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<< Trauma In Pregnancy: Double Jeopardy (2008)
ED Management Of Major Trauma In Pregnancy
Aggressive fluid resuscitation is essential in the pregnant patient because of the dilutional anemia of pregnancy; up to 30% of blood volume can be lost before obvious signs of maternal shock appear. Maternal shock may also be associated with severe fetal distress.
Early intubation is recommended if the patient is obtunded or has any signs of respiratory compromise. A pregnant patient in the third trimester is more likely to be a difficult airway for a number of reasons, and it is important to be prepared for this possibility. Pregnancy causes fluid retention and weight gain, which leads to swelling of the airway tissues. Additionally, pregnant patients have decreased oxygen reserves and may desaturate quickly. Progesterone causes relaxation of the lower esophageal sphincter and increases the risk of aspiration. In pregnancy, pCO2 is normally decreased; a normal level may suggest respiratory compromise.
Induction and paralytic agents may be used during pregnancy; however, these medications do cross the placenta in small amounts and may affect the initial resuscitation of the baby if delivery is imminent.14
Pressure from the gravid uterus pushes the diaphragm up several centimeters, so if a chest tube is required, it should be placed 1-2 interspaces higher than usual to avoid entering the abdomen. When evaluating the patient’s circulation and volume status, it is important to keep in mind the normal hemodynamic changes of pregnancy. A pregnant patient may lose a significant amount of blood, even more than a liter, before showing any signs of instability. Fetal distress may be the earliest sign. Aggressive fluid resuscitation and transfusion with O negative blood should be initiated in any unstable patient. Vasopressors should be avoided, if possible, since they compromise blood flow to the uterus and lead to decreased fetal oxygen delivery. If vasopressors are needed to save the life of the mother or maintain maternal vital signs, they should not be withheld. After the initial primary survey, a systematic evaluation similar to non-pregnant patient evaluations should be performed.
Early intubation is recommended if the patient is obtunded or has any signs of respiratory compromise. A pregnant patient in the third trimester is more likely to be a difficult airway for a number of reasons, and it is important to be prepared for this possibility. Pregnancy causes fluid retention and weight gain, which leads to swelling of the airway tissues. Additionally, pregnant patients have decreased oxygen reserves and may desaturate quickly. Progesterone causes relaxation of the lower esophageal sphincter and increases the risk of aspiration. In pregnancy, pCO2 is normally decreased; a normal level may suggest respiratory compromise.
Induction and paralytic agents may be used during pregnancy; however, these medications do cross the placenta in small amounts and may affect the initial resuscitation of the baby if delivery is imminent.14
Pressure from the gravid uterus pushes the diaphragm up several centimeters, so if a chest tube is required, it should be placed 1-2 interspaces higher than usual to avoid entering the abdomen. When evaluating the patient’s circulation and volume status, it is important to keep in mind the normal hemodynamic changes of pregnancy. A pregnant patient may lose a significant amount of blood, even more than a liter, before showing any signs of instability. Fetal distress may be the earliest sign. Aggressive fluid resuscitation and transfusion with O negative blood should be initiated in any unstable patient. Vasopressors should be avoided, if possible, since they compromise blood flow to the uterus and lead to decreased fetal oxygen delivery. If vasopressors are needed to save the life of the mother or maintain maternal vital signs, they should not be withheld. After the initial primary survey, a systematic evaluation similar to non-pregnant patient evaluations should be performed.
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