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ATLS
Trauma in WOMAN
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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 beconsulted early in the evaluation of pregnant traumapatient.
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Anatomic alteration of pregnancy
Fundal height
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Blunt trauma The uterus and its
contents(fetus andplacenta) are morevulnerable for trauma thanbowel
Penetrating trauma Penetrating trauma to upper
abdomen result in complexintestinal injury
Anatomic alteration of pregnancy
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Increased plasma volume : decreased Hct(31-35% in late pregnancy)
Anatomic alteration of pregnancy
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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
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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 thenonpregnant state
Anatomic alteration of pregnancy
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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
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Progesterone : hypocapnia is common in latepregnancy
Diaphragm elevate : reduce residual volume
Increase inspiratory capacity
FVC slightly change
Increase O2 consumption
PaCO2 35-40 mmHg may indicate impending respiratory failur
Anatomic alteration of pregnancy
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Pituitary gland increases in size and weightby 30% to 50% : pituitary insufficiency
Anatomic alteration of pregnancy
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Pubic symphysis widening 4-8 mm
SI-joint space
Anatomic alteration of pregnancy
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Eclampsia : mimic head injury Seizure occur with associated
hypertension, hyperreflexia, proteinuria,and peripheral edema
Anatomic alteration of pregnancy
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Mechanism of Injury
abdominal wall, uterine myometrium,amniotic fluid
buffer
Enlarged and engorged pelvic vesselsin gravid uterus
massive retroperitonealhemorrhage after blunt trauma
IncidenceMotor vehicle accidents/pedestrians59.6%Falls 22.3%Direct assaults 16.7%Other 0.1%
lunt Injury
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CollisionsUnrestrained pregnant women
higher risk of premature delivery and fetaldeath
RestrainLap belt alone
forward flexion and uterine compressionUterine rupture or abruptio placentae
Lap belt + shoulder restraintsgreater surface area for dissipating thedeceleration force
Prevent forward flexion over the gravid uterus
lunt Injury
Mechanism of Injury
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lunt Injury
Mechanism of Injury
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Enlarged gravid uterus other viscera injury uterine injury
netrating Injury
Mechanism of Injury
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DetermineMaternal and fetal outcome
Treatment methodMajor injury
typically associated with fetal injuryadmit to facility with trauma + obstetriccapability
Minor trauma
Severity of Injury
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DetermineMaternal and fetal outcome
Treatment methodMajor injuryMinor trauma
occasionally associated with abruptioplacentae and fetal lossclosely observed
Severity of Injury
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1. Primary survey & resuscitation of mother
2. Primary survey & resuscitation of fetus3. Adjunct to primary survey for the mother
4. Adjunct to primary survey for the fetus
5. Secondary survey of mother
6. Definitive care
Assessment andtreatment
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Assessment andtreatment
ABCDE assessment
Manually place uterus to the left sidepressure on IVC VR CO
Primary survey & resuscitation of mother
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Proper immobilization in pregnant patient
Log roll 4-6 inches or 15 to the left
Primary survey & resuscitation of mother
Assessment andtreatment
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d
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Fetal deathMost common : Maternal shock & death
Second most common : Abruptioplacentae
Primary survey and resuscitation of the FETUS
Abruptio placentaeAbrup tio placentaeVaginal bleeding (70%)Uterine tenderness
Frequent uterine contractionsUterine tetanyUterine iritability
Investigation : U/S
Assessment andtreatment
d
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Fetal deathRare cause : Uterine rupture
Primary survey and resuscitation of the FETUS
Uterine ruptureUterine rup tureAbdominal tenderness, guarding, rigidity, orrebound tendernessProfound shock Abnormal fetal lie; transverse or obliqueEasy palpation of fetal partInability to readily palpate the uterine fundus
Investigation : X-ray extended fetalextremities, abnormal fetal osition, and free
Assessment andtreatment
A d
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Risk factor for fetal lossMaternal HR > 110/min
Injury severity score > 9Evidence of placentalabruptionFetal HR > 160 or < 120
Ejection during a motorvehicle accidentMotorcycle or pedestriancollisions
Primary survey & resuscitation of the FETUS
Assessment andtreatment
A d
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CVP monitoringuesful in maintaining the relative
hypervolemia required in pregnancy
Pulse oximetry
ABG
HCO3 is normally low in pregnantpatient
Adjunct to primary survey and resuscitation for the MOTHER
Assessment andtreatment
A d
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Consult OBFetal distress can occur any time
Fetal heart rate : 120-160/minMater blood volume status and fetal well-being
Fetal heart toneIntermittent doppler u/s after GA 10 wk
Cardiac tocodynamometerUseful after GA 20-24 wk
Radiographic study should be perform asnecessary
benefit > risk
Adjunct to primary survey and resuscitation for the MOTHER
Assessment andtreatment
A d
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Adjunct to primary survey and resuscitation for the MOTHER
Assessment andtreatment
A d
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Hx & PE and I/C for CT scan, FAST, DPLsame as non-pregnant patient
DPLCatheter should be placedabove the umbilicus
with open technique
Secondary assessment
Assessment andtreatment
A d
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Pay attention to uterine contractionsregular contractions suggesting earlylabor
tetanic contraction suggesting abruptioplacentae
Perform pelvic examination by OB doctordecision for emergency cesareansection
Admission to hospitalVaginal bleedingUterine irritabilityAbdominal tenderness, pain, orcramping
Evidence f hypovolemiaChange or absence of fetal heart tones
Secondary assessment
Assessment andtreatment
A t d
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OB consultation
Extensive placental separation or amnioticfluid embolization
Widespread intravascular clotting DICfibrinogen (
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Fetomaternal hemorrhageFetal anemia and death
Isoimmunization in Rh-negative motherMg : Rh immunoglobuin therapy
within 72 hr of injury in allpregnant Rh negative
trauma patient unlessthe injury is remotefrom uterus
Definitive care
Assessment andtreatment
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The Battered, Abused Child
A discrepancy exists between the history and thedegree of physical injury
A prolonged interval has passed between thetime of injury and presentation for medical care
The history includes repeated trauma, treated insame or different EDs.
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The Battered, Abused Child
The history of injury changes or differentbetween parents or guardians.
Shopping of hospitals or doctors
Parents respond inappropriately to or do notcomply the medical advice
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The Battered, Abused Child
Multicolored (multi-stage ) bruises
Evidence of frequent previous injuries, typified by oldscars or healed fractures on x-ray examination
Perioral injury
Injury to the genital or perianal area
Fracture of long bones in children younger than 3years of age
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The Battered, Abused Child
Ruptured internal viscera without antecedent major blunttrauma
Multiple subdural hematoma, especially without a fresh skullfracture
Retinal hemorrhages
Bizarre injuries : bite, cigarette burns, rope marks
Sharply demarcated second-third degree burn in unusual area
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