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Dr.Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India.

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Presentation on theme: "Dr.Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India."— Presentation transcript:

1 Dr.Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India.


3 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

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

5 (1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: , 1984

6 Respiratory alkalosis Reduce oxygen reserve Residual volume decreased by 40% Respiratory rate increased Impaired buffering capacity D iaphragm elevation Respiratory system

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

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

9 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.

10 Different elastic properties in uterus & placenta shearing 3 % of minor trauma and up to 50 % in severe trauma

11 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


13 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


15 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.


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

18 Plain x-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy

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


21 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 A Normal ABG Report in a Pregnant Patient Is ABNORMAL

25 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 O 2. Left lateral tilt. Volume replacement.


29 Airway Assess & control Pre oxygenate and sellicks maneuver Breathing Assess and manage Circulation Assess maternal circulation IV access Tilt to left if > 20 wks

30 Unstable Mother

31 Stable mother

32 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 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 ~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

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

36 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


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

39 EARLY !

40 What is Best for the Mother is Best for the Fetus! Remember


42 kids are not just small adults

43 The priorities are same as that of the adult.

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


47 Oxygenation Oral airway Intubation



50 Sellicks maneuver

51 Uncuffed tube Short trachea


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

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

55 Normal hemodynamics Abnormal hemodynamics Further evaluation 10 ml/kg PC Observe Operate Normal Abnormal Further evaluation Operate Observe Operate

56 Packed RBCs Type specific / O-negative Warmed

57 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 Peripheral venous access Avoid femoral venous access Intraosseous - < 6 yrs of age

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

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

61 Gastric distention FAST Dont delay for CT

62 Open Fontanelle, Suture lines Dont allow hypotension GCS =?

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

64 Full Fontanel Split sutures Altered state of Consciousness Paradoxical Irritability Persistent Emesis Setting Sun Sign

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

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

67 Pseudo subluxation SCIWORA Take normal side Treat when in doubt

68 History Blood loss Early splinting Child abuse

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


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