MOD E Tech Trauma in Pregnancy Flashcards
Trauma in Pregnancy
Anatomical & Physiological Changes
- Pregnancy causes anatomical & physiological changes to the body’s systems that affect the potential patterns of injuries
- The Paramedic is dealing with 2 (or more) patients and must be alert to changes that have occurred throughout the pregnancy
Trauma in Pregnancy
Respiratory System
Respiratory System
- Oxygen demands increase by approx. 15% in late pregnancy (IHCD)
- Tidal volume - +20% by 12 weeks (IHCD)
+40% by 40 weeks (IHCD)
- Residual volume
- Vital capacity ¯
- Respiratory rate is slightly
- Airway resistance ¯
Many women are mildly breathless in pregnancy. This should not be confused with the “air hunger” of shock
Airway changes:
- Full dentition
- Necks may appear short and obese
- Engorged breasts
- Slight oedema of upper airway
- Increased risk of regurgitation and aspiration
These factors can make intubation difficult
Physiological changes which influence airway management:
- Relaxation of cardiac sphincter
- Increased intra-gastric pressure
- Delayed gastric emptying
These combined factors may lead to Mendelson’s Syndrome
Trauma in Pregnancy
Cardiovascular System
- Blood volume rises by >45% (JRCALC 2013)
- Plasma increase > Red cell increase
\ “Haemodilution of Pregnancy”
- Heart Rate increases by 10 – 15 bpm
- Cardiac Output increases by 20-30% in the first 10 weeks of pregnancy (JRCALC 2013) as a result of 3 factors
- Hormonal
- Metabolic
3 Vascular
Trauma in Pregnancy
Blood Pressure:
Blood Pressure:
•Systolic falls in first half of pregnancy (10 – 15mmHg)
•
•Diastolic falls more than Systolic
•
• Venous pressure in legs = oedema & varicose veins
•
•Rises to near pre-pregnancy levels by term
Trauma in Pregnancy
Hypovolaemia:
- Compensate effectively for some time
- Minimal changes in maternal signs
- Base diagnosis on observed or anticipated blood loss
- Change from compensation to decompensation is rapid
- 35% blood loss can occur before clinical signs of shock develop
Compensation for blood loss is possible because of:
• maternal blood and red cell volume
•
•Increased volumes fill larger intravascular space
•
•¯ Placental blood flow early in haemorrhage
•
- Maternal circulation maintained at cost of foetus
- Shunting of blood away from placenta maintains maternal circulation
•
• blood volume now fills intra-vascular space
•
•As bleeding continues and volume falls patient has little in the way of further compensating mechanisms
•
- Decompensation is precipitous
- Decompensated shock is very difficult to reverse in pregnant women
•
•Maintain high index of suspicion about risk of blood loss
•
•Early fluid resuscitation
•
•Keep on-scene times to a minimum
Supine Hypotension
Supine Hypotension
- Gravid uterus presses on inferior vena cava reducing venous return
- ¯ Cardiac filling
- ¯ Cardiac Output
- Compensatory vasoconstriction
- ¯ BP = Maternal syncope
- ¯ Aortic pressure allows aortic compression
- ¯ Uterine perfusion
- Foetal oxygenation jeopardised
Management of supine hypotension:
- “Normal” feature of late pregnancy
- No woman in 3rd trimester should be nursed fully supine
Manage:
- Left lateral
- On spinal board or scoop – 15-30° left lateral tilt
- Manual uterine displacement
Postural Hypotension
Postural Hypotension
•¯ peripheral resistance = sudden drop in BP on standing
•
Management:
- Change position slowly
- Sit up first, legs out straight, pause
- Swing legs over edge of bed, pause
- If no dizziness - stand up
Domestic violence
•30% starts during pregnancy
•
•? Protection issue for mother and baby
•
•Can cause miscarriage, stillbirth and maternal death
RTC’s
RTC’s
•Injury result from lack of seat belt use
•
Maternal mortality:
- Thrown from car - 33%
- Not ejected - 5%
Foetal mortality:
- Mother thrown from car - 47%
- Mother not ejected - 11%
Trauma in Pregnancy
Women die from:
Women die from:
- Haemorrhage
- Uterine rupture
•
Foetus’s die from:
•Placental abruption
•
•Maternal and foetal mortality are both reduced when a three-point seat belt is worn
•
•Always wear a full seat belt. Above and below the bump - not over it
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- Foetal hypoxia will occur before evidence of maternal shock
- Early & aggressive control of mother’s airway
- Oxygen (maintain 94-98%)
- Ventilatory support
- I.V. fluids - en route if necessary (Paramedic intervention)
- C-spine control
- Rapid evacuation to hospital with obstetric & trauma facilities
- Assess blood glucose en route
•
DO NOT transport supine on a longboard/scoop
- <c>ABCDEF</c>
- Foetal hypoxia will occur before evidence of maternal shock
- Early & aggressive control of mother’s airway
- Oxygen (maintain 94-98%)
- Ventilatory support
- I.V. fluids - en route if necessary (Paramedic intervention)
- C-spine control
- Rapid evacuation to hospital with obstetric & trauma facilities
- Assess blood glucose en route
•
DO NOT transport supine on a longboard/scoop
Summary
- There are 2 patients, mother and foetus
- The only way to save both is to save the mother first
- Always assess & stabilise mother first
- The physiological changes of pregnancy require careful and prompt attention to oxygenation and fluid replacement
- Haemorrhage is frequently concealed in pregnant victims and hypovolaemic shock is inevitably severe once the signs manifest themselves
•
•Failure to relieve vena caval compression kills the mother and the foetus
•
•The pregnant trauma victim should always be considered to have time critical injuries and be transported accordingly
