Clinical Challenges in Trauma Surgery: The Pregnant Trauma Patient

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 9 December 2021

⏱️ 26 minutes

🔗️ Recording | iTunes | RSS

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Summary

Has anyone else ever felt the anxiety of hearing the EMS radio call in a pregnant trauma patient, knowing you will soon be getting two patients in one? How do we prioritize our assessment, diagnostic work up, and treatment options for our patient when we have a second patient growing in her uterus? Join our Miami Trauma team including Drs. Urréchaga, Neeman, and Rattan as they discuss how to navigate the physiologic changes and management considerations for the pregnant trauma patient!

Learning Objectives:
- Understand the physiology of the pregnant patient and how it changes how we clinically assess them in the trauma bay
- Emphasize the basics of the primary and secondary assessment in the pregnant patient
- Identify when radiology adjuncts are appropriate
- Identify laboratory and diagnostic adjuncts that are unique to the pregnant patient’s work up
- Discuss treatment options for mom and fetus depending on clinical status

Quick Hits:
1. Sick mom before sick baby - stick to basics and treat mom like any other trauma patient
2. Misuse of seatbelts are an important risk factor for morbidity and mortality in pregnant patients. The lap belt must lie below the uterus and shoulder strap should lie between the breasts.
3. Injured pregnant women should be screened for intimate partner violence.
4. Despite changes in pregnant patient physiology, they can still present with compensated shock. Always have a high index of suspicion when interpreting vital signs and remember to offload patient to the left in order to decompress the IVC.
5. For fetal viability: get FHT when mother’s condition allows. Remember- Fetal distress could be the first sign of maternal hypovolemia
6. NEVER withhold indicated imaging just to avoid radiation in a pregnant patient. Try shielding the uterus when possible, but always proceed with diagnostic imaging when necessary.
7. One more time- sick mom = sick baby!

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Transcript

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0:00.0	Behind the Night, the surgery podcast, relevant and engaging content designed to help you dominate the day.
0:13.0	Hey behind the life listeners, we're the University of Miami writer trauma team and today we're coming to you with a clinical challenge case.
0:29.0	Our name is Eva Rachiga, a surgery resident, and we also have Ori Nieman, our trauma fellow and Dr. Rishi Ratan, our trauma critical care attending surgeon.
0:37.0	Today's case will be one that manages to confuse and provoke anxiety in many trainees, even at upper levels of training, the pregnant trauma patient.
0:46.0	You know, as the trauma surgeon on call, there's always more tension going around when the alert is in for 200 patients arriving at the Bay at the same time.
0:57.0	Who do I tend to first, what am I missing in the other Bay, who gets priority for exam, for scan, for intervention, for operation.
1:08.0	With an injured pregnant patient, we are dealing with two patients, two lives at potential risk.
1:15.0	And if the degree of difficulty and level of stress don't seem to bother you just yet, we should of course add that one of our patients has expected aberrations in physiology, anatomy, hematology and coagulation.
1:30.0	The other potential patient, well, we can't even evaluate the other patient the way we are trained on a daily basis for they reside within the first patient's uterus.
1:41.0	Yeah, Ori, those are all very true points and we all can relate to that.
1:45.0	Additionally, it should be definitely mentioned that nearly one in 10 years pregnancies are affected by trauma.
1:49.0	And trauma unfortunately is the leading cause of non obstetric maternal and fetal mortality during pregnancy with an overall 6 to 7% more maternal mortality rate.
1:59.0	And fetal mortality has been quoted as high as 61% in major trauma and 80% of maternal shock is present.
2:06.0	This incidence increases with gestational age with around half occurring in the third trimester.
2:11.0	While motor vehicle collisions comprise nearly half of these traumas, the two next leading causes are falls and assaults, often from intimate partner violence, accounting for nearly a quarter of trauma and pregnancy.
2:22.0	Thanks, Eva. And note here about intimate partner violence before going on.
2:27.0	Studies from multiple countries across the globe have reported rates from one to as high as 57% during pregnancy.
2:36.0	And this abuse is associated with increased rates of spontaneous abortion, neonatal intensive care unit admission, preterm labor and low birth weight.
2:44.0	Additionally, for the mother, it has been strongly associated with parrypartum depression.
2:49.0	It is very important to screen any woman presenting with trauma for intimate partner violence, depression and suicide risk.
2:58.0	Given its prevalence and its significant effect on morbidity and mortality for both mom and the fetus, it's very important to any emergency provider to understand the physiologic diagnostic and management considerations that different when it comes to treating the pregnant trauma patient at all stages of pregnancy.
3:12.0	So today we will run through a case that will help us do just that.
	...

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