Presentation on theme: "Dr.Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India."— Presentation transcript:
Dr.Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India.
The Leading cause of non-obstetrical mortality Causes of Trauma (1) Motor vehicle accident Domestic abuse & assault Falls Penetrating injury (1) Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14: , 1997
Some alterations mimic shock supine hypotensive syndrome Some alterations hide shock Increased blood volume Some alterations can aggravate traumatic bleeding uterus
(1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: , 1984
Respiratory alkalosis Reduce oxygen reserve Residual volume decreased by 40% Respiratory rate increased Impaired buffering capacity D iaphragm elevation Respiratory system
Decrease GI motility Decrease peritoneal irritation Upward position of abdominal viscera Gastrointestinal system
Bladder is displaced upward >10 wks Dilatation of renal pelvis and ureters
Premature Contractions Rarely progress to preterm delivery Tocolysis is not proven in trauma. (1) (1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: , 1990.
Different elastic properties in uterus & placenta shearing 3 % of minor trauma and up to 50 % in severe trauma
Rare, 0.6 % of severe abdominal trauma (1) Direct trauma after 12 wks of gestation Prior Surgery (C/S ) the risk 1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990 Uterine Rupture
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
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 (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.
Every women in the Reproductive age group must be tested for pregnancy
Best modality to assess both fetus and mother Not sensitive: Colonic lesions Sub-placental hematoma Safe procedure
If < 24 weeks, intermittent fetal doppler If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity
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
A Normal ABG Report in a Pregnant Patient Is ABNORMAL
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.
Pre-hospital Consideration Prevention of maternal hypoxia and hypotension. Airway patency with adequate O 2. Left lateral tilt. Volume replacement.
Airway Assess & control Pre oxygenate and sellicks maneuver Breathing Assess and manage Circulation Assess maternal circulation IV access Tilt to left if > 20 wks
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.
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.
~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
4 Minute Rule: Maternal CPR for 4 minutes, Infant should be delivered by the 5 th minute.
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
Anatomic and physiologic changes Vigorous fluid and blood replacement Treat the mother first and treat her just like any other trauma patient Remember
What is Best for the Mother is Best for the Fetus! Remember
kids are not just small adults
The priorities are same as that of the adult.
Size & shape : smaller body mass-greater force applied per unit body area Skeleton: more pliable – internal organ damage -without overlying bony # Equipment : appropriate size
Smaller in diameter,shorter in length Epiglottis – long, floppy,narrow Large occiput-flexion Narrowest portion –below vocal cords Larynx – Anterior & caudal Large tongue Airway