Clinical 7.5 Gline Trauma

Question 1

Most common causes of Maternal Death in Pregnancies

Answer 1

MVA: head injury

Question 2

Most common cause of fetal death in pregnancies

Answer 2

MVA: maternal shock (placenta abrupta is the 2nd most common)
direct fetal injury occurs in less than 1 % of pregnancy related trauma

Question 3

Two main categories of trauma in pregnancy

Answer 3

Blunt (motor vechicles, falls, domestic violence)

Penetrating (gunshot, stab)

Question 4

Physiologic changes in pregnancy, how these changes affect the management of the pregnant trauma victim

Answer 4

Anatomic
Physiologic 
Cardiac
Pulmonary
Gastric

Question 5

Anatomic

Answer 5

During the 1st 12 wks the uterus is protected by the bony pelvis.
As the uterus grows more injuries occur to the fetus.
intestines, stomach and bladder are lifted higher in the abdomen and are more protected from lower abdominal injuries.

Question 6

Physiologic

Answer 6

Maternal BV rapidly increases in 1st trimester and peaks at 32-34 wks Total increase 45%.
Plasma volume grows but red blood cell mass grows less leading to PHYSIOLOGIC ANEMIA
The increased BV may mask the true hematologic status.
The pregnant patient may lose 30-50% of circulating volume before manifesting signs of shock.
Be mindful of RH problems.
12 wks- Blood flow increases to uterus from 60ml/min to 600ml/min.
Total circulating volume flow through uterus every 8 to 11 minutes.
20 wks-size of uterus compresses IVC in supine position. This can lower Cardiac output 28% and systolic BP by 30 mmHg. This venous congestion increases pressure in lower extremities.

Question 7

Cardiac

Answer 7

Cardiac Output increases 1-1.5 liters min to 6 L/min by wk 10.
HR increases 20 bpm in 2nd trimester.
BP decreases in 1st trimester returns to normal in 3rd trimester.
if patient is lying on back can compress IVC and AORTA.

Question 8

Pulmonary

Answer 8

Tidal Volume increases 40% and decreases functional residual capacity by 20%.
The diaphragm is raised 4cm at term complicating chest tube placement and increasing the risk of tension pneumothorax.
Chest tubes should be placed 1-2 interspaces higher than the usual 5th interspace.

Question 9

Gastric

Answer 9

Small bowel & stomach elevated complicating upper abdominal injuries.
Delay in gastric emptying which increases risk of aspiration.
Sensitivity of abdomen to injury and irritation from intraperitoneal blood becomes diminished.
Liver and Spleen are unaffected by pregnancy.
As in non-pregnant pts, splenic injury remains the most common etiology of in-abdominal hemorrhage.

Question 10

Diagnosis and treatment

Answer 10

Always stabilize mother. Fetal survival depends on mother surviving. ABC’s
Oxygen and 2 large bore IV’s.
LR or NS at 3:1 replacement first 30-60 minutes.
Left Lateral Tilt
Avoid vasopressers until fluid replaced.
Try to determine fetal age (FDLMP, Ultrasound, Fundal Height).
Fetal Monitoring at least 4-6 hours for minor trauma and 24 hours for more severe.
US and Radiologic studies (first trimester all or none theory, stay under 5-10 rads).
Cardiac monitoring, pulse ox. (cardioversion up to 300J can be used in all three trimesters)