Presentation on theme: "Trauma in Pregnancy & Paediatric Trauma"— Presentation transcript:
1Trauma in Pregnancy & Paediatric Trauma Dr .Patibandla SowjanyaDept. Accident & Emergency MedicineVinakaya 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.
2Two 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.
3Incidence The Leading cause of non-obstetrical mortality Causes of Trauma (1)Motor vehicle accidentDomestic abuse & assaultFallsPenetrating injuryT 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
4Cardiovascular Some alterations mimic shock supine hypotensive syndromeSome alterations hide shockIncreased blood volumeSome alterations can aggravate traumatic bleedinguterus
5Supine 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
6Respiratory system Reduce oxygen reserve Diaphragm elevation Respiratory alkalosisReduce oxygen reserveResidual volume decreased by 40%Respiratory rate increasedImpaired buffering capacityDiaphragm elevationThe 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.
7Gastrointestinal system Decrease GI motilityDecrease peritoneal irritationUpward position of abdominal viscera
8Genitourinary System Bladder is displaced upward >10 wks Dilatation of renal pelvis and ureters
9Injuries unique to pregnancy Premature ContractionsRarely progress to preterm deliveryTocolysis 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 shearingAbruptio placenta is most common blunt injuryBlunt 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 inVag. 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.
10Abruptio PlacentaDifferent elastic properties in uterus & placenta “shearing”3 % of minor trauma and up to 50 % in severe trauma
11Uterine Rupture Rare, 0.6 % of severe abdominal trauma (1) Direct trauma after 12 wks of gestationPrior Surgery (C/S ) the riskIt 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
15Penetrating Injury Gravid uterus alter injury pattern to the mother. If missile enter upper abdomen; increased probability of harmIf enters below uterine fundus visceral injury less likelySurgical 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.
17Pregnancy TestEvery women in the Reproductive age group must be tested for pregnancy
18Modalities for Evaluating Trauma Plain x-raysUltrasoundCT & MRICardiotocographic MonitoringDPLLaparotomyEssentially 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.
19Ultrasound Best modality to assess both fetus and mother Not sensitive:Colonic lesionsSub-placental hematomaSafe procedure
21Fetal Monitoring If < 24 weeks, intermittent fetal doppler If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity
22A 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 – 15/15C/O – diffuse pain in chest & abdomen
32Key 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.
33Modification 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.
34Perimortem Cesarean Section ~200 successful cases reported in the literatureMaternal CPR <5 minutes, fetal survival excellent23 weeks gestation survival chance is 0%Maternal CPR >20 minutes, fetal survival unlikelyPerimortem Cesarean SectionIndications:*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.
35Perimortem Cesarean Section 4 Minute Rule:Maternal CPR for 4 minutes, Infant should be delivered by the 5th minute.
36Perimortem Cesarean Section Vertical incision from xyphoid to pubisContinue straight down through abdominal wall and peritoneumCut through uterus and placentaBluntly open uterus and remove fetusCut and clamp cord
40What is Best for the Mother is Best for the Fetus! RememberWhat is Best for the Mother is Best for the Fetus!Recommended Reading:1) Trauma in Pregnancy, ATLS Manual, Chapter 11, 1994Concise, 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.