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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?