253. Trauma in Pregnancy

General

Trauma is most common cause of non-obstetric cause for maternal death (MVC, interpersonal injury, falls). Even minor trauma with no external signs of maternal injury can cause fetal demise.

Pregnancy causes hypervolemia state which can lead to 30% lose of blood volume before mother will show signs of shock.

Quick assessment: after 12 weeks, should be able to palpate uterus past pubic synthesis. After 20 weeks, should be at umbilicus or greater.

Supine Hypotension Syndrome: after 20 weeks, uterus can compress IVC. If backboard, place 30 degree wedge on right hip to move uterus to the left.

Need to do sterile pelvic exam over blind manual exam due to looking for source of bleeding/injury, fluid. Look for premature rupture of membranes – amniotic fluid will fern under drying fluid under microscope exam. Also pH will be 7 whereas vaginal fluid is acidic (pH 5).

Preventative measure: Seatbelt worn with lap band at the lowest possible position under the uterus. Shoulder strap worn between the breasts and on the side of the uterus.

If need to do chest tube, place 1-2 intercostal spaces higher.

Uterine Rupture

Relatively uncommon though high fetal mortality. usually from pelvic fractures.

Fetomaternal hemorrhage

Hard to assess at bedside. Apt test is qualitative test. Kleihauer-Betke is a lab test looking for >5mL of blood in mother – is quantitive test though will likely not get quickly. Don’t need to worry about it – only from admitting service.

If Rh- mother, just give rhogam, even with minor trauma. Have 72 hour window to give. 50mcg if <12 weeks, 300mcg if >12 weeks.

Abruptio Placentae

Most common cause of fetal death in trauma. 1-5% of minor traumas, 40-50% of major trauma. Shear forces applied to placenta base causing placenta separation from uterine wall. Usually abdominal pain with vaginal bleeding in third trimester. Ultrasound may miss rupture/injury (only 24% sensitive). Most sensitive indicator is fetal demise/stress.

Need to have tocomonitoring for at least 4-6 hours. Most pregnancies >20 weeks require monitoring/observation. Partial abruption (<25%) and <32 weeks can be watched with expectant management rather than emergent C-section (though likely will still be admitted for monitoring regardless from the ED).

Management/Treatment

With moderate trauma, go ahead and apply oxygen.

Focus initially on treating mother first before looking at fetus. Healthy mother leads to healthy fetus. Go ahead and call for fetal monitoring though on arrival. Will need 4-6 hours monitoring if after 22 weeks. Fetal viability usually at 25-26 weeks. Low threshold for admission (tenderness, >3 contractions/hr, late decals, vaginal bleeding, rupture of membranes, serious injury).

Ct scans: no adverse fetal outcomes outside of cancer risk if rad <5 total in pregnancy. CT chest < 1 rad, abd/pelvis 2-5 rads. IV contrast can lead to neonatal hypothyroidism. MRI contrast contraindicated.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 253: Trauma in Pregnancy

Rosens, Chapter 182: Trauma in Pregnancy

CrashingPatient.com, Trauma in Pregnancy

253. Trauma in Pregnancy

252. Geriatric Trauma

General

Generally, geriatric means > 55yo.

Falls most common cause of injury in patients > 65yo. MVC are second. most injuries (falls, MVCs, burns) have higher mortality in older population. EMS should transfer geriatric trauma patients (MVC, peds vs MVC, falls from standing with CHI) to trauma center.

View geriatric trauma patient as trauma + medical patient.

Vitals can be skewed – reflex tachycardia can be blunted. “Normal” BP could be significant hypotension in elderly patient. (SBP < 90 in elderly trauma has 80-100% mortality). Also look at medications for HR/BP blunting affect (B-blockers).

Get elderly off backboards ASAP to prevent pressure ulcers.

Head Injuries

Higher mortality from TBI. Both New Orleans Criteria and Canadian Head CT criteria do not include elderly age>60 ie order CT brain/cervical on almost all of these CHIs.

Anticoagulated head injury without any signs/symptoms still has 7-14% risk of ICH. Use PCCs for anti coagulated head trauma due to low volume compared to FFP (also faster reversal).

Higher incidence of SDH secondary to greater stretching of bridging veins. Delayed presentations of symptoms as well due to brain atrophy.

Cervical Spine Injuries

Liberal CT cervical spine in elderly. 2x more likely to have C-spine injury than adults.

Odontoid type II are most common cervical spine injury. Usually due to fall with head impaction. Only 10% have neuro deficits. Type II most common (fx at base of dens). Surgery for type II depends on NSGY. Type I/III usually don’t require surgery – get hard collar.

Central cord syndrome: weakness in upper extremities > lower extremities. Usually after hyperextension injury. Usually no fracture, though usually associated with cervical canal stenosis (25% over 55 have some stenosis). Typically stable though may require decompression surgery. Need MRI if concerned with negative CT.

Cervical Extension-Distraction Injury: hyperextension injury with frontal headache injury as well. Patient able to extend neck back further than they use to (“able to lay down on pillow whereas before they couldn’t). Almost like ‘open book’ fracture – usually unstable and requires surgery.

Chest Trauma

With patient >65yo, risk of pneumonia increases by 27% with every rib fracture. Mortality increases by 19%. Worry about adequate pain control that might lead to splinting/atecleasis.

Abdominal Trauma

Abdominal exam notoriously unreliable in geriatric population.

Pelvic fractures: severe bleeding may be better managed with OR than angio. Less transfusion when packed vs angio. Sacral fractures are now being treated with percutaneous pinning or cement due to mobility issue with long term care. Xrays aren’t great, need CT.

Labs/Management

Look at lactate/base deficit levels initially and overtime.

Start light on crystalloid. Consider starting at 250-500cc bolus first and reassessing after finished.

Number of injuries (not just severity) can lead to increased mortality.

Low threshold for admission particularly if they live by themselves.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 252: Geriatric Trauma

Rosens, Chapter 184: Geriatric Trauma

What’s New In Trauma, William Mallon, AAEM 2017

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252. Geriatric Trauma

251. Trauma in Children

General

Trauma most common cause of death in children > 1.

Primary Survey

ABCDEF

Airway: keep c-spine immobilized with towels to keep child from moving to maintain immobilization. Infant immobilization may require shoulder padding due to large head preventing neck flexion. Ok for infant in car seat to be immobilized in car seat in most situations. Remember Down’s kid are higher risk for c-spine injuries due to axial instability.

Breathing: BVM likely easier for children than adults in route. EMS doesn’t need to intubate in route. Wait for more controlled setting as trauma bay. Apply oxygen in more severe traumas. Hemothorax: operative thoracotomy if initial output > 15mL/kg or 4mL/kg/hr.

Circulation: NS/LR bolus 20mL/kg. If still hypotensive after 3 boluses, start PRBC at 10mg/kg. Access: Consider IO early (can give meds/PRBC through). Femoral central line if needed as well. Umbilical vein cannulation on umbilicus of infant 7-10days old.

Disability: Consider AVPU score (Alert, Verbal, Painful, Unresponsive). Modified GCS table for pediatrics (below).

Exposure: Children more likely to become hypothermic secondary to larger surface area.

F: FAST and Family at bedside for calming/comfort.

Secondary Survey

Just as adult secondary survey. AMPLE (Allergies, Medications, Past medical history, Last meal, Events/Environment) history. Continue to watch for changes in mental status, vitals.

Head Trauma

TBI most common cause of death in injury related deaths. <2yo: falls; 2yo-adolescents: Falls/MVCs, >adolescents: sports/MVC.

Falls from as low as 27 inches can cause serious injury in infants.

Children more prone to TBI due to shear trauma forces secondary to incompletely myelinated brain. Parietal bone fracture accounts for 60-70% of fractures. Next is occipital, then frontal, then temporal. Isolated skull fracture with normal neurological exam with NSGY consult can be discharged with close f/u and observation at home rather than expensive hospitalization. Diastatic Fracture: extends through suture line causing leptomeningeal cyst “growing fracture” which can develop into bone erosion. 1/2 of all intracranial injuries don’t have a skull fracture.

Scalp hematomas: Caput succedaneum – connective tissue hematoma that can cross suture line. Subgaleal hematoma – above periosteum – can cross suture line. Cephelohematoma: hematoma that forms/adheres to periosteum – doesn’t cross suture line.

Increased ICP: HOB 30 degrees, head/neck straight, mannitol 0.5-1.0g/kg, hypertonic 3% 6.5-10mL/kg; consider furosemide 1mg/kg though this is less recommended.

Seizures can occur. 50% of post-trauma seizures have abnormal CT. Prophylactic treatment with GCS < 8 (basically severe injuries). Fosphenytoin 20meq/kg or keppra. Impact seizure – occurs immediately after injury with return to baseline, normal level of consciousness.

0-2yo: Look for neuro abnormalities, AMS, scalp abnormalities (contusion, abrasion, laceration, cephalohematoma), vomiting. Low threshold for young infants to get CT scan. Signs include full fontelle, split sutures, persistent vomiting, setting sign – bilateral lower eye gas unable to lift eyes.

Spinal Trauma

Relatively uncommon due to increased flexibility.

SCIWORA: spinal cord injury with radiographic abnormality. Likely due to weaker blood supply than adults.50% onset of paralysis is delayed. May have some initial neuro deficits or symptoms including numbness/tingling, parathesesis.  Now abnormalities usually seen on MRI. Steroids still controversial (likely not recommended anymore). If given, give 30mg/kg methylprednisone.

50% of all spinal injuries and 67% of cervical injuries in kids < 12 involve occipital or C2. Anatomic fulcrum at C2-C3 in infants due to large head/small muscles. 98% of C-spine pediatric fractures are C1-C3 (Garton, 2008)

NEXUS: still decent but only 2.5% of the study population was under 8yo.

Plain X-rays aren’t perfect. Cervical X-rays need to include lateral, AP, and odontoid view.

Pseudosubluxation: C2 on C3 can occur in up to 40% of the time in children up to adolescents. Use posterior cervical line and relation to spinolaminar line (line of Swischuk) to anterior cortical margin of spinous process of C2. No more than 1.5mm of displacement.

Chest Trauma

20x higher mortality if MVC involves associated chest trauma. Aortic transection less likely in children than adults.

Pneumothorax: listen at axilla for breath sounds secondary to wide transmission of breath sounds.

Commotio cordis: sudden impact to chest wall leading to immediate dysrhythmia/vfib.

Rib fractures are less likely in children due to more compliance so can still have significant pulmonary contusion.

Abdominal Trauma

Low risk for abdominal injury if: no low BP, no abdominal tenderness, no femur fracture, no elevated LFTs, no microscopic hematuria, and no decrease in hematocrit under 30.

Spleen injury most common abdominal organ injuries. usually conservative management though due to thicker splenic capsule. Kehr’s sign: left shoulder pain with spleen injury.

Liver often managed conservatively too though higher rate of mortality from hemorrhage than spleen.

Pancreas: most common cause of acute pancreatitis in children. Handlebar injury. Can have normal CT initially.

Bowel: Jejunum most common segment of bowel injuries. Duodenal hematoma can cause obstruction.

Consider diaphragmatic rupture with seatbelt sign with respiratory distress – usually left sided due to liver.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 251: Trauma in Children

Rosens, Chapter 165: Pediatric Trauma

What’s New in Trauma, William Mallon, AAEM 2017

251. Trauma in Children

250. Trauma in Adults

General

MVC leading cause of death ages 1-44.

Trimodal distribution of trauma deaths.

  1. First rise: prehospital setting. Death due to severe head or vascular injury. Treatment would be mainly preventive measures (seatbelt, traffic laws, etc).
  2. Second rise: immediately after ED arrival. Major head,chest,abdominal injury. Treatment includes rapid transport, prompt resuscitation and assessing for emergent surgery.
  3. Third rise: ICU. Delayed death from SIRS, organ failure. ICU management treatment.

Primary Survey

Assessing quickly for immediate/emergent interventions. Ask EMS for mechanism of injury, suspected injuries, vitals, treatment already given.

Head-on collision: facial injuries, lower extremity injuries, aortic injuries. Rear-end collision: hyperextension neck injuries, c-spine fracture, central cord syndrome. T-bone collision: thoracic injuries, abdominal injuries, pelvic injuries, clavicle/humerus/rib fractures. Rollover: crush injury, spinal compression fracture. Ejected: spinal injuries, significant mortality. Windshield damage: facial/skull/cervical spine. Steering wheel damage: likely unrestrained, thoracic injury, cardiac contusion, aortic injuries. Dashboard: pelvic/acetabalur injury, hip dislocation. Seatbelt worn: sternal/rib, pulmonary contusion, chance fractures, abdominal injuries. Peds vs auto: tibia/fibula injuries, knee injuries. High speed: Waddel’s triad: tibia/fibula, truncal injuries, craniofacial injury. Bicycle: handlebars causing spleen/liver injuries, penetration.

ABCDEs

Airway with cervical protection: Look for airway obstruction, jaw thrust with cervical protection in obtunded. Consider having someone hold neck while assessing head. Logroll if vomit with suction. If GCS less than or equal to 8, intubate. Always RSI (not delayed sequence intubation). Consider NEXUS and Canadian C-spine rule in minor trauma to reduce CT scans (X-rays mis 15% of fractures). If obtunded, assume C-spine injury until proven otherwise (negative CT doesn’t fully r/o either due to ligament injury).

Breathing: Go ahead and place oxygen on patients with trauma early just in case things turn south and you have some pre-oxygenation. Check chest/neck for deviated trachea (tension pneumothorax), crepitus (pneumothorax), paradoxical movement of chest (flail chest). Consider needle thoracotomy for tension pneumothorax. Consider large bore (36Fr) chest tube for hemothorax. Massive hemothorax – consider thoracotomy if initial blood output 1L or 200ml/hr.

Consider ketamine for RSI (KSI). 2mg/kg. Nice due to good pain control, able to do procedures after intubation. Now known to have neuro-protective properties. Increases CPP (Himmelseher, 2005).

Circulation: Check HR, BP, level of consciousness, skin color, presence/magnitude of peripheral pulses. Hemorrhage degree: Classes I-IV. Think about tennis score (0, 15, 30, 40) – different class levels of amount % hemorrhage lost. BP decreases usually around Class III. Apply direct pressure or compression bandage on severe external bleeding (no tourniquets, consider staples for early stabilization of scalp laceration). Establish 2 18g IV though consider IO for early access if unable to get IV quickly. If hypotensive, give 2L NS, then consider blood (type O+ unless child-bearing women). Use FAST ultrasound exam to look for intraperitoneal bleeding or pericardial tamponade. If stable, perform CT scan with IV contrast.  If penetrating trauma with hypotension – early OR. If >10 units of blood, massive transfusion protocol likely needed: 1:1:1 PRBCs:FFP:platelets. Prevent acidosis/hypothermia. TXA: give early for significant hemorrhage. Better in first 3 hours, particularly in first hour. Give 1g over 10 minutes, then another 1g over 8 hours.

Disability: Quick neuro exam, pupil seize/reactivity, GCS. Consider checking glucose in altered patient. Don’t get distracted by obvious ortho injury – stick with the systemic algorithm.

Exposure: Disrobe patient completely looking for bruising, open fractures, lacerations, foreign bodies (leave deeply embedded FB though you can cut if it allows you to shorten the protrusion). Log roll with in-line cervical stabilization to palpate the back. Rectal not really needed unless considering severe spinal cord injury or rectal bleeding. Consider conscious alert patients having bad experiences with clothes being cut off, pain management (Trauma Professional’s Blog, 2017).

Traumatic Arrest: If blunt injury with no signs of life, extremity high mortality – no need for thoracotomy. If blunt with arrest in ED with possible abdominal trauma, consider thoracotomy to clamp aorta (though Rebola is new treatment for this). Strong recommendation for penetrating chest with signs of life in transport or in the ED to do thoracotomy.

Secondary Survey

Head to toe exam. If blood at meatus of penis, hold off on doing foley until retrograde urethrogram. Pelvic exam for vaginal bleeding looking for lacerations.

Most frequently missed injury is orthopedic.

If obtunded, pan CT (head/neck, chest/abdomen/pelvis, spine reconstruction).

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 250: Trauma in Adults

Rosens, Chapter 33: Multiple Trauma

What’s New in Trauma, William Mallon, AAEM 2017

250. Trauma in Adults