1. Trauma in Pregnancy & Paediatric Trauma
Dr .Patibandla Sowjanya
Dept. Accident & Emergency Medicine
Vinakaya Mission Research Foundation (D.U)
Salem, Tamilnadu, India.
Pregnancy is one of the special challenges in traumatology and it produces changes that alter the usual course of trauma management, obviously, due to the existence of the 2nd life that is both helpless and hidden from view.

2. Two for One Caring for the Pregnant Trauma Patient
Pregnancy is one of the special challenges in traumatology and it produces changes that alter the usual course of trauma management, obviously, due to the existence of the 2nd life that is both helpless and hidden from view.

3. Incidence The Leading cause of non-obstetrical mortality
Causes of Trauma (1)
Motor vehicle accident
Domestic abuse & assault
Falls
Penetrating injury
T in P remains the leading cause of non O. morbidity & Mort. accounting for 46 % of fatalities in pregnant women.
Since women remains active during preg it is reported that 6-7 % of them will have trauma.
The major cause of maternal death are the same as those in non pregnant; head injuries and hypovolemia.
Injury in pregnant women may be intentional or unintentional.
MVC & falls are most common cause of injury.
However, homicide and suicide accounts for 1/3 of cases.
In one study domestic violence occurred in at least 8-17 % of cases during pregnancy. Single kick to abdomen in late preg. is associated with abruption placentae and fetal loss.
In one series, 57% of the maternal deaths were due to homicides and 7% due to suicides.
Causes of traumatic injury roughly parallel those seen in the general population, blunt being more common.
10% of maternal deaths from trauma are due to head injury, like the general population.
Maternal death rate is not statistically different from the general matched population.
Trauma, however, does seem to raise the rate of fetal loss and placental abruption over baseline rates in pregnant population.
(1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14: , 1997  

4. Cardiovascular Some alterations mimic shock
supine hypotensive syndrome
Some alterations hide shock
Increased blood volume
Some alterations can aggravate traumatic bleeding
uterus

5. Supine Hypotensive Syndrome
Elevating the mother's right hip 10-15cm completely relieves aortocaval compression in 58% of term parturients
(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: , 1984

6. Respiratory system Reduce oxygen reserve Diaphragm elevation
Respiratory alkalosis
Reduce oxygen reserve
Residual volume decreased by 40%
Respiratory rate increased
Impaired buffering capacity
Diaphragm elevation
The respiratory system with its changes brings about a state of physiologic respiratory alkalosis of pregnancy.
Dilation of the renal pelvises and ureters occurs after the 10th week.
The bladder is displaced up and forward after the 10th week.

7. Gastrointestinal system
Decrease GI motility
Decrease peritoneal irritation
Upward position of abdominal viscera

8. Genitourinary System Bladder is displaced upward >10 wks
Dilatation of renal pelvis and ureters

9. Injuries unique to pregnancy
Premature Contractions
Rarely progress to preterm delivery
Tocolysis is not proven in trauma.(1)
Very common after maternal trauma. It indicates uterine contusions or blood irritating the uterine muscle. They rarely progress to preterm delivery.
Placenta is devoid of elastic tissue while myometrium is very elastic predisposing to shearing
Abruptio placenta is most common blunt injury
Blunt trauma will deform the elastic and flexible myometrium which gets sheared from the relatively inflexible placenta.
Results b/c of ………..resulting in shearing effect and subsequently leading to seperatiion between placenta and the uterus.
It is common following blunt abdo. T., occurs in
Vag. Blding and abd. Tenderness are comon but abruption may be clinically occult.
CTG is most sensitive and indicates fetal distress.
U/S is specific but is not sensitive, it detects only 50 % of the cases
(1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: , 1990.

10. Abruptio Placenta
Different elastic properties in uterus & placenta “shearing”
3 % of minor trauma and up to 50 % in severe trauma

11. Uterine Rupture Rare, 0.6 % of severe abdominal trauma (1)
Direct trauma after 12 wks of gestation
Prior Surgery (C/S ) the risk
It is not used to determine the need for the rhogam but ..
Quantitation of feto-maternal haemorrhage (FMH) by flow cytometry (FC) has been shown to be more accurate than the Kleihauer-Bekte test.
1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

12. Uterine Rupture

13. Maternal-Fetal hemorrhage
4 to 5 X more common in injured pregnant women
Causes isoimmunization & fetal death
? Kleihauer-Betke test - volume of fetal blood
To determine amount of Rhogam needed

14. Blunt Injury Abdomen

15. Penetrating Injury Gravid uterus alter injury pattern to the mother.
If missile enter upper abdomen; increased probability of harm
If enters below uterine fundus visceral injury less likely
Surgical exploration does not worsen fetal survival rate. Only rarely does the pregnancy need to be removed to repair maternal injuries.
Fetal demise is not an indication to perform C-Section while undergoing exploratory laparotomy. Fetus will be expulsed spontaneously within one week.
Stabbings may be explored locally and observed, imaged, or undergo formal laparotomy to ascertain extent of injury. This will be institution and surgeon variable.
(1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

16. Stab Injury

17. Pregnancy Test
Every women in the Reproductive age group must be tested for pregnancy

18. Modalities for Evaluating Trauma
Plain x-rays
Ultrasound
CT & MRI
Cardiotocographic Monitoring
DPL
Laparotomy
Essentially each of these modalities has the same advantages and disadvantages in the pregnant as in the nonpregnant patient.
Laparotomy is safe for both the mother and the fetus and there is no increased risk compared to the nonpregnant cohort. It is obviously invasive but the most complete and accurate study to evaluate for injury.
CT is safe. It may be somewhat difficult to interpret due to crowding of viscera in the upper abdomen. It is good for diagnosing retroperitoneal injuries.
DPL has historically been a relative contraindication in pregnancy. But it is safe if performed using an open technique and above the level of the uterus by someone experienced in the technique. It gives no information about the retroperitoneum or intrauterine injury.
Ultrasound may be very operator dependent.
Laparoscopy is still under scrutiny and not yet recommended for routine use.

19. Ultrasound Best modality to assess both fetus and mother
Not sensitive:
Colonic lesions
Sub-placental hematoma
Safe procedure

20. Fundal height

21. Fetal Monitoring If < 24 weeks, intermittent fetal doppler
If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

22. A 28 yrs female with 29 weeks pregnancy brought to ER after RTA with the suspected abdominal injury .
HR – 110, BP – 110 / 70, Spo2 – 98% on RA , RR – 28/min , GCS – 15/15
C/O – diffuse pain in chest & abdomen

24. Remember
A Normal ABG Report in a Pregnant Patient Is ABNORMAL

25. Management Avoid distractions and avoid focus on the fetus.
Be aggressive! But temper with common sense.
An apparently stable mother may be compensating at expense of the fetus.

27. Pre-hospital Consideration
Prevention of maternal hypoxia and hypotension.
Airway patency with adequate O2.
Left lateral tilt.
Volume replacement.

29. Initial maternal Resuscitation
Airway
Assess & control
Pre oxygenate and sellick’s maneuver
Breathing
Assess and manage
Circulation
Assess maternal circulation
IV access
Tilt to left if > 20 wks

30. Unstable Mother

31. Stable mother

32. Key interventions to Prevent Arrest
Place the patient in the left lateral position or manually and gently displace the uterus to the left.
Give 100% oxygen.
Give a fluid bolus.
Immediately reevaluate.

33. Modification to BLS Guidelines for Arrest
Relieve aortocaval compression by manually displacing the gravid uterus.
Generally perform chest compression higher on the sternum to adjust for the shifting of pelvic and abdominal contents toward the head.

34. Perimortem Cesarean Section
~200 successful cases reported in the literature
Maternal CPR <5 minutes, fetal survival excellent
23 weeks gestation survival chance is 0%
Maternal CPR >20 minutes, fetal survival unlikely
Perimortem Cesarean Section
Indications:
*Fetus >26 weeks gestation (>1000 grams birth weight)
*Reasonable certainty of maternal demise
*Knowledge of the operative technique
*Available resources to appropriately resuscitate and support the infant.
*Presence of any fetal heart activity during the mother’s course.
If the mother has brain death, but adequate vital signs to maintain the pregnancy, then there is no need for emergent delivery.
There are reported cases of maternal improvement after perimortem C-Section.
One author has recommended if unsuccessful CPR has been performed for 4 minutes, then C-Section should be performed in the 5th minute. Perimortem C-Section has been recommended at up to 25 minutes.

35. Perimortem Cesarean Section
4 Minute Rule:
Maternal CPR for 4 minutes, Infant should be delivered by the 5th minute.

36. Perimortem Cesarean Section
Vertical incision from xyphoid to pubis
Continue straight down through abdominal wall and peritoneum
Cut through uterus and placenta
Bluntly open uterus and remove fetus
Cut and clamp cord

37. Perimortem Cesarean Section

38. Remember Anatomic and physiologic changes
Vigorous fluid and blood replacement
Treat the mother first and treat her just like any other trauma patient

39. When to Intervene and Consult
EARLY !

40. What is Best for the Mother is Best for the Fetus!
Remember
What is Best for the Mother is Best for the Fetus!
Recommended Reading:
1) Trauma in Pregnancy, ATLS Manual, Chapter 11, 1994
Concise, nuts and bolts text.
2) T. Esposito, “Trauma During Pregnancy,” Emergency Medicine Clinics of North America, vol. 12, No. 1, Feb. ‘94, p. 167.
Excellent review and discussion, well written.
3) S. Higgins, “Emergency Delivery: Prehospital Care, Emergency Department Delivery, Perimortem Salvage,” Emergency Medicine Clinics of North America, vol. 5, No. 3, Aug. ‘87, p. 529.
Quick review of post (peri) mortem C-Section included.
4) The Challenge of Trauma in Pregnancy, Emergency Medicine Reports, vol. 16, num. 18, Sept 4, 1995.

41. Paediatric Trauma

42. kids are not just small adults

43. The priorities are same as that of the adult.

44. Unique characteristics
Size & shape : smaller body mass-greater force applied per unit body area
Skeleton: more pliable – internal organ damage -without overlying bony #
Equipment : appropriate size

45. Airway Smaller in diameter,shorter in length
Epiglottis – long, floppy,narrow
Large occiput-flexion
Narrowest portion –below vocal cords
Larynx – Anterior & caudal
Large tongue

47. Airway management
Oxygenation
Oral airway
Intubation

50. Sellick’s maneuver

51. Difficulty in maintaining tube position
Uncuffed tube
Short trachea

53. Breathing & Ventilation
Respiratory rate
Volume
Hypoventilation-res.acidosis
Caution – bicarbonate
Tube thorocostomy

54. Circulation Recognize heamodynamic changes
Tachycardia and poor skin perfusion are early signs of shock

55. Fluid bolus Normal hemodynamics Abnormal hemodynamics
Further evaluation ml/kg PC
Observe Operate Normal Abnormal
Further evaluation Operate
Observe Operate

56. Blood
Packed RBC’s
Type specific / O-negative
Warmed

57. Haemodynamic normality
Slowing of the HR ( 130/mt )
Return of normal skin colour
Increased warmth of extremities
Improving GCS
Increasing sys. BP (>80 mm Hg )
Urinary output of 1-2 ml/Kg/hour

58. Venous access Peripheral venous access Avoid femoral venous access
Intraosseous - < 6 yrs of age

59. Thermoregulation Refractory to treatment Prolongs coagulation times
Affect CNS
Overhead heat lamps or heaters or thermal blankets

60. Thoracic injuries Rib # - severe injury force Compliant chest wall
Lung & Cardiac contusion Aortic transection Diaphragmatic rupture

61. Abdominal trauma
Gastric distention
‘FAST’
Don‘t delay for CT

62. Head injuries Open Fontanelle, Suture lines Don’t allow hypotension
GCS =?

63. V- Score Appropriate words/ smiles = 5 Cries but consolable = 4
Persistently irritable = 3
Restless, agitated = 2
None = 1

64. Signs of raised ICP in Infants
Full Fontanel
Split sutures
Altered state of Consciousness
Paradoxical Irritability
Persistent Emesis
Setting Sun Sign

65. Management of Raised ICP
Head End Elevation
Hyperventilation
Mannitol gm/Kg
Pentobarbital 1-3 mg/Kg or Phenobarbitone
Hypothermia ( C)

66. Spine Flexible interspinous ligaments Anteriorly wedged vertebrae
Flat facet
Larger head greater flexion extension injuries
Ligamentous injuries more common

67. X-ray Pseudo subluxation ‘SCIWORA’ Take normal side
Treat when in doubt

68. Musculoskeletal trauma
History
Blood loss
Early splinting
Child abuse

69. Remember Same priority like an adult
Unique anatomic& physiologic changes
Early surgical intervention

70. Thank you