trauma and the pregnant patient

History
The patient is a 35 y.o. female who arrives as a level 2 trauma transfer from OSH.  She arrives via MedFlight on a back board with c-collar in place. She was a restrained (lap belt only) driver of MVC that hit pole head-on.  + airbag deployment.  Denies LOC.  Currently complaining of right elbow pain, left ankle pain and abdominal pain.  No n/v since event.  GCS 15 at scene and on arrival to trauma bay.  Vitals stable en route, has received 2L IVF. FAST reported as negative from OSH, otherwise no additional imaging performed at OSH.

Of note, the patient is a G1P0 at 25 weeks gestation.

OB and Trauma present when pt arrived.

Vitals:  BP 96/64    P 104   R 16   SpO2 99%    T 98.8F
A: patent
B:  b/l BS
C:  RRR.  2+ radials, fems, DP/PT on mom.  FHT 168 BPM
D:  GCS 15
E:  pt exposed, no obvious defomities.  log rolled off BB.

Secondary survey revealed abdomen that is soft but distended, more of a 34-36wk abdomen rather than 25?  Small abrasion over rt elbow.  TTP over distal left tib/fib and ankle without deformity or open lac/abrasion.

FAST:  + in RUQ

Decision?  OR vs CT– discussed risks of CT radiation to baby,
Patient was ‘somewhat’ stable at that time with BP ranging from 90-110 systolic, deicison was made to go to CT scanner at that time

Final dx: Grade 3 Splenic lac

Received PRBC in TB, transferred to IR for embolization then SICU after

Teaching points:

1.  Trauma in pregnancy = still a trauma.  Must do A, B, C’s first still!!

2.  To treat baby is to treat mom.  Pay extra attention to vitals– decrease in mom’s pressure = decrease in profusion to baby.  We obtained FHT initially while obtaining mom’s vitals (prior to rolling pt), then placed on continuous toco once pt was rolled and off BB.

3.  Remember hemodynamics in prenancy– increase in maternal blood volume leads to relative anemia (at baseline CO is increased, HR increased and BP decreased– mimics appearance of shock!).  Also remember that left lat decubitus will decrease pressure on IVC and increase VR.

4.  Important labs:  T&C (remember Rhogam!), fibrinogen, coags– in addition to typical trauma labs.  Administer steroids to preterm mom/fetus in case of emergent delivery.

5.  Imaging:  Try to sheild the fetus as much as possible, but NO imaging should be withheld if indicated to fully evaluate the mother/trauma.  In our case, doing the CT prevented mom from needing the OR.

6.  Delayed gastric emptying in pregnancy = have suction ready as increased risk for vomiting if needing to intubate.  Also, delayed reserves as uterus/baby pushed up on diaphragm.

7.  Even if no apparent injury, high risk for abruption or other comlications– OBSERVE these patients for at least 24 hrs after event on TOCO to ensure FWB and no decline in status.  You can have abruption without vaginal bleeding!

8.  In extreme cases, do not forget about post-mortem C-section: best when performed within 5 minutes of arrest.  Procedure– vertical incision through abdomen and vertical incision through uertus to deliver the baby.

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