Trauma in Pregnancy & Paediatric Trauma

1. Dr .Patibandla Sowjanya Dept. Accident & Emergency Medicine Vinakaya Mission Research Foundation (D.U) Salem, Tamilnadu, India. Trauma in Pregnancy & Paediatric Trauma

2. Two for OneCaring for the PregnantTrauma Patient

3. Incidence • The Leading cause of non-obstetrical mortality • Causes of Trauma (1) • Motor vehicle accident • Domestic abuse & assault • Falls • Penetrating injury (1)Connolly A, Katz VL, Bash KL, et al: Trauma and pregnancy. Am J Perinatol 14:331-336, 1997

4. Cardiovascular • Some alterations mimic shock supine hypotensive syndrome • Some alterations hide shock Increased blood volume • Some alterations can aggravate traumatic bleeding uterus

5. Supine Hypotensive Syndrome (1) Milson I, Forssman L: Factors influencing aortocaval compressionin late pregnancy, Am J Obtst Gynecol 148: 764-771, 1984

6. Respiratory system • Respiratory alkalosis • Reduce oxygen reserve • Residual volume decreased by 40% • Respiratory rate increased • Impaired buffering capacity • Diaphragm elevation

7. Gastrointestinal system • Decrease GI motility • Decrease peritoneal irritation • Upward position of abdominal viscera

8. Genitourinary System • Bladder is displaced upward >10 wks • Dilatation of renal pelvis and ureters

9. Injuries unique to pregnancy • Premature Contractions • Rarely progress to preterm delivery • Tocolysis is not proven in trauma.(1) (1) GoodwinTM, Breen MT: Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma, Am J Obstet Gynecol162: 665-671, 1990.

10. Abruptio Placenta • Different elastic properties in uterus & placenta “shearing” • 3 % of minor trauma and up to 50 % in severe trauma

11. Uterine Rupture • Rare, 0.6 % of severe abdominal trauma (1) • Direct trauma after 12 wks of gestation • Prior Surgery (C/S ) the risk 1. Pearlman MD, Tintinalli JE, Lorenz RP: Blunt trauma during pregnancy, N Engl J Med 323:1609, 1990

12. Uterine Rupture

13. Maternal-Fetal hemorrhage • 4 to 5 X more common in injured pregnant women • Causes isoimmunization & fetal death • ? Kleihauer-Betke test - volume of fetal blood • To determine amount of Rhogam needed

14. Blunt Injury Abdomen

15. Penetrating Injury • Gravid uterus alter injury pattern to the mother. • If missile enter upper abdomen; increased probability of harm • If enters below uterine fundus visceral injury less likely (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.

16. Stab Injury

17. Pregnancy Test • Every women in the Reproductive age group must be tested for pregnancy

18. Modalities for Evaluating Trauma • Plain x-rays • Ultrasound • CT & MRI • Cardiotocographic Monitoring • DPL • Laparotomy

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

20. Fundal height

21. Fetal Monitoring • If < 24 weeks, intermittent fetal doppler • If > 24 weeks, then continuous cardiotocographic monitoring to assess FHR and uterine activity

22. A 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 – 15/15 C/O – diffuse pain in chest & abdomen

24. Remember • A Normal ABG Report in a Pregnant Patient Is ABNORMAL

25. Management • Avoid distractions and avoid focus on the fetus. • Be aggressive! But temper with common sense. • An apparently stable mother may be compensating at expense of the fetus.

27. Pre-hospital Consideration • Prevention of maternal hypoxia and hypotension. • Airway patency with adequate O2. • Left lateral tilt. • Volume replacement.

29. Initial maternal Resuscitation Airway Assess & control Pre oxygenate and sellick’s maneuver Breathing Assess and manage Circulation Assess maternal circulation IV access Tilt to left if > 20 wks

30. Unstable Mother

31. Stable mother

32. Key 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.

33. Modification 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.

34. 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

35. Perimortem Cesarean Section • 4 Minute Rule: Maternal CPR for 4minutes, Infant should be delivered by the 5th minute.

36. Perimortem Cesarean Section • Vertical incision from xyphoid to pubis • Continue straight down through abdominal wall and peritoneum • Cut through uterus and placenta • Bluntly open uterus and remove fetus • Cut and clamp cord

37. Perimortem Cesarean Section

38. Remember • Anatomic and physiologic changes • Vigorous fluid and blood replacement • Treat the mother first and treat her just like any other trauma patient

39. When to Intervene and Consult • EARLY !

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

41. Paediatric Trauma

42. kids are not just small adults

43. The priorities are same as that of the adult.

44. Unique characteristics • Size & shape : smaller body mass-greater force applied per unit body area • Skeleton: more pliable – internal organ damage -without overlying bony # • Equipment : appropriate size

45. Airway • Smaller in diameter,shorter in length • Epiglottis – long, floppy,narrow • Large occiput-flexion • Narrowest portion –below vocal cords • Larynx – Anterior & caudal • Large tongue

47. Airway management • Oxygenation • Oral airway • Intubation

50. Sellick’s maneuver