Trauma Bullets - June 2020

October 27, 2020


Transfer from an outside hospital: 28 y/o female 4 months pregnant with multiple pelvic fractures and a left-sided first rib fracture

Hematologic changes in pregnancy

-Maternal blood volume can be increased up to 50%

-RBC mass increases by 20-30%, however this is smaller than the increase in plasma volume which leads to a physiologic anemia of pregnancy

-This leads to an attenuated initial response to hemorrhage, therefore IV fluids should be administered aggressively

-The pregnant patient is also coagulopathic with increases in clotting factors and VWF

-Pregnant patients may also have a mild leukocytosis (6-16K WBC)

-Cardiac output increases 30-50%

-Decreased lower esophageal sphincter tone and delayed gastric emptying can lead to increased aspiration risk

-The enlarged uterus causes elevation of the diaphragm by approximately 4cm, resulting in a 20% decrease in FRC

General resuscitation principles in pregnancy

-Maintain maternal pulse ox >95% secondary to increase in basal oxygen consumption of the mother and fetal sensitivity to maternal hypoxia

-Be judicious with uterine displacement.  A gravid uterus of >20 weeks runs the risk of IVC compression and decreased venous return leading to maternal hypotension when lying flat

-Placement of a towel or wedge under the right hip and manual displacement of the uterus are all acceptable measures to decrease IVC compression

-Recall that any treatment needed to help the mother helps the fetus

-If a trauma CT is necessary for maternal management/resuscitation, it is a necessary test.  Radiation exposure of less than or equal to 5msv is generally acceptable in the pregnant patient

-Kleihauer-Betke test: measure of the amount of fetal hemoglobin transfer from the fetus to the mother’s bloodstream

-It is safe to assume that any maternal abdominal trauma can lead to materno-fetal hemoglobin transfer and Rhogam should be considered in rh negative mothers

-Any viable pregnancy (20 weeks or greater) should be monitored for a minimum of several hours in an OB triage unit

-Intimate partner violence is the leading cause of trauma in pregnancy, all patients should be screened

Perimortem C-Section

-Primary goal is improvement of maternal resuscitation

-Decreases uterine compression of the IVC, increasing maternal venous return.  In addition this reroutes all the blood flow diverted to the uterus back to the maternal circulation

-Fetus is viable at 24 weeks.  If the fundus of the uterus is at the umbilicus, viability is a reasonable assumption

-At 24 weeks gestation, there is a 20-30% chance of fetal survival if neonatal facilities are available

-Decision should be made to perform within 4 minutes of beginning resuscitation.  Fetus should be out by the 5th minute.  At 0-5 minutes post-arrest the fetus has 70% chance of having no neurologic sequelae.  At 5-10 minutes this drops to 15%

-Vertical incision should be made from the xiphoid process to the pubis

-Vertically incise the lower portion of the uterus and carefully dissect the upper half to avoid cutting the fetus

-Remove the fetus, clamp and cut the cord, consider packing of the uterine cavity

-CPR is continued throughout the entire procedure

Related Posts

While we make every effort to produce accurate information, we are still learning. This clinical material on this website represents how we have interpreted what we have seen or read. We welcome any comments, suggestions or correction of errors. We take no money from drug or device companies. By reading the content of this website, you agree not to use this information as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Consult your own physician for any medical issues that you may be having. This entire disclaimer applies to any and all content on this website. Under no circumstances shall any of the contributors on this website be responsible for damages arising from use of this website.

This website should not be used in any legal capacity whatsoever, including but not limited to establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the website.

Stay in Touch

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form