ATLS Trauma in WOMAN

Introduction
Any female patient between ages of 10 and 50 years
can be pregnant.

In a pregnant patient, there are 2 patient :

Mother and fetus

The best initial treatment is optimal resuscitation of

the mother and early assessment of the fetus.

A qualified surgeon and an obstetrician should be

consulted early in the evaluation of pregnant trauma patient.

Anatomic alteration of pregnancy

Fundal height

Anatomic alteration of pregnancy

Blunt trauma
The uterus and its
contents(fetus and placenta) are more vulnerable for trauma than bowel

Penetrating trauma
Penetrating trauma to upper
abdomen result in complex intestinal injury

Anatomic alteration of pregnancy

Increased plasma volume : decreased Hct
(31-35% in late pregnancy)

Anatomic alteration of pregnancy

Increased WBC (up to 15,000-25,000) Mildly elevated serum fibrinogen and other clotting factors Shorted PT & aPTT Unchanged bleeding time Decreased serum albumin

Anatomic alteration of pregnancy

Cardiac output : increase plasma volume and decrease PVR of the uterus and
placenta

HR : Consider when interpreting tachycardia response to hypovolemia BP during second trimester Supine hypotension syndrome : compression of IVC Variable CVP, response to volume is the same as in the nonpregnant state

Anatomic alteration of pregnancy

Axis may shift leftward ~ 15o Flattened or invert T wave in leads III & aVF &
precordial leads may be normal

Increase ectopic beats

Anatomic alteration of pregnancy

Progesterone : hypocapnia is common in late
pregnancy

PaCO2 35-40 mmHg may indicate impending respiratory failure

Diaphragm elevate : reduce residual volume Increase inspiratory capacity FVC slightly change Increase O2 consumption

Anatomic alteration of pregnancy

Prolong gastric emptying time RBF GFR BUN & Cr Glycosuria Physiologic renal calices & renal pelvis & ureter
dilatation (Rt>LT)

Anatomic alteration of pregnancy

Pituitary gland increases in size and weight
by 30% to 50% : pituitary insufficiency

Anatomic alteration of pregnancy

Pubic symphysis widening 4-8 mm SI-joint space

Anatomic alteration of pregnancy

Eclampsia : mimic head injury
Seizure occur with associated
hypertension, hyperreflexia, proteinuria, and peripheral edema

Mechanism of Injury
abdominal wall, uterine myometrium,
amniotic fluid buffer

Blunt Injury

Enlarged and engorged pelvic vessels

in gravid uterus massive retroperitoneal hemorrhage after blunt trauma

Incidence

Motor vehicle accidents/pedestrians

59.6% Falls Direct assaults Other 22.3% 16.7% 0.1%

Mechanism of Injury
Collisions
Unrestrained pregnant women
higher risk of premature delivery and fetal
death

Blunt Injury

Restrain
Lap belt alone
forward flexion and uterine compression Uterine rupture or abruptio placentae

Lap belt + shoulder restraints

greater surface area for dissipating the
deceleration force

Prevent forward flexion over the gravid uterus

Mechanism of Injury

Blunt Injury

Mechanism of Injury

enetrating Injury
Enlarged gravid uterus
other viscera injury uterine injury

Severity of Injury
Determine
Maternal and fetal outcome Treatment method
Major injury typically associated with fetal injury admit to facility with trauma + obstetric
capability Minor trauma

Severity of Injury
Determine
Maternal and fetal outcome Treatment method
Major injury Minor trauma occasionally associated with abruptio
placentae and fetal loss closely observed

Assessment and treatment

1. Primary survey & resuscitation of mother 2. Primary survey & resuscitation of fetus 3. Adjunct to primary survey for the mother 4. Adjunct to primary survey for the fetus 5. Secondary survey of mother 6. Definitive care

Assessment and treatment

Primary survey & resuscitation of mother

ABCDE assessment Manually place uterus to the left side

pressure on IVC VR CO

Assessment and treatment

Primary survey & resuscitation of mother

Proper immobilization in pregnant patient Log roll 4-6 inches or 15 to the left

Assessment and treatment

Primary survey & resuscitation of mother

Fluid resuscitation
Physiologic hypervolemia
Significant blood loss before
hypovolemic signs occur Fetal and placenta deprived of blood while maternal condition and V/S stable Crystalloid and early type-specific blood are indicated

Do not use vasopressors

Vasopressors reduce uterine blood flow
fetal hypoxia

Assessment and treatment

Primary survey and resuscitation of the FETUS

Fetal death
Most common : Maternal shock & death Second most common : Abruptio
placentae Abruptio placentae Vaginal bleeding (70%) Uterine tenderness Frequent uterine contractions Uterine tetany Uterine iritability

Investigation : U/S

Assessment and treatment

Primary survey and resuscitation of the FETUS

Fetal death
Rare cause : Uterine rupture
Uterine rupture Abdominal tenderness, guarding, rigidity, or rebound tenderness Profound shock Abnormal fetal lie; transverse or oblique Easy palpation of fetal part Inability to readily palpate the uterine fundus Investigation : X-ray extended fetal extremities, abnormal fetal position, and free

Assessment and treatment

Primary survey & resuscitation of the FETUS

Risk factor for fetal loss Maternal HR > 110/min Injury severity score > 9 Evidence of placental
abruption Fetal HR > 160 or < 120 Ejection during a motor vehicle accident Motorcycle or pedestrian collisions

Assessment and treatment

Adjunct to primary survey and resuscitation for the MOTHER

CVP monitoring
uesful in maintaining the relative
hypervolemia required in pregnancy

Pulse oximetry ABG

HCO3 is normally low in pregnant
patient

Assessment and treatment

Adjunct to primary survey and resuscitation for the MOTHER

Consult OB
Fetal distress can occur any time

Fetal heart rate : 120-160/min

Mater blood volume status and fetal well-being

Fetal heart tone

Intermittent doppler u/s after GA 10 wk

Cardiac tocodynamometer
Useful after GA 20-24 wk

Radiographic study should be perform as

necessary benefit > risk

Assessment and treatment

Adjunct to primary survey and resuscitation for the MOTHER

Assessment and treatment

Secondary assessment

Hx & PE and I/C for CT scan, FAST, DPL

same as non-pregnant patient

DPL
Catheter should be placed above the umbilicus with open technique

Assessment and treatment

Secondary assessment

Pay attention to uterine contractions regular contractions suggesting early

labor tetanic contraction suggesting abruptio placentae

Perform pelvic examination by OB doctor decision for emergency cesarean

section

Admission to hospital Vaginal bleeding Uterine irritability Abdominal tenderness, pain, or

cramping Evidence f hypovolemia Change or absence of fetal heart tones

Assessment and treatment

Definitive care

OB consultation Extensive placental separation or amniotic

fluid embolization Widespread intravascular clotting DIC
fibrinogen (<250 mg/dl), other clotting
factors and platelets

Mg : Urgent uterine evacuation and replacement of clotting & platelets as necessary

Assessment and treatment

Definitive care

Fetomaternal hemorrhage
Fetal anemia and death Isoimmunization in Rh-negative mother Mg : Rh immunoglobuin therapy within 72 hr of injury in all pregnant Rh negative trauma patient unless the injury is remote from uterus

The Battered, Abused Child

A discrepancy exists between the history and the

degree of physical injury

A prolonged interval has passed between the

time of injury and presentation for medical care same or different EDs.

The history includes repeated trauma, treated in

The Battered, Abused Child

The history of injury changes or different

between parents or guardians.

Shopping of hospitals or doctors Parents respond inappropriately to or do not

comply the medical advice

The Battered, Abused Child

Multicolored (multi-stage ) bruises Evidence of frequent previous injuries, typified by old

scars or healed fractures on x-ray examination

Perioral injury Injury to the genital or perianal area Fracture of long bones in children younger than 3
years of age

The Battered, Abused Child

Ruptured internal viscera without antecedent major blunt trauma Multiple subdural hematoma, especially without a fresh skull fracture Retinal hemorrhages Bizarre injuries : bite, cigarette burns, rope marks Sharply demarcated second-third degree burn in unusual area