Contents:

Protocol for paging Trauma team The Trauma Team Primary Survey Secondary Survey Radiology Placement Head injuries Spinal Injuries Chest Injury Blunt abdominal Trauma Penetrating abdominal Trauma Urological Injuries Eye Trauma

Hand Injuries Burns Carbon monoxide poisoning Obstetric Trauma Paediatric Trauma Paediatric resuscitation chart Hypothermia Universal Precautions Blood Alcohol Testing Patient transfers into Liverpool Patient transfers out of Liverpool Telephone numbers Acknowledgments

CONSIDERATIONS

• Pregnancy alters physiological function in most body organs.
• Laboratory norms are often different.
• Labour may ensue and be unrecognised.
• Response of both mother and fetus depends on gestational age (< 12 weeks, little change in treatment except caution with drugs eg. anaesthetic gases.
• Presence and degree of maternal Hypovolemia, resulting in a anoxia and acidosis of the fetus.
• Trauma in pregnancy carries a high maternal mortality rate and very high fetal mortality rate.
• Penetrating injuries present the same risk to pregnant females as non-pregnant females. As the uterus rises, the pelvis and fetus becomes vulnerable to both blunt and penetrating trauma. The amniotic fluid provides some protection. Where blunt injury is severe, the most common injury to the fetus is fractured skull and intracranial haemorrhage. Pelvic fractures are often associated with haemorrhage due to increased hormonal activity creating a more vascular region.
• Other causes of fetal death due to trauma include placental disruption and uterine rupture.
• During the second and third trimester, the uterus becomes the largest abdominal organ and may shield many other organs. The fetus becomes most vulnerable to penetrating and blunt injury.

PHYSIOLOGICAL CHANGES DURING PREGNANCY

• Hyperkinetic state resulting in
  • increased heart rate
  • increased cardiac output
  • reduced blood pressure (often to 90/60)
  • increased or reduced venous pressure, however the response is unchanged
  • increased blood plasma (by 40-50%)
• Raised tidal volume and minute ventilation (respiratory alkalosis)
• Dilutional anaemia
• Prolonged gastro intestinal emptying so assume stomach is full
• Raised uterine and pelvic blood flow

ASSESSMENT AND RESUSCITATION

The best care for the unborn baby is the best care for the mother.

If maternal death is imminent, resuscitation of the mother must be continued until fetal age is determined.

Pregnant women do not tolerate hypoxia well, but the unborn baby will tolerate hypoxia longer than normal.

When maternal survival is likely, aggressive resuscitation must be continued Remember, the mother may appear clinically stable as blood is shunted from the uterus which is a non-vital organ thereby increasing blood plasma volume by 30%. Pregnant women often have a low blood pressure and some degree of tachycardia normally. These physiological changes often make it difficult to assess the degree of hypovolemia.

PRIMARY EVALUATION

This should include the ABCs. Always administer continuous oxygen. Pregnant women may loose 35% of their blood volume before they appear haemodynamically unstable. The fetus may be shocked even when the mother appears haemodynamically stable.

To determine whether PV bleeding is fetal or maternal an APPT test may be performed by biochemistry.

MANAGEMENT

When spinal injuries are not suspected, the injured patient should be transported and evaluated lying on the left lateral side. If spinal injuries are suspected, then the right hip should be elevated on a sandbag and the uterus manually moved to the left so that it is not resting on the inferior vena cava.

Pregnant women are prone to gastric reflux due to the height of the uterus. A naso-gastric tube should be considered to prevent aspiration of gastric contents.

Special injuries associated with pregnant women may be:

• Traumatic rupture of the uterus.
• Amniotic fluid emboli or extensive placental separation which may cause DIC
• Pelvic fracture with massive retroperitoneal bleeding due to engorged pelvic vessels.
• Tearing of broad ligaments results in massive haemorrhage and rapid fetal death.
• Peritoneal lavage via a supra umbilical incision is performed for the same indications as for a non-pregnant patient.
• If abdominal surgery is required, it is performed through a midline incision.
• Aggressive initial management, resuscitation and stabilisation of the mother is necessary. The fetus is best protected by a stabilised intra uterine environment.
• Any live fetus delivered is primarily a trauma case and management is the responsibility of the trauma team who will assume management in partnership with the paediatric and critical care departments.

SECONDARY EVALUATION

This includes fetal heart rate and monitoring using an ul~asonic doppler cardioscope. Hypoxia of the fetus is demonstrated by inadequate acceleration of the fetal heart rate in response to uterine contractions. X-rays should be done when necessary despite pregnancy for evaluation of injuries.

ADDITIONAL TESTS FOR TRAUMA IN PREGNANCY

Platelet Count

FDP analysis

Clotting time

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