Trauma

Treating a pregnant trauma patient involves special considerations to ensure the safety of both the mother and fetus. Here's an approach based on standard guidelines:

Primary Survey (Mother First!)

  1. Airway:

    • Ensure the airway is patent and protected. Pregnant patients may have increased risk of airway obstruction due to edema.
    • Anticipate difficult intubation; use smaller-sized endotracheal tubes if necessary.

  2. Breathing:

    • Provide 100% oxygen via mask or intubation to maintain maternal oxygenation, as hypoxia can quickly harm the fetus.
    • Monitor for respiratory compromise, especially in later pregnancy when the diaphragm is elevated.

  3. Circulation:

    • Address maternal circulation first; fetal survival depends on maternal stability.
    • Use crystalloid fluids or blood products to manage hypovolemia.
    • Tilt the patient to the left (15-30 degrees) or manually displace the uterus to avoid supine hypotension caused by aortocaval compression.

  4. Disability (Neurological):

    • Evaluate the Glasgow Coma Scale (GCS) and check for signs of head trauma.
    • Monitor for seizures, which could indicate eclampsia in pregnant patients.

  5. Exposure:

    • Fully expose the patient to identify all injuries, but prevent hypothermia.

Secondary Survey (Detailed Assessment)

  • Fetal Assessment:

    • After maternal stabilization, assess fetal heart tones (normal: 120-160 bpm) using Doppler or ultrasound.
    • If gestation >20 weeks, initiate continuous fetal monitoring.

  • Imaging:

    • Perform imaging studies as needed for maternal evaluation. Use shielding when possible, but prioritize necessary imaging (e.g., X-ray, CT scan).
    • MRI is preferred for detailed soft-tissue evaluation when applicable.

Special Considerations

  1. Resuscitative Measures:

    • Manage hemorrhagic shock aggressively; pregnant patients may compensate until significant blood loss has occurred.
    • Type and crossmatch blood, and use Rh immunoglobulin (e.g., Rhogam) for Rh-negative mothers if indicated.

  2. Trauma-Specific Interventions:

    • Perform perimortem cesarean delivery if maternal cardiac arrest occurs and gestation is >24 weeks.
    • Evaluate for placental abruption with signs like uterine tenderness, vaginal bleeding, or contractions.

  3. Multidisciplinary Care:

    • Involve obstetrics, neonatology, and trauma surgery teams early.
    • Consult a perinatologist if complex fetal issues are identified.

  4. Medications:

    • Avoid teratogenic drugs (e.g., certain anesthetics or antibiotics).
    • Manage pain appropriately, considering fetal safety.

Post-Evaluation Monitoring

  • Observe both the mother and fetus for complications such as preterm labor, placental abruption, or worsening trauma-related injuries.
  • Administer tocolytics or corticosteroids if preterm delivery is imminent.

By prioritizing maternal stabilization, you maximize fetal survival chances, emphasizing the mother-first approach.

 

Making the Diagnosis and Management_Adult

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