Baby on Board! The Pregnant Trauma PatientBaby on Board! The Pregnant Trauma Patient Gillian...
Transcript of Baby on Board! The Pregnant Trauma PatientBaby on Board! The Pregnant Trauma Patient Gillian...
BabyonBoard!ThePregnantTraumaPatient
GillianSchmitz,MD,FACEP
OBJECTIVES
1. Maternal-fetal anatomy & physiology2. Approach to Resuscitation3. Uterine pathology4. Fetal Monitoring5. Perimortem cesarean delivery (PMCD)6. Evidence based approach for disposition
AnatomicChanges
AnatomicChanges
PhysiologicChanges
• HRincreases10-20bpm• BPdecreasesby10-15mmHG
• Canlose30-35%circulatingbloodvolumebeforemanifestingclinicalsignsofshock!
Increasedminute
ventilation
Respiratoryalkalosis
Fasterdesaturation
Respiratory
• Tidal volume• Respiratory rate• O2 consumption• PCO2
• Arterial pH
• é (by 25%)• é (40-50%)• é (15-20%)• ê (27-32)• é (7.40-7.45)
Relative hypocapnea & faster desaturation
Renal / GI
• Kidneys• Bicarbonate• Base excess• Creatinine• Gastric emptying
• hydronephrosis• ê (19-25)*• ê (3-4) • ê
• ê
SupineHypotensionSyndrome
Labs
ApproachtoResuscitation:PrimarySurvey
ADEQUATERESUSCITATIONOFMOTHER
Airway:earlyRSI
• é riskdifficultintubation• Failedintubation8xé– éWeightgain(aspirate)– éRespiratorytractmucosaledema• Smallertube
– é Airwayresistance– ê Respiratorysystemcompliance– é Oxygenrequirements
No. 325, June 2015 Guidelines for the Management of a Pregnant Trauma Patient
Vital Signs in Pregnancy
–Normal is NOT normal –Up to 30% (2 L) loss of blood volume
before vital signs change–Maternal shock = fetal survival 20%
ApproachtoResuscitation:SecondarySurvey
• Headtotoeexam• Abdominalexam/fetalviability• GUexam• Fetalmonitoring/earlyOBconsultation• EarlyNGtubeplacement/IVF/blood
• ADEQUATERESUSCITATIONOFMOTHER
ImaginginPregnancy
PlacentalAbruption
PlacentalAbruption
FetalMonitoring
UterineRupture
PenetratingTrauma
Intimate Partner Violence
• Focus is on the fetus–Abdomen (60%)
• éPreterm delivery• éFetal demise
DomesticViolence
• Thinkaboutit• Askwhenpatientisalone• Socialservicesevaluationorreferral
InjuryPrevention
Expectantmomwithseaton
© Mark Pearlman MD
ResuscitativeHysterotomy
SurvivingInfantswithTimeofMaternalArrestin
Perimortem CSection
KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.
MaternalImprovementafterCsection
KatzV,Balderston K,DeFreest M.Perimortem cesareandelivery:wereourassumptionscorrect?.AmJObstet Gynecol.2005Jun.192(6):1916-20;discussion1920-1.
Considerations
• EstimatedGestationalAge
• Adequacyofresuscitativeefforts
• ElapsedTime
WhatdoIneed?
TreatmentAlgorithm>20weeks
Unstable Stable
Resuscitate
TransfertoOR
PerimortemCsection
TreatmentAlgorithm>20weeksStable
FASTExam/Ultrasound
+ -
Serialexams
ConsiderCT
FetalMonitoringOBconsultation
SurgicalandOBconsultation
CTvs OR
FetalMonitoringADMIT
Unstable
TreatmentAlgorithm>20weeksStable
CTneg
TocodynamometerMonitoring
• Monitoringfor4hoursissufficienttoruleoutmajortrauma-relatedcomplicationsinlowriskpatients
FetalMonitoring
HospitalizationanduterineactivitymonitoringbyEFMfor24hoursforpatientswith:
• uterinetenderness,vaginalbleeding• contractionsduringamonitoringperiodof4hours
• ruptureofthemembranes• atypicalorabnormalfetalheartrate• highriskmechanismofinjury(motorcycle,pedestrian,
• highspeedcrash)
Fetomaternal Hemmorhage
• Apttest• Kleihauer-Betke (KB)test• Rhogam• Tetanus
TakeHomePoints
• Focusresuscitationonmom• Notallminortraumaisminor!• Vitalsignsnotreliableindicators• Imaginginpregnancy• PMCSnowResuscitativeHysterotomy
Questions?