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Chapter 11 Trauma in Women

Chapter 11 Trauma in Women. A: Anatomic 12 weeks - rise out of pelvis 20 weeks - at umbilicus 34-36 weeks - at the costal margin 2nd trimester - amniotic fluid embolism 3rd trimester - abruptio placentae. B. Blood Volume and Composition 1.Volume: 1200-1500 ml -signs of hypovolemia

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Chapter 11 Trauma in Women

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  1. Chapter 11 Trauma in Women • A: Anatomic • 12 weeks - rise out of pelvis • 20 weeks - at umbilicus • 34-36 weeks - at the costal margin • 2nd trimester - amniotic fluid embolism • 3rd trimester - abruptio placentae

  2. B. Blood Volume and Composition 1.Volume: 1200-1500 ml -signs of hypovolemia 2. Increased in WBC, fibrinogen , clotting factors 3. Decreased in Hb, PT, aPTT, albumin 4. Blood pressure falls 5-15 mmHg in 2nd trimester 5. CVP is variable 6. ECG: flattened or inverted T waves in leads II, III, AVF

  3. C. respiratory Increased in tidal volume Decreased in residual volume Hypocapnea ( Pco2 of 30 mmHG) in late pregnancy D. Musculoskeletal 7th months: the symphysis pubis widens (4-8mm) The sacroiliac-joint space increased

  4. Mechanism of Injury A. Blunt Injury 1. Direct Injury 2. Indirect Injury Abrutio Placentae & Uterine Rupture Seat belt: forward flexion and uterine compression B. Penetrating Injury Dense uterine musculature & Amnion Low incidence of maternal visceral injury

  5. Assessment and Management A: Primary Survey and Resuscitation 1. Maternal: Hyperventilation 4 - 6 inches elevation of right buttock Fetus may be in shock before maternal hypovolemia shock signs Vasopressors - fetal hypoxia B: Fetus: Uterine rupture Abruptio placentae Continued fetal heart tones 20 -24 wks of gestation

  6. B. Adjuncts to primary survey • Maternal: • Monitor on her left side after physical examination • Monitor of the CVP response to fluid • Maternal bicarbonate is usually low • Fetus: • 20-24 wks heart tones: 120- 160 beats / min • Continous monitor with cardiotocodynamometry • Consultation if abnormal fetal heart rates

  7. C. Secondary Assessment • 1. DPL: perform above the umbilicus • Presence of uterine contractions • 2.Vaginal Examination: • Amniotic fluid with PH of 7 - 7.5 : • ruptured of chorioamniotic membrane • Bleeding in 3rd trimester: • disruption of placenta • impending fetal death • The fetus may be in jeopardy even with apparent, minor maternal injury

  8. D. Definite Care • Uterine rupture: shock or no s/s • Placental abruptio: leading cause of fetal death • 30% no vaginal bleeding • All pregnant Rh-negative trauma patient should considered for RH immunoglobulin therapy. • Initial management is directed at resuscitation and stabilization of the pregnant patient. • Perimortem c/s may be successful if it is done within 4-5 mins arrest.

  9. Radiography in Pregnant Women • No fetus risk: 5 - 10 rad. • The maximum risk attributable to 10 rad of exposure is approx. 0.1 % • After 20th weeks of gestation: cause no fetal abnormalities. • Routine C-spine, CXR, Pelvis obtained with shielding: negligible fetal exposure • CT beam in direct line to fetus: 3 - 9 rad. • CT scan above uterus: < 3 rad to fetus.

  10. Radiography to fetus varies: • 1. The type of study • 2. The size of patient • 3. Position of the fetus • 4. Type of machine • 5. Method of shielding • 6. The number of section obtained • 7. Fetal/uterine size • 8. Coned x-ray beam aimed > 10 cm away from • fetus are not dangerous.

  11. Estimated Radiation Dose to the Pelvic Uterus/ Radiography • Type of examination Dose (mrad) • Low dose group • Head < 1 • C- spine < 1 • T-Spine < 1 • CXR < 1 • Extremities < 1 • High Dose Group • L-spine 204 - 1260 • Pelvis 190 - 357 • Hip and Femoral ( proximal) 124 - 450 • IVP 503 - 880 • Urethrocystography 1500 • Abdomen ( KUB) 200 - 503

  12. Upper-Limit Fetal Dose From Angiography and CT Scan Studies • Type of examination Dose (mrad) • Angiography • Cerebral < 100 • Cardiac Cath < 500 • Aortography < 100 • CT scanning • Head ( 1 cm slices) < 50 • Chest ( 1 cm slices) < 1000 • Upper abdomen( 20 1-cm slices < 3000 • > 2.5 cm from uterus) • Lower Abdomen ( 10 1-cm slices 3000 - 9000 • directly over the uterus/fetus

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