Trauma Bullets - June 2020

October 27, 2020
Clinical

Case

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

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