000-25,000)

Mildly elevated serum fibrinogen and other clotting factors

Shorted PT & aPTT

Unchanged bleeding time

Decreased serum albumin



7/37

Cardiac output : increase plasma volume and decrease PVR of the uterus and

placenta

HR : Consider when interpreting tachycardia response to hypovolemia

BP during second trimester Supine hypotension syndrome : compression of IVC

Variable CVP, response to volume is the same as in thenonpregnant state



8/37

Axis may shift leftward ~ 15o

Flattened or invert T wave in leads III & aVF &precordial leads may be normal

Increase ectopic beats



9/37

Progesterone : hypocapnia is common in latepregnancy

Diaphragm elevate : reduce residual volume

Increase inspiratory capacity

FVC slightly change

Increase O2 consumption

PaCO2 35-40 mmHg may indicate impending respiratory failur



10/37


11/37

Pituitary gland increases in size and weightby 30% to 50% : pituitary insufficiency



12/37

Pubic symphysis widening 4-8 mm

SI-joint space



13/37

Eclampsia : mimic head injury Seizure occur with associated

hypertension, hyperreflexia, proteinuria,and peripheral edema



14/37

Mechanism of Injury

abdominal wall, uterine myometrium,amniotic fluid

buffer

Enlarged and engorged pelvic vesselsin gravid uterus

massive retroperitonealhemorrhage after blunt trauma

IncidenceMotor vehicle accidents/pedestrians59.6%Falls 22.3%Direct assaults 16.7%Other 0.1%

lunt Injury


15/37

CollisionsUnrestrained pregnant women

higher risk of premature delivery and fetaldeath

RestrainLap belt alone

forward flexion and uterine compressionUterine rupture or abruptio placentae

Lap belt + shoulder restraintsgreater surface area for dissipating thedeceleration force

Prevent forward flexion over the gravid uterus

lunt Injury

Mechanism of Injury


16/37

lunt Injury

Mechanism of Injury


17/37

Enlarged gravid uterus other viscera injury uterine injury

netrating Injury

Mechanism of Injury


18/37

DetermineMaternal and fetal outcome

Treatment methodMajor injury

typically associated with fetal injuryadmit to facility with trauma + obstetriccapability

Minor trauma

Severity of Injury


19/37

DetermineMaternal and fetal outcome

Treatment methodMajor injuryMinor trauma

occasionally associated with abruptioplacentae and fetal lossclosely observed

Severity of Injury


20/37

1. Primary survey & resuscitation of mother

2. Primary survey & resuscitation of fetus3. Adjunct to primary survey for the mother

4. Adjunct to primary survey for the fetus

5. Secondary survey of mother

6. Definitive care

Assessment andtreatment


21/37


ABCDE assessment

Manually place uterus to the left sidepressure on IVC VR CO

Primary survey & resuscitation of mother


22/37

Proper immobilization in pregnant patient

Log roll 4-6 inches or 15 to the left

Primary survey & resuscitation of mother



23/37

d


24/37

Fetal deathMost common : Maternal shock & death

Second most common : Abruptioplacentae

Primary survey and resuscitation of the FETUS

Abruptio placentaeAbrup tio placentaeVaginal bleeding (70%)Uterine tenderness

Frequent uterine contractionsUterine tetanyUterine iritability

Investigation : U/S


d


25/37

Fetal deathRare cause : Uterine rupture

Primary survey and resuscitation of the FETUS

Uterine ruptureUterine rup tureAbdominal tenderness, guarding, rigidity, orrebound tendernessProfound shock Abnormal fetal lie; transverse or obliqueEasy palpation of fetal partInability to readily palpate the uterine fundus

Investigation : X-ray extended fetalextremities, abnormal fetal osition, and free


A d


26/37

Risk factor for fetal lossMaternal HR > 110/min

Injury severity score > 9Evidence of placentalabruptionFetal HR > 160 or < 120

Ejection during a motorvehicle accidentMotorcycle or pedestriancollisions

Primary survey & resuscitation of the FETUS


A d


27/37

CVP monitoringuesful in maintaining the relative

hypervolemia required in pregnancy

Pulse oximetry

ABG

HCO3 is normally low in pregnantpatient

Adjunct to primary survey and resuscitation for the MOTHER


A d


28/37

Consult OBFetal distress can occur any time

Fetal heart rate : 120-160/minMater blood volume status and fetal well-being

Fetal heart toneIntermittent doppler u/s after GA 10 wk

Cardiac tocodynamometerUseful after GA 20-24 wk

Radiographic study should be perform asnecessary

benefit > risk



A d


29/37



A d


30/37

Hx & PE and I/C for CT scan, FAST, DPLsame as non-pregnant patient

DPLCatheter should be placedabove the umbilicus

with open technique

Secondary assessment


A d


31/37

Pay attention to uterine contractionsregular contractions suggesting earlylabor

tetanic contraction suggesting abruptioplacentae

Perform pelvic examination by OB doctordecision for emergency cesareansection

Admission to hospitalVaginal bleedingUterine irritabilityAbdominal tenderness, pain, orcramping

Evidence f hypovolemiaChange or absence of fetal heart tones

Secondary assessment


A t d


32/37

OB consultation

Extensive placental separation or amnioticfluid embolization

Widespread intravascular clotting DICfibrinogen (


33/37

Fetomaternal hemorrhageFetal anemia and death

Isoimmunization in Rh-negative motherMg : Rh immunoglobuin therapy

within 72 hr of injury in allpregnant Rh negative

trauma patient unlessthe injury is remotefrom uterus

Definitive care



34/37

The Battered, Abused Child

A discrepancy exists between the history and thedegree of physical injury

A prolonged interval has passed between thetime of injury and presentation for medical care

The history includes repeated trauma, treated insame or different EDs.


35/37


The history of injury changes or differentbetween parents or guardians.

Shopping of hospitals or doctors

Parents respond inappropriately to or do notcomply the medical advice


36/37


Multicolored (multi-stage ) bruises

Evidence of frequent previous injuries, typified by oldscars or healed fractures on x-ray examination

Perioral injury

Injury to the genital or perianal area

Fracture of long bones in children younger than 3years of age


37/37


Ruptured internal viscera without antecedent major blunttrauma

Multiple subdural hematoma, especially without a fresh skullfracture

Retinal hemorrhages

Bizarre injuries : bite, cigarette burns, rope marks

Sharply demarcated second-third degree burn in unusual area

Date post:	05-Apr-2018
Category:	Documents
Upload:	lukkaew-dhatchai-charoensilawath
View:	228 times
Download:	0 times

ATLS in Woman

Documents