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Trauma in the Elderly and Pregnant Woman Introduction In the pregnant trauma patient there are two patients potentially at risk Need to consider the influence of: - pregnancy related anatomic changes - pregnancy related physiological changes Incidence and aetiology of trauma in pregnancy A major contributor to maternal mortality worldwide In NZ, Australia, UK and USA trauma is the leading cause of associated maternal deaths 2/3’s : MVA 1/3: - domestic violence - assaults - suicide Pregnancy is a risk factor for being assaulted Types of trauma Penetrating (knife, foreign object) - foetus at greater risk with enlarge uterus - indications for laparotomy same as for non pregnant woman Blunt ( MVA, assault) Burns - Foetus: - consider fluid loss, hypoxaemia and sepsis - Pregnant woman - admit for smoke inhalation etc, add %5 to estimation if anterior abdomen involved in burn Mechanisms and Prevention MVC: leading cause of blunt injury Only 46% pregnant trauma patients are restrained Fears about seat-belt related harm to fetus Lap belt low at the pelvic brim Unbelted has 2x risk of premature birth and 4x risk of fetal death Only 17% women counselled on appropriate use significant cause of blunt and penetrating injury Violence: ALWAYS HAVE A HIGH INDEX OF SUSPICION Rule out domestic & sexual violence Four groups of Trauma patients to consider The patient that is injured but unaware they are pregnant - all women should be considered pregnant until proven otherwise - Teratogenic effects The pregnant patient where gestation < 26 weeks - maternal resus primary goal Where gestation >26 weeks - two patients to consider Perimorteum state - early caesarean: maternal resus, fetal survival Anatomy Uterine enlargement - 12 weeks, 20 weeks and 36 weeks - at 20 weeks fundal height at umbilicus Uterine wall thins Amniotic fluid Placenta Descent of foetal head Upward displacement of - GIT - Diaphragm Estimated Foetal Age 1st trimester uterus is thick walled and intra-pelvic Out of pelvis > 12 weeks 2nd trimester uterus contains a large amount of amniotic fluid 3rd trimester uterus is thin walled, large, fetal head engages pelvis At 36 weeks uterus reaches costal margin Ensure distended abdomen is 2dary to fetus and not blood Physiological changes in pregnancy Cardiovascular Respiratory Haematological Gastrointestinal Neurological Renal Cardiovascular Increases Cardiac output from first trimester CO markedly increased by 20 weeks HR increases by 15 beats/min BP decreases by 10 mmHg, nadir @ 20 weeks, then increases to pre-pregnancy values @ term Decreased peripheral vascular resistance Increased volume of distribution secondary to placenta Maternal haemorrhage is compensated for by foetal distress ( compare to non pregnant where the patient would become tachycardic and hypotensive Supine Hypotension Syndrome 30 degree tilt after 20 weeks Loss of 30% blood volume before symptomatic Low venous return when supine ( up to 30%) Respiratory System By 20 weeks, decrease in FRC and an increase in tidal volume No changes in FEV1 and respiratory rate Respiratory Alkalosis: - secondary to physiological hyperventilation - resulting decrease in PaCO2, increase in PaO2 and a decrease in bicarbonate concentration Haematological System Plasma volume increases by 45% (6-8 weeks) Physiological anaemia - dilutional effect Increased red cell mass Haemoglobin 105/L WCC 6,000 – 16,000 ( 1st and 2nd trimester) WCC 20,000 – 30,000 (periparteum) Hypercoagulable state Fibrinogen concentration increases Gastrointestinal System Increased risk of gastric aspiration: - secondary to increase in intra-abdominal pressure - and relaxation of the lower oesophageal sphincter Delayed gastric emptying In a Trauma patient do early gastric decompression Neurological Enlarged pituitary - result more susceptible to shock Pre-eclampsia - don’t forget this mimics head injury Consider doses and which anaesthetic drugs to use Renal System Glomerular hyper filtration -- therefore a reduction in normal plasma creatinine (35-40 mmol/l) Case 1 27 year old female 8 months pregnant Unbelted passenger involved in a high speed MVA On arrival: What next? primary survey unremarkable Obvious seat belt sign over pregnant abdomen Seat belt Vital Signs enroute HR 104/min Respiratory Rate 25/min BP 104/54 SpO2 98% on room air On arrival Patient is confused, agitated and not following commands She is breathing rapidly and shallowly Her Vital signs are now: - HR 120/min - BP 90/40 - SpO2 92% on 2l Nasal Prongs Examination She has bruising to her abdomen There is subcutaneous emphysema of the chest wall What now? ? Intubation ? Fast Scan How sensitive is a fast scan in pregnancy? How are you going to manage her airway? FAST SCAN Is less sensitive for free fluid in the pregnant patient than in non-pregnant patients Sensitivity decreases with gestational age secondary to altered fluid flow in the abdomen Remember small amounts of intraperitoneal fluid normally present in pregnancy How do you Know she is Pregnant? Ask her? bhCG on all women of childbearing age - bHCG doubles q 1.6 days early on then q 3 -4 days by 7th week - if > 18000 can see gestational sac Ultrasound / FAST - 11% pregnancy diagnosed in the trauma room Outline of Trauma in Pregnancy Primary survey and resuscitation of mother Foetal assessment and detecting injury Secondary survey of mother with special considerations Perimortem Caesarean section - fetomaternal haemorrhage - imaging - medication Critical Care concerns Mechanism & Prevention EARLY OB CONSULT Trauma in Pregnancy Hospitalization in 0.4% of pregnant women Leading cause of non-obstetrical mortality Causes of death Mother head injury foetus - maternal shock - placental abruption - direct injury (GSW to fetus or pelvic fractures of mother What do I need to do care for the unborn child? - CARE FOR THE MOTHER Mother - Initial Management A : Endotracheal intubation, avoid nasal passages B: (pre)oxygenate well ( will desaturate < 1min) Watch potential for aspiration, watch chest tube placement C: foetal distress first sign of maternal hypotension - Supine Hypotensive Syndrome (SHS) (tilt to left >20 wks) D: Eclampsia vs brain injury E: Estimate age of foetus Resuscitation Call for help early - multidisplinary team - involve an obstetrician Displace uterus laterally and left if above umbilicus Assess ABC Estimate gestational age if not known Uterine fundus > 4 finger breaths above umbilicus at 4 months If defibrillation, remove foetal monitoring equipment Tilt to left Why displace uterus laterally? After 20 weeks gestation, uterus may compress great vessels when patient supine The compression causes: - decrease in systolic BP up to 30 mmHg - 30% decrease in stroke volume - Result decreased uterine blood flow Manual deflection or placement of patient in lateral decubitus position avoids uterine compression Mother Physiology A: friable mucous membranes (E2), decreased LES tone, increased abdominal pressure B: higher diaphragm – 20% less FRC, 20% increased oxygen consumption Increased Vt and minute ventilation (50%) C: Elevated HR (10-15), SV (23%), CO (25 – 43%) – anaemia with hypervolaemia - lower SVR, BP 10 – 15 mmHg/lowest 2nd trimester Low venous return when supine (30% C)) BLOOD > 10 weeks increasing plasma (45% at term) > increased RBC (15-30%) - CAN MASK UP TO 30% blood loss Hypercoagulable state Respiratory Support Supplemental oxygen Anoxia develops more quickly in advanced pregnancy like this case because of the respiratory physiology during pregnancy - increased RR (40 to 50%) - oxygen consumption increased by 15 to 20% at rest - PaO2 increased - PaCO2 decreased - decreased bicarbonate Aim for oxygen saturations > 95% ABG for PaO2 and PaCO2 Placental oxygenation good when PaO2> 70 mmHg ? Chest Tube for this pregnant patient? Yes surgical emphysema Remember diaphragm in a higher position - Result: place chest tube one or two interspaces higher Cardiovascular Signs of maternal haemorrhage? - look for foetal distress NOTE: significant blood loss can occur in the uterine wall or retroperitoneal space without external bleeding 30% maternal blood loss before respiratory distress Volume Replacement 2 large bore IV lines Volume replacement superior to vasopressors that can reduce uterine blood flow initially Continue until hypovolaemia, hypoxia and foetal distress resolve Aim to maximise uterine perfusion and oxygenation Start blood transfusion if significant blood loss suspected or occurred Abdominal changes in pregnant woman Pregnant women sustain abdominal trauma more easily The enlarged uterus - protects against visceral injury from lower abdominal penetrating injury - protect retroperitoneal structures Penetrating injuries above uterus are more likely to cause bowel injuries Rebound tenderness and guarding less prominent Increased vascularity and blood flow Dilated pelvic vasculature - increased risk of retroperitoneal haemorrhage from abdominal and pelvic trauma Blood flow to uterus 600ml/min Foetal oxygenation is dependent on uterine blood flow, there is no autoregulation Uterine blood flow also reduced by - vasoconstriction (drugs) - maternal hypercarbia and hypocarbia Complications of Trauma Often life-threatening Uterine rupture Placental abruption Amniotic fluid embolism Fetomaternal haemorrhage and alloimmunization Preterm labour Premature rupture of membranes Serious pelvic injury can lead to maternal hypotension as a result of direct injury to foetus, uterus, placenta and uterine vessels Causes of maternal death Most are due to head trauma or haemorrhage shock Commonest cause of Foetal death In severe maternal injury, it is maternal death In “minor” injury it is placental abruption Factors associated with increased foetal mortality Maternal hypotension High maternal injury severity score Ejection from motor vehicle Maternal pelvic fracture Car vs pedestrian Maternal history of alcohol use Motorcycle crash Maternal smoking history Uterine rupture Ref American Family Physician October 2004: 70 (7) p1303 Foetal Viability by age Beyond umbilicus is likely viable (> 24 weeks) Foetal Assessment Avoid fetal hypoxia at all costs Maternal blood oxygen content Uterine blood flow Fetal oxygen dissociation curve is shifted to left: small change in maternal PaO2 = large change in fetal oxygen saturation Avoid maternal hyperventilation Maternal alkalosis poorly tolerated Leads to uterine vasoconstriction How Do I manage the Foetus Resuscitate the mother Oxygen & blood Monitor the fetus cardiotocographic monitoring (CTM) if >20 weeks, x 6 hrs (EAST Guidelines, 2005) Watch for warning signs of injury to the fetus Vaginal bleeding, fetomaternal hemorrhage, uterine contractions, uterine rupture, placental abruption, premature labour Fetal distress is often first sign of maternal hypotension Foetal Injury Treat maternal injuries first Uterine rupture: rare, rapidly fatal Placental abruption: 3-50% of trauma - >50% fatal for foetus - Uterine contractions, pain, bleeding 78%) - Can lead to DIC, haemorrhagic shock, renal failure Can bleed profusely with pelvic fracture due to dilated veins - Foetus rarely directly injured until 3rd trimester (skull, long bones) Kleihauer-Betke(KB) test to detect foetal blood mixed into maternal blood Foetal Monitoring • A) Uterine contractions: 90% stop spontaneously B) Fetal HR: • Normal HR (120-160) • Beat to beat variability • Baseline variability • Decelerations (esp. late) Foetal Monitoring Case: She becomes hypotensive - how do you manage this? She now goes into cardiac arrest in the resuscitation bay after CT - how do you manage this How do you CPR in a pregnant Trauma patient? External chest compression more difficult - decreased chest compliance Hand position on sternum - above centre - need to accommodate for upward displacement of the diaphragm by gravid uterus May be not effective 2nd and 3rd trimester: - aortacaval compression - decreased cardiac output May require a caesarean to perform effective CPR - within 4-5 minutes Secondary survey Medical and Obstetric History Head to toe physical examination Include a pelvic examination to identify: - vaginal bleeding - ruptured membranes - bulging perineum Log roll to the left Consider imaging Bloods: FBC Coags, U & E’s KB test ( kleihauer – Betke test for patients in their 2nd and 3rd trimester) Secondary Survey and Considerations Secondary Survey: Pelvic examination: ◦ ◦ ◦ ◦ Ongoing CTM: ◦ ◦ Vaginal bleeding Ruptured membranes Bulging perineum Prolapsed cord Presence of contractions Abnormal fetal heart rate and rhythm Special considerations: Fetomaternal hemorrhage Imaging Medications Consider Domestic violence Pregnancy often represents dependency and loss of autonomy and control Abusers will take advantage of this Think of it as a possibility Look for signs - emotional withdrawal, depression, self-blame - look for signs of older injury Imaging Concerns Do not defer imaging as pt. is pregnant (benefit outweighs risk) Risk related to ionizing radiation and IV contrast i.e. Fetal risk of harm less than risk of death/ harm from missed injuries or delays in treatment CXR: 0.001 rads CT abdo/pelvis: 0.6-5.0 rads Teratogenicity: Fetal exposure to 10 – 50 rads in first 6 weeks of gestation Increased risk of childhood leukemia's (RR 1.5-2.0) Mental retardation with 5 – 15 rads at 8-15 weeks Therefore exposure to < 5 rads is safe Oncogenicity: Other: No increase in fetal anomalies or pregnancy loss if < 5 rads exposure (American College of Obstetrics & Gynecology) Diagnostic Imaging Foetus most vulnerable during 1st 15 weeks of gestation Risk of radiation is small compared to risk of missed or delayed diagnosis of trauma X-rays of extremities, CT scan of head and neck should be undertaken if necessary USS can assess solid organ injury, intraperitoneal fluid, gestational age, fetal activity, foetal presentation, placental location and amniotic fluid volume USS is not as reliable an indicator in recent placental abruption CT scan Fetomaternal haemorrhage Mixing of fetal blood into maternal circulation Complications: ◦ Maternal isoimmunization ◦ Mother Rh (-), fetus Rh (+) ◦ Fetal exsanguination ◦ ◦ All pregnant women > 12 weeks gestation Watch false positives with sickle cell trait • • 300 mg IM (72 hr. window), repeat in 12 weeks + 300 mg for each 30ml of fetal-maternal transfusion KB test to detect fetal Hb in maternal circulation RhoGAM® if KB test positive Medication Concerns A) Direct risk of teratogenicity or death to the foetus SAFE Tetanus toxoid Fentanyl, morphine LMW Heparins Propofol Cephalosporins Penicillins AVOID Benzodiazepines Metronidazole Warfarin Pancuronium Furosemide Prednisone Direct risk of placenta vasoconstriction and hypoxia Most vasoconstrictors Caesarean Delivery Urgent delivery if imminent maternal death CPR not successful within 4 minutes Stable mother, non-reassuring CTG During laparotomy, gravid uterus prevents adequate surgery for injuries Perimortem Caesarean section for optimum survival of foetus an mother if within 4 min - irreversible brain da,mage after 4 – 6 min - pregnant patient anoxia sooner - Effective resuscitation with empty uterus - Improved fetal survival with shorter time to delivery Summary In pregnant trauma usual ABC management principles apply BUT need to be more vigilant Oxygen and IV fluids for all If mom >20 weeks, tilt left side down Best chance for fetus is to treat mother well If mom Rh (–) think of Rhogam Don’t defer important imaging Give appropriate medications Involve obstetricians early in the trauma Estimate fetal age References Queensland Clinical Guidelines Trauma in pregnancy 2014 Guidelines for the management of a pregnant trauma patient by Society of Obstetricians and Gynaecologists of Canada June 2015 Imaging of the Trauma in a pregnant patient (Seminars in USS CT and MRI 2012) Trauma management of the pregnant patient Critical Care Clinics 32 (2016) 109-117 Blunt Trauma in Pregnancy American Family Physcian 2004 (70) 7 1303 – 1310 Trauma in the pregnant patient: an evidence based approach to management EBMEDICINE.Net April 2013 (15) 4 Trauma in the elderly patient What are the issues in trauma in this group Mechanisms of trauma Are the injuries different than in the younger age group? Should you use a different diagnostic approach? Do therapeutic options differ for these patients? Are they often under triaged because of their age? Epidemiology People have a longer life expectancy ( 82 years by 2050) Rapid increase in “older” adult population By 2030 1 in 5 people will be > 65 They are more independent and have a more active lifestyle than in previous generations Result: more injuries The realities of growing old Mobility scooter racing Geriatric marathons General The elderly account for 10 to 12% of all trauma victims They consume a significant amount of health care resources ( up to 255 of trauma related) They have higher mortality rates Higher complication rates Definitions Elderly = over age 65 years Young- old = 65 – 80 years Old old = over age 80 years ATLS Recommendations: - all traumatized patients > 55 should be considered for evaluation in a trauma centre - physiological age more important than chronologic age “Joys” of growing old: Physical realities Loss of hearing Deteriorating vision Weakening of musculoskeletal system Breakdown of skin hydration/replacement cycle Body becomes less efficient Existence of multiple chronic diseases Multiple medications Cardiovascular Less cardiovascular reserve Less vascular compliance Less cardiac compliance Diminished catecholamine response ( less beta receptor activity) Poor AV conduction/loss of pacemaker cells Decline in cardiac index linearly with age ( CO(SV x HR)/BSA Respond to hypovolaemia with increased SVR vs increased CO Unable to tolerate and respond to fluctuations in blood volume CVS continued Underlying CAD increases risk of myocardial infarction ( 50% pts> 65 have CAD) - hypoxia - anaemia - hypotension Medications affect response to trauma - beta-blockers - calcium channel blockers - diuretics CVS Hypertension - ? Baseline BP, may mask early shock - 110 the new SBP not 90 CHF Dysrhthmia PVD Respiratory Lung less compliant Increased dead space - hypoventilation/illness/immobility VC, FEV1, PaO2 decrease with age Increased residual volume Respiratory muscle weaker in the elderly Airway management may be affected by changes in the aging Chest wall more rigid and brittle - result more prone to traumatic injuries Respiratory continued Diminished alveolar surface - diminishes max O2 uptake by as much as 55% Less responsive to hypoxia Less cilia Chromic lung disease - Restrictive/obstructive - hypoxia/hypercarbia Neurological Dura adherent to inside of skull Brain atrophies - more tendency to move inside skull during trauma - more likely to develop CNS bleeds Spinal stenosis can complicate evaluation Cognitive impairment increases with age Decreased reaction times Musculoskeletal Osteoporosis - more prone to fractures Decreased joint mobility - spinal column problematic Vertebral compression Kyphosis/lordosis Medications Anticoagulants - increased risk of bleeding Cardiac medications - beta and calcium-channel blockers - affect response to volume loss Diuretics - volume contraction - potassium depletion Predisposing factors for trauma Diminished sight Problems with gait/coordination - impaired sensation/proprioception - muscle weakness - degenerative joint disease - neuromuscular disorders - dementia Diminished hearing Renal/urinary Renal perfusion decreases by 10% per decade Hormonal response decreases (vasopressin) - impaired sodium retention Less bladder capacity/compliance Chronic renal failure/impairment Nephrotoxic medications/infusions Hydration status Characteristics of injury in the elderly Mores severe response to any given mechanism Decreased ability to respond to trauma Trauma can trigger/exacerbate pre-existing medical problems Patterns of injury differ in the elderly Mechanisms of Injury What is the most common mechanism of injury in the elderly? What is the most common LETHAL mechanism of injury in the elderly? Mechanisms Falls MVA Car vs pedestrian Elder abuse/assault/burns Penetrating trauma Falls Most common mechanism 40% of elderly trauma 3.8% of elderly have a significant fall each year Ground falls most common Usually occur at home 28% of falls due to an underlying medical condition MUST determoine cause of fall Injuries sustained from falls Fractures 8% Major injuries 10% Peri-injury fatality rate from falls 12% 50% will die within one year of fall Head injuries a significant problem - 1 in 50 may require neurosurgery - up to 16% will have n abnormal CT ( contusion 36%, Subdural 33%) - highest risk fall on stairs or from height - fall from a standing position still a significant risk MVA second most common mechanism 28-30% of all trauma in the elderly Fatality rate 21% Accident Characteristics MVA Occur in daytime Close to home At an intersection Usually involve 2 cars Frequently due to a syncopal episode Less likely due to alcohol, excessive speed or reckless driving Auto vs Ped Third most common mechanism Accounts for 9 to 25% of trauma case Fatality rate - 30 -55% - most common lethal mechanism Specific Injuries Spinal Head Chest Aortic Abdominal Extremity Soft tissue Spinal Aging predisposes to spinal injury Most common mechanism is falls Requires extreme caution Low threshold to image spine Bony injuries - most commonly occur C1 – C3 - type II odontoid fracture most common Spinal cord injuries - often from hyperextension - central cord syndrome Spinal Mortality rate 26% Thoracic and lumbar spine - compression fractures most common - may occur with minimal trauma - common in osteoporotic patients - Head Injury Most common mechanism is falls Types of injury - Cerebral contusion - lower incidence than younger patients - epidural haematomas - dura adheres to inside of skull - subdural haematomas - more common with age - stretching of bridging veins - greater movement of atrophied brain - more likely to be on anticoagulants Head Injury Assessment difficult - history may be difficult to obtain - subtle alterations in baseline mental status difficult to evaluate - may mimic dementia Low threshold to get head CT - isodense SDH at 7 – 20 days after injury - may need iv contrast - often undertriaged Head injury High mortality and morbidity - survival to discharge 21% - favourable outcome 11% - mortality higher still if patient over 80 ( 4x Chest Injuries Chest Wall injuries - Highly morbid and mortal injuries - predisposing factors chest wall more rigid osteoporosis less pulmonary reserve Chest Injuries Rib Fractures - more common injury - more prone to complications ( pneumonia, hypoventilation) - Lap-shoulder belts do not prevent these injuries - actually may cause them - check for rib fractures, sternal fractures, flail chest Aortic injuries Suspect if mediastinum > 8 cm Low threshold to perform CT chest or aortogram Abdominal Injuries Seen in up to 30% of elderly trauma victims Abdominal USS unreliable CT if haemodynamically stable Mortalit rte 4 – 5 times higher than in younger patients Management of Elderly Trauma patient Pre hospital - rapid transportation - early assessment - information from witnesses/prehospital personnel key Watch closely for rapid deterioration Airway/breathing All need supplemental oxygen Airway management maybe difficult BMV - cachexia, edentulous Intubation - decreased mouth opening - decreased neck mobility - RSI drugs choices maybe limited by pre-existing medical conditions Circulation Fluid/ blood resuscitation may be complicated by pre-existing medical conditions Medications alter response to resuscitation History What happened BEFORE the trauma Fall - consider syncope, hypovolaemia, CV or CVA, alcohol Single Car MVA - consider acute medicl event Traps BP - may be deceivingly normal - many patients have underlying hypertension - increasing SVR is response to hypovolaemia Pulse - maybe falsely normal - medication effects - decreased catecholamine response Imaging Spine plain plus CT CXR Echocardiography FAST Head CT References ACS TQIP Geriatric Trauma Management Guidelines American College of Surgeons 2014 Evaluation and management of geriatric trauma An eastern association for the Surgery of Trauma practice management guideline J Trauma Acute Care Surg (73) 5 supplement 4 S345 –S369 The Changing face of major trauma in the UK Emerg Med J 2015;32:911-915 Polytrauma in the elderly: predictors of the cause and time of death Scandinavan Journal of Trauma, Resuscitation and Emergency Medicine 2010 18-26 Injury in the aged: Geriatric Trauma at the crossroads Review Trauma Acute Care Surg (78) 6 2015 1197-1209 Systolic Blood pressure criteria in the national Trauma Triage Protocol for geriatric trauma 110 is the new 90 J Trauma Acut Care Surg 78 (2) 352-359
