International Trauma Life Support for Prehospital Care Providers Sixth Edition for Prehospital Care Providers Sixth Edition Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Patricia M. Hicks, MS, NREMTP Roy Alson, PhD, MD, FACEP Donna Hastings, EMT-P John Emory Campbell, MD, FACEP and Alabama Chapter, American College of Emergency Physicians Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Chapter 19 Trauma in Pregnancy Chapter 19 Trauma in Pregnancy

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Pregnancy

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Overview Dual goals in managing pregnant trauma Physiological changes of pregnancy Response to hypovolemia Types of injuries most commonly associated Initial assessment and management Trauma prevention in pregnancy 2Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Pregnancy Unique challenges Vulnerability of pregnant trauma patient Potential injuries to unborn child Dual roles Provide care to mother Provide care to fetus 3Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Pregnancy Leading cause of morbidity and mortality 6–7% of pregnancies experience some trauma 1 in 12 injured experience significant trauma Major causes Motor-vehicle collisions Falls Abuse and domestic violence Penetrating injuries Burns 4Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pregnant Patient Increased risk for trauma Fainting spells, hyperventilation, excess fatigue commonly associated with early pregnancy Balance and coordination affected by changes throughout pregnancy 5Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Fetal Development 6Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Viability Assessment 7Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Physiologic Changes 8Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Physiologic Changes Respiratory system Diaphragm elevated due to uterine size Decreased thoracic volume Relative alkalosis Predisposed to hyperventilation 9Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Vital Signs in Pregnancy Do not mistake normal vital signs for signs of shock. Normal pulse: 10–15 beats faster Blood pressure: 10–15 mmHg lower 30–35% blood loss before significant blood pressure change Be alert to all signs of shock. Frequent ITLS Ongoing Exams 10Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Response to Hypovolemia Vasoconstriction and tachycardia Reduction of uterine blood flow by 20–30% Fetal heart rate and blood flow decreases Fetus becomes hypoxemic High-flow oxygen is essential. Maternal shock has 80% fetal mortality rate 11Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma in Pregnancy ITLS Primary and Secondary Surveys Optimize maternal and fetal outcome High-flow oxygen rapidly administered Fetal hypoxia occurs before maternal hypoxia Fluid administration must be prompt Fluid volume needed is greater Frequent Ongoing Exams Mortality of fetus related to maternal treatment 12Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Supine Hypotension Venous return decreases 30% in supine position with 20-week or larger uterus. Acute hypotension Syncope Fetal bradycardia 13Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Supine Hypotension Transport position Tilt or rotate backboard 20–30 o to patient’s left Elevate right hip 4–6 inches with towel Manually displace uterus to left 14Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Supine Hypotension Transport position Better stabilized with vacuum backboard More comfortable than standard backboard 15Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Evaluation of Uterine Size 16Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ 17 Relatively minor abdominal trauma can cause fetal death. Maternal death is most common cause of fetal death. Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Pregnant Trauma Arrest Treated same as for other victims Defibrillation settings are same Drug dosages are same Fluid volume needed increases 4 liters normal saline rapid infusion during transport If mother unsalvageable: Continue CPR Notify hospital of possible cesarean section 18Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Types of Trauma Motor-vehicle collisions Penetrating injuries Domestic violence Falls Burns 19Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Motor-Vehicle Collisions 65–75% of pregnancy-related trauma <1% injured when minor vehicle damage Seatbelts significantly decrease mortality Has not shown any increase in uterine injury 20Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Motor-Vehicle Collisions Maternal death Head injury Most common Uncontrolled hemorrhage Second most common Assess pelvis Fetal injury 21Trauma in Pregnancy - Fetal distress Fetal death Placental abruption Uterine rupture Preterm labor

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Abdominal Trauma Physiologic changes Decreased sensitivity Gradual stretching Hormonal changes Uterus very vascular Clinical presentation Guarding, rigidity, rebound response absent Abdominal trauma requires ED evaluation 22Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Penetrating Injuries Gunshot wounds and stabbings Entry below fundus Uterus absorbs force, protects maternal organs High fetal mortality rate: 40–70% Lower maternal mortality rate: 4–10% Entry above fundus Bowel injury due to displacement 23Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Domestic Violence 10% experience abuse during pregnancy Proximal and midline injuries Face and neck most common Low birth weight Abused by spouse or boyfriend: 70–85% (U.S.) 24Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Falls Injury from falls Increase with progression of pregnancy Center of gravity altered Proportionate to force and body part impacted Pelvic injuries Placental separation Fetal fractures 25Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Burns Fluid volume needed increases Mortality and morbidity Maternal mortality same as non-pregnant Fetal mortality increases with >20% BSA 26Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Trauma Prevention Proper seat-belt use Report domestic violence Counseling for domestic violence Patient education Multiple changes associated with pregnancy Physiological, anatomical, emotional 27Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Summary Trauma in Pregnancy Knowledge of physiological changes Hypotension and hemorrhage easily overlooked Rapid evaluation and interventions to stabilize Aggressive oxygen administration Aggressive fluid resuscitation Prevent supine hypotension Fetal care depends on maternal care. 28Trauma in Pregnancy -

Campbell, International Trauma Life Support, 6th Ed. © 2008 Pearson Education, Inc., Upper Saddle River, NJ Discussion 29Trauma in Pregnancy -