TRAUMA IN PREGNANCY

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TRAUMA IN TRAUMA IN PREGNANCYPREGNANCYTRAUMA IN TRAUMA IN PREGNANCYPREGNANCY

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OVERVIEWOVERVIEWOVERVIEWOVERVIEW

• Anatomy and physiologyAnatomy and physiology

• PathophysiologyPathophysiology

• Evaluation and managementEvaluation and management

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THE PREGNANT THE PREGNANT TRAUMA PATIENTTRAUMA PATIENTTHE PREGNANT THE PREGNANT

TRAUMA PATIENTTRAUMA PATIENT• Two patients with separate needsTwo patients with separate needs

– Mother

– Fetus

• Twin goals of managementTwin goals of management– Support mother

– Identify needs of the fetus

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PHYSIOLOGIC CHANGES PHYSIOLOGIC CHANGES OF PREGNANCYOF PREGNANCY

PHYSIOLOGIC CHANGES PHYSIOLOGIC CHANGES OF PREGNANCYOF PREGNANCY

• Changes related to gestational Changes related to gestational ageage

• Major shift of circulatory system Major shift of circulatory system to provide blood flow to uterusto provide blood flow to uterus

• Mother at more riskMother at more risk– Increased risk of injury

– Less able to compensate for shock

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CARDIOPULMONARCARDIOPULMONARY CHANGESY CHANGES

CARDIOPULMONARCARDIOPULMONARY CHANGESY CHANGES

• Increased cardiac output by 20-Increased cardiac output by 20-30%30%

• Pulse Pulse increasesincreases by 10-15 by 10-15 beats/minutebeats/minute

• BP BP decreasesdecreases by 10-15mmHg by 10-15mmHg

• Increased resting respiratory rateIncreased resting respiratory rate

• Elevation of diaphragm by uterus Elevation of diaphragm by uterus decreases thoracic volumedecreases thoracic volume

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SYSTEMIC BLOOD SYSTEMIC BLOOD VOLUMEVOLUME

SYSTEMIC BLOOD SYSTEMIC BLOOD VOLUMEVOLUME

• Increased plasma volumeIncreased plasma volume

• Increased red cell volumeIncreased red cell volume

• Blood volume increases 45-50%Blood volume increases 45-50%

• ““Anemia of Pregnancy”Anemia of Pregnancy”– Rise in plasma volume is greater than

the rise in red cell volume

– Results in a “relative” anemia

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ABDOMENABDOMENABDOMENABDOMEN

• Delayed gastric emptyingDelayed gastric emptying– Increased risk of vomiting and

aspiration

• Uterus becomes the largest Uterus becomes the largest abdominal organabdominal organ– More likely to be injured from either

blunt or penetrating trauma

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URINARY SYSTEM URINARY SYSTEM CHANGESCHANGES

URINARY SYSTEM URINARY SYSTEM CHANGESCHANGES

• Bladder is displaced upward and Bladder is displaced upward and forward by enlarging uterusforward by enlarging uterus

• Increased risk of bladder injury Increased risk of bladder injury from blunt or penetrating traumafrom blunt or penetrating trauma

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CHANGES IN THE CHANGES IN THE UTERUSUTERUS

CHANGES IN THE CHANGES IN THE UTERUSUTERUS

• Uterine blood flow increasesUterine blood flow increases– Nonpregnant = 2% cardiac output

– Pregnant = 20% cardiac output

• Uterine vessels constrict in Uterine vessels constrict in response to catecholamine response to catecholamine release in release in earlyearly shock shock– 20-30% decrease in uterine blood flow

– Risk fetal hypoxia and death

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CAUSES OF CAUSES OF TRAUMATIC FETAL TRAUMATIC FETAL

DEATHDEATH

CAUSES OF CAUSES OF TRAUMATIC FETAL TRAUMATIC FETAL

DEATHDEATH

#1 - Maternal death

#2 - Maternal shock

#3 - Abruptio placenta

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FETAL FETAL DEVELOPMENTDEVELOPMENT

FETAL FETAL DEVELOPMENTDEVELOPMENT

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SUPINE SUPINE HYPOTENSION HYPOTENSION

SYNDROMESYNDROME

SUPINE SUPINE HYPOTENSION HYPOTENSION

SYNDROMESYNDROME• The enlarging uterus can The enlarging uterus can

compress the inferior vena cava compress the inferior vena cava when the mother is in the supine when the mother is in the supine positionposition– Reduces venous return and cardiac

output by up to 30%

– More likely after the 20th week of pregnancy

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COMPRESSION OF COMPRESSION OF THE VENA CAVA CAN THE VENA CAVA CAN

CAUSECAUSE

COMPRESSION OF COMPRESSION OF THE VENA CAVA CAN THE VENA CAVA CAN

CAUSECAUSE

• Maternal Maternal hypotensionhypotension

• SyncopeSyncope

• Fetal bradycardiaFetal bradycardia

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PACKAGING OF PREGNANT PACKAGING OF PREGNANT TRAUMA PATIENTSTRAUMA PATIENTS

PACKAGING OF PREGNANT PACKAGING OF PREGNANT TRAUMA PATIENTSTRAUMA PATIENTS

• Full spinal immobilizationFull spinal immobilization

• Tilt backboard 20-30 degrees to Tilt backboard 20-30 degrees to the leftthe left

• May manually displace the uterus May manually displace the uterus to the left but not as effectiveto the left but not as effective

• Short backboards and similar Short backboards and similar devices not useful because of devices not useful because of difficulty attaching strapsdifficulty attaching straps

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ASSESSMENTASSESSMENTASSESSMENTASSESSMENT• Assessment sequence same as for Assessment sequence same as for

nonpregnant patientsnonpregnant patients– BTLS Primary Survey

Initial Assessment Rapid Trauma Survey or Focused Exam

– Detailed Exam

– Ongoing Exam

• Priorities same as for nonpregnant Priorities same as for nonpregnant patientspatients

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DO NOT CONFUSE DO NOT CONFUSE NORMAL VITAL NORMAL VITAL

SIGNS IN SIGNS IN PREGNANCY FOR PREGNANCY FOR SIGNS OF SHOCKSIGNS OF SHOCK

DO NOT CONFUSE DO NOT CONFUSE NORMAL VITAL NORMAL VITAL

SIGNS IN SIGNS IN PREGNANCY FOR PREGNANCY FOR SIGNS OF SHOCKSIGNS OF SHOCK

• Pulse is 10-15 beats/min. fasterPulse is 10-15 beats/min. faster

• BP is 10-15mmHg lowerBP is 10-15mmHg lower

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SHOCK IN SHOCK IN PREGNANCYPREGNANCY

SHOCK IN SHOCK IN PREGNANCYPREGNANCY

• Can lose 30% of blood volume Can lose 30% of blood volume before having significant change before having significant change in BPin BP

• Can have significant occult Can have significant occult intrauterine or abdominal bleedingintrauterine or abdominal bleeding– Uterus is very vascular

– May not have abdominal tenderness early even with significant bleeding

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MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT

• 100% oxygen100% oxygen– Very important

– You are treating the fetus also

• Transport with full spinal Transport with full spinal packagingpackaging– Tilt backboard to the left

• Treat specific injuriesTreat specific injuries

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MANAGEMENT OF MANAGEMENT OF SHOCKSHOCK

MANAGEMENT OF MANAGEMENT OF SHOCKSHOCK

• IV accessIV access– Two large bore IVs of NS or RL

• May require larger volume of May require larger volume of fluids for resuscitationfluids for resuscitation– Blood should be given early

• If PASG is indicated, inflate leg If PASG is indicated, inflate leg compartments onlycompartments only

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MATERNAL MATERNAL CARDIAC ARRESTCARDIAC ARREST

MATERNAL MATERNAL CARDIAC ARRESTCARDIAC ARREST

• Manage same as the nonpregnant Manage same as the nonpregnant patientpatient

• Perform CPRPerform CPR

• Notify hospital to be prepared for Notify hospital to be prepared for possible emergency c-sectionpossible emergency c-section

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SUMMARYSUMMARYSUMMARYSUMMARY• Treating two patientsTreating two patients

• Physiologic changes increase the Physiologic changes increase the risk of injury and shockrisk of injury and shock

• Treat shock earlyTreat shock early

• Prevent and treat hypoxiaPrevent and treat hypoxia

• Prevent supine hypotension Prevent supine hypotension syndromesyndrome

• Frequent reassessmentFrequent reassessment

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QUESTIONS?QUESTIONS?QUESTIONS?QUESTIONS?