1. Presented by DR. Jameel T Miro

2. Does trauma management differ for the pregnant ? Yes No Physiologic and Anatomic changes of pregnancy Two patients requiring treatment!!! ATLS Protocol the same Priorities same as in non-pregnant patient

3. What is the Incidence and why its an important topic ? The Leading cause of non-obst. mortality -46% Trauma during pregnancy – 10% So many morbidities Preterm Labor in 11.4 % P. Abruption in 1.58 % Dead Mother = Dead Fetus Most common cause of fetal death from trauma is maternal death

4. What is the types of trauma ? Causes of Trauma MVA 54.6 % Domestic abuse & Assault 22.3% Falls21.8 % Penetrating inj.1.3 %

5. Hemodynamic Changes of Pregnancy (Mean Values) Non P.Trim. 1Trim. 2Trim. 3 HR70788285 Sys. BP115110102114 Dias. BP70606370 C. Output4.5 66 CVP9.07.54.03.8 Bld V (ml)4000420050005600 Hct with Fe (%)40363436 WBC (cell/mm 3 )7200910097009800

6. Anatomic changes Intestinal tract is displaced upward and posterior As gestation continues the uterus becomes more vulnerable as the walls thin and there is less protection by amniotic fluid

7. Why we should know the physiological changes in pregnancy Normal pregnant vital signs mimic hypo perfusion Assessment more difficult Fetus can be in distress while mother appears stable Retroperitoneal bleeding more common to non pregnant.

8. What is the approach ? AIRWAY + SPINE recall the increased risk of aspiration consider early endotracheal intubation. assume full stomach sellick’s maneuver

9. Breathing auscultate for breath sounds and pulse oximetry A chest tube thoracostomy : placed 1 or 2 intercostal spaces higher than usual to avoid diaphragmatic injury. By 3 rd trimester increase the need of oxygen 10- 20% Fetal oxygenation may be comprmized Exlude the lethal causes : tension pnemothorax, flail chest etc.

10. Circulation Assess maternal circulation + IV access If greater than 20 weeks’ gestation should be placed in the left-lateral decubitus position Early crystalloid fluid replacement fetal distress maybe the first sign of maternal hemodynamic compromise ( so it’s a vital sign )

11. secondary survey HEAD TO TOE include the back Remember the Baby (fetal assessment) CTG at least 4 hr Pregnancy history Fundal height The uterus for tenderness and contractions sterile speculum examination The cervix

12. What is the radiographic diagnostic modalities ? Plain Films – X-rays Ultrasound CT & MRI Cardiotocographic Monitoring DPL Laparotomy

13. Radiographic risks Risk of 1 rad to fetus is approx. 0.003 < 5-10 rads causes No risk on congenital malformation, abortions or intra-uterine growth ret. Smaller risk of increase in childhood cancer Radiation doses > 10 rads 6 % chance of severe mental ret. < 3 % chance childhood cancer.

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

15. FAST ?? How much fluid can FAST detect? 250 cc total 100 cc in Morison’s pouch Does FAST replace CT? Only at the extremes. Unstable patient, (+) FAST  OR Stable patient, low force injury, (-) FAST  consider observing patient.

16. CT SCAN Complementary to U/S & DPL Penetrating wounds of flank & back Can miss diaphragmatic and bowel injuries Spiral CT reduces radiation exposure by 14-30 %

17. Diagnostic peritoneal lavage CT & U/S are better in stable patient. Hypotensive unstable pt. Can be performed in any trimester Gravid uterus does not reduce the accuracy of DPL for OR does not assess retroperitoneal hemorrhage or intra-uterine pathology

18. Special consedration Fetomaternal Hemorrhage Abruptio Placenta Ruptured Uterus Penetrating Injury If below uterine fundus visceral injury less likely (0%) Fetal death rate is 67% Stabbing Injury Rare, only 19 cases reported in literature ( Laprotomy)

19. Injury Severity Score head, face, thorax, abdomen, extremities (incl. pelvis). headfacethoraxabdomenpelvis 1 Minor, 2 Moderate, 3 Serious, 4 Severe, 5 Critical, 6 Maximal (currently untreatable). ISS = A^2 + B^2 + C^2 A Polytrauma is defined as ISS >= 16Polytrauma Indication of severity, prognosis and hospital stay

20. 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

21. summery ABC secondary survey ….. Fetous !! Limit radiation to 5 rads High index of suspicion for abruptio placenta. If mother unstable or arrested, with viable fetous conider primortem c/s !!!

22. Remember What is Best for the Mother is Best for the Fetus!

23. Thank you