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1680 SECTION 21: Trauma and desmopressin in patients with intracranial hemorrhage taking aspirin or clopidogrel have been mixed, one guideline recommends desmopressin, but would reserve platelet transfusion only for patients undergoing a neurosurgical procedure. Admit patients with bleeding on head CT to an intensive care unit. The disposition of patients taking warfarin but with a normal initial CT scan is challenging because such patients have a reported rate of delayed intracranial hemorrhage between 1% and 8%. 73,74 Admission for a repeat head CT at 24 hours will catch most, but not all, delayed hemorrhages. Discharge after an initial negative head CT is also reasonable in patients with lower INRs and caregivers to watch them closely at home.  RIB FRACTURES AND RESPIRATORY FAILURE Maintain a low threshold for admitting elderly patients with rib fractures for a period of observation until good pain control and pulmonary toilet are ensured. More severe thoracic injuries, such as hemopneumothorax, pulmonary contusion, flail chest, and cardiac contusion, can quickly lead to decompensation in the elderly, especially those with baseline respiratory insufficiency. Pain control after chest wall trauma is vital to encourage ventilation in order to reduce atelectasis and the risk of infection. Pain control is challenging because the elderly may have decreased tolerance for opioid analgesics, which can have profound respiratory (hypoventilation), hemodynamic (hypotension), and CNS effects (imbalance and delirium). Continuous pulse oximetry and capnometry are helpful to assess oxygenation and ventilation. Serial arterial blood gas analysis may provide early insight into respiratory function and reserve. Consider prompt tracheal intubation and use of mechanical ventilation in patients with more severe injuries, respiratory rates >40 breaths/min, or when the partial pressure of arterial oxygen is <60 mm Hg or the pressure of arterial carbon dioxide is >50 mm Hg.  SHOCK Multiple studies have shown that occult hypoperfusion is frequently present even with normal vital signs. 16,17 The optimal approach to opti mizing hemodynamics is unknown. A general strategy is to perform the initial imaging necessary to identify life-threatening injuries (e.g., chest radiograph, CT of the head, spine, chest, abdomen, and pelvis) and then transport to the intensive care unit, after which nonessential imaging and interventions (e.g., extremity radiographs and suturing) can be performed. Resuscitate the elderly trauma patient with small volumes of isotonic crystalloid (normal saline or lactated Ringer’s), watching for a response, to avoid underresuscitation or volume overload. Strong consideration should be made for early red blood cell transfusion, which may enhance oxygen delivery and minimize tissue ischemia. Depending on the type of injury and severity of blood loss, consider switching to blood transfusion after 1 to 2 L of crystalloid resuscitation. Routine use of pulmonary artery catheters is no longer recommended.  ENVIRONMENTAL AND IATROGENIC INJURY The decreased lean muscle mass and impaired peripheral circulation associated with aging make the elderly patient more susceptible to pressure sores and hypothermia. Patients with prolonged extrications or transport in cool climates may be hypothermic. Expose the patient as needed for a thorough examination, but keep the patient covered as much as possible to maintain body heat.

ation associated with aging make the elderly patient more susceptible to pressure sores and hypothermia. Patients with prolonged extrications or transport in cool climates may be hypothermic. Expose the patient as needed for a thorough examination, but keep the patient covered as much as possible to maintain body heat. Hypothermia not explained by environmental factors may be a sign of sepsis or endocrine abnormalities. Logroll patients onto a padded surface as soon as possible. DISPOSITION AND FOLLOW-UP Have a low threshold for admitting geriatric trauma patients. Admit elderly patients with polytrauma, significant chest wall injuries, abnor mal vital signs, or evidence of overt or occult hypoperfusion to the intensive care unit. Even in patients without the need for inpatient treatment or observation, consider whether the patient is immediately ready to return home with a trial of ambulation and discussion of their home situation. In patients whose preinjury mobility was already tenuous, pain, decreased mobility, and medications may make a return to home dangerous. While opioid analgesics may be necessary, they may also cause delirium, decrease balance, and impair ambulation. Observation for establishment of a safe and effective pain regimen, consultation with physical therapy, and assurance of a safe home environment may be advisable to prevent a secondary injury.  OUTCOME The ultimate goal is to return the elderly trauma patient to the preinjury state of function. Immediately after discharge, about half of survivors return home, and half go to skilled nursing or rehabilitation facilities. The general consensus is that elderly trauma patients benefit from preferential triage to trauma centers and from aggressive and thoughtful resuscitation. In light of investigations showing that elderly patients often return to preexisting health status after trauma, aggressive resuscitation efforts for geriatric trauma patients are warranted in keeping with their preexpressed end-of-life care preferences. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Trauma in Pregnancy Ciara J. Barclay-Buchanan Melissa A. Barton INTRODUCTION AND EPIDEMIOLOGY Trauma is the leading cause of non–obstetric-related morbidity and mortality in pregnant women. 1,2 Seven percent of all pregnant women will experience a traumatic injury, of whom 0.4% will require admission. 3 Blunt trauma is more common than penetrating trauma. Motor vehicle crashes, falls, and assaults compose the major causes of blunt trauma during pregnancy. 2,4 Motor vehicle crashes account for 50% of pregnancy-related trauma, and placental abruption can occur even with low-speed deceleration crashes. 3,5 The best predictors of fetal loss or other adverse outcomes are crash severity and lack or improper use of seat belts. 6 Pregnant women should be advised to use both seat belts and air bags .7 For proper fit, the lap belt should be worn under the gravid uterus (i.e., across both anterior superior iliac spines and the pubic symphysis) with the shoulder harness positioned snugly between the breasts and off to the side of the uterus. 7 Combined with proper body positioning (i.e., mother seated 10 inches from the dash and steering column) and seat belt placement, the benefits of air bags appear to outweigh the risks. 7,8 Falls occur most frequently during the second and third trimesters. This risk is likely due to weight gain affecting balance and coordination. Twenty-seven percent of women fall at least once during pregnancy; the vast majority occur indoors and/or on stairs. One in three women are raped, physical assaulted, and/or stalked by an intimate partner in their lifetime. 10 Studies have shown that 3% to 9% of pregnant woman are abused during their pregnancy.

nation. Twenty-seven percent of women fall at least once during pregnancy; the vast majority occur indoors and/or on stairs. One in three women are raped, physical assaulted, and/or stalked by an intimate partner in their lifetime. 10 Studies have shown that 3% to 9% of pregnant woman are abused during their pregnancy. 11,12 Consider intimate partner violence in all cases of trauma and use screening tools. 10,13 Provide social services consultation or referral if there is concern for the mother’s safety.1 Trauma during pregnancy is associated with several complica tions, including preterm labor, premature rupture of membranes, placental abruption, fetal maternal hemorrhage, uterine rupture, cesarean section, and pregnancy loss. Placental abruption is second only to maternal death as the most common cause of fetal death. Pla cental abruption may also lead to the introduction of placental products CHAPTER Tintinalli_Sec21_p1669-1766.indd 1680 8/1/19 12:20 PM

tion, fetal maternal hemorrhage, uterine rupture, cesarean section, and pregnancy loss. Placental abruption is second only to maternal death as the most common cause of fetal death. Pla cental abruption may also lead to the introduction of placental products CHAPTER Tintinalli_Sec21_p1669-1766.indd 1680 8/1/19 12:20 PM CHAPTER 256:  Trauma in Pregnancy      1681 into the maternal circulation, stimulating disseminated intravascular coagulation or amniotic fluid embolism. Even minor maternal injuries have been associated with placental abruption and sudden fetal demise. A fetus is considered viable at 22 to 24 weeks of gestation or a weight of 500 grams. Achieving successful outcomes for both mother and fetus requires a collaborative effort by the prehospital, ED, trauma, obstetrics, and neonatology (neonatal intensive care unit) teams. The emergency physician should be well-versed in the care of the pregnant patient as this will enhance her care in the setting of trauma. Fetal survival is dependent on maternal survival. Therefore, resuscitation of the mother always takes priority. ANATOMIC AND PHYSIOLOGIC CHANGES OF PREGNANCY See Chapter 25 “Resuscitation in Pregnancy, ” and Table 25-1 for detailed discussion of the important physiologic changes in pregnancy that affect resuscitation. Key points are presented below. Maternal blood volume expands at approximately week 10 of gesta tion and peaks at week 28 with a 45% increase from baseline. Cardiac output increases by 30% to 50%. The relative hypervolemic state can mask clinically significant injuries. A pregnant woman may lose 30% to 35% of her circulating blood volume before manifesting clinical signs of shock. Uterine blood flow increases significantly during pregnancy. Uterine injury can result in severe maternal hemorrhage. The uterine fundus remains relatively protected in the pelvis until about week 12 of gestation when it reaches the level of the pubic symphysis. Direct fetal injury during the first trimester is relatively rare in blunt abdominal trauma as the fetus is protected by the bony pelvis. However, if the maternal pelvis is fractured or the trauma occurs later in preg nancy when the fetal head is engaged, fetal injury may occur and typi cally involves the skull and brain. After week 12 of gestation, the uterus becomes an intra-abdominal organ. By week 20, the uterus has reached the umbilicus and continues to grows approximately 1 cm beyond the umbilicus per each additional week of gestation. During direct abdominal trauma or deceleration injury, intrauterine pressure increases. While the relatively elastic uterus deforms, as with even a mild deceleration injury, the relatively inelastic placenta can shear from the uterine wall, causing placental abruption. Additionally, as an intra-abdominal organ, the uterus is at risk for rupture during blunt abdominal trauma. Mothers at ≥20 weeks of gestation are at risk of supine hypotension syndrome, in which venous return and cardiac output are decreased by compression of the maternal inferior vena cava by the gravid uterus while the mother is lying in the supine position. During pregnancy, the diaphragm elevates by as much as 4 cm, so adjust the anatomic landmarks for thoracostomy tube insertion by one to two ribs spaces cranially. Physiologic changes affect the ability to compensate for respiratory compromise. Anticipate difficult intubation due to upper airway hyperemia and friability. Gastric emptying time is delayed, increasing the risk for aspiration. The small bowel is moved upward in the abdomen by the enlarging uterus, which increases the chance of complex bowel injuries in pen etrating trauma of the upper abdomen. The bladder moves anteriorly into the abdomen in the third trimester, becoming more vulnerable to injury.

delayed, increasing the risk for aspiration. The small bowel is moved upward in the abdomen by the enlarging uterus, which increases the chance of complex bowel injuries in pen etrating trauma of the upper abdomen. The bladder moves anteriorly into the abdomen in the third trimester, becoming more vulnerable to injury. The gravid uterus passively stretches the abdominal wall and peritoneum as it enlarges, which may lead to diminished sensitivity to irritation from intraperitoneal blood. PRINCIPLES OF RESUSCITATION The algorithm for trauma resuscitation of the pregnant patient is the same as the nonpregnant patient with a few special considerations. Although there are two patients, priority is given to the mother as maternal resuscitation is the best fetal resuscitation. Fetal survival is dependent on early and aggressive maternal resuscitation. Never withhold critical maternal interventions or diagnostic procedures out of concern for potential adverse fetal consequences. Develop a major trauma protocol for pregnant patients that includes the ED, trauma service, and OB teams. For minor direct or indirect abdominal trauma (e.g., low-speed motor vehicle accident, ground-level fall, or minor assault), a simpler protocol involving the ED and obstetric teams is suf ficient. The simpler protocol should include cardiotocodynamometry and fetal heart rate monitoring as soon as possible after ED arrival. PREHOSPITAL CARE Prehospital providers should ask about the possibility of pregnancy when evaluating women of childbearing age. When possible, a known pregnant woman at >20 weeks of gestation should be triaged to a hospital with trauma, obstetric, and neonatal capabilities. 14 Women at >20 weeks of gestation who require spinal immobilization should be placed in a semileft lateral decubitus position to prevent inferior vena cava compression by the gravid uterus. This positioning is accomplished by placing a wedge or rolled blanket under the right side of the spine board and tilting the entire patient approximately 30 degrees to the left (see Figure 25-2). MATERNAL AND FETAL ASSESSMENT AND TREATMENT  PRIMARY SURVEY Prioritize the primary survey of the mother. Manage the maternal air way and ensure adequate ventilation. Administer supplemental oxygen to maintain a pulse oximetry >95% because compensation for hypoxia is limited in pregnancy. Similarly, consider early endotracheal intubation when indicated by the nature or severity of injuries. Maintain cervical spine immobilization as indicated. Establish large-bore peripheral IV access above the diaphragm. Avoid placing IV lines in the femoral region or lower extremity because of uterine inferior vena cava compression and the possibility of injured pelvic veins. Keep the patient in the semi-left lateral decubitus position or use a second provider to continually manually displace the gravid uterus. Identify and control sources of hemorrhage since hypovolemia exacerbates fetal hypoperfusion. Increase the crystalloid infusion volume by 50% to account for the patient’s additional plasma volume. Do not administer vasopressors until volume and blood are replaced to minimize risk of uteroplacen tal hypoperfusion. Perform a brief neurologic assessment. Expose the patient and provide warm fluids and blankets. An in-depth fetal assessment should not occur during the airway, breathing, circulation, disability, and exposure phase of trauma evaluation. However, assess fetal heart tones and uterine size by ultrasonography if maternal resuscitation allows.  ADJUNCTS TO THE PRIMARY SURVEY Place the mother on continuous telemetry and pulse oximetry monitoring. Perform frequent blood pressure checks.

hing, circulation, disability, and exposure phase of trauma evaluation. However, assess fetal heart tones and uterine size by ultrasonography if maternal resuscitation allows.  ADJUNCTS TO THE PRIMARY SURVEY Place the mother on continuous telemetry and pulse oximetry monitoring. Perform frequent blood pressure checks. Place a nasogastric tube early; delayed stomach emptying and diminished lower esophageal sphincter tone increase the risk of aspiration of gastric contents. Obtain a portable single view anteroposterior chest and pelvis radiographs as indicated by the nature of the injury. Perform an extended FAST to identify intra-abdominal or thoracic injury. The sensitivity and specificity of abdominal US for the detection of intraperitoneal fluid are similar in pregnant and nonpregnant patients.  SECONDARY SURVEY After completing the primary survey and performing resuscitative steps, proceed with the secondary assessment. Obtain pertinent medical, surgical, obstetrical, and social histories. Perform a head-to-toe examination of the patient. Perform a thorough abdominal examination: assess for ecchymosis, abdominal and uterine tenderness, and fundal height. The loss of a palpable uterine contour or palpation of fetal parts is suggestive of uterine rupture. Uterine rupture accounts for <1% of all injuries and is more likely to occur during the late second and third trimesters and when there is direct and forceful impact on the uterus. The fetal mortality rate is high. The classic clinical presentation for placental abruption includes abdominal pain, abdominal and uterine tenderness, painful vaginal Tintinalli_Sec21_p1669-1766.indd 1681 8/1/19 12:20 PM

ng the late second and third trimesters and when there is direct and forceful impact on the uterus. The fetal mortality rate is high. The classic clinical presentation for placental abruption includes abdominal pain, abdominal and uterine tenderness, painful vaginal Tintinalli_Sec21_p1669-1766.indd 1681 8/1/19 12:20 PM 1682 SECTION 21: Trauma bleeding, and tetanic uterine contractions, but severe placental abruption can occur without such signs. A sterile pelvic examination can identify injuries of the lower genital tract, vaginal bleeding, and rupture of amniotic membranes. To assess for amniotic membrane rupture, test vaginal fluid with pH paper. Fluid in the vagina with a pH of 7 is suggestive of amniotic fluid; a pH of 5 is consistent with vaginal secretions. Evidence of ferning on microscopic evaluation of dried vaginal fluid suggests membrane rupture and an amniotic fluid leak (see Figure 100-3).  CARDIOTOCOGRAPHIC MONITORING AND OBSTETRICAL US For pregnant women at ≥20 weeks of gestation, begin cardiotoco graphic and fetal heart rate monitoring in the ED as soon as maternal resuscitation allows. The protocol for pregnant trauma patients should include the mobilization of an obstetrical nurse or obstetrician to the ED to begin monitoring. Even minor blunt abdominal trauma or deceleration injury can result in placental abruption and fetal distress. 5 Observe for uterine contractions and assess fetal heart rate patterns (see Figure 101-1). Uterine irritability may be precipitated by abdominal trauma; preterm labor occurs in 25% of trauma cases after 22 to 24 weeks of gestation. Decelerations, tachycardia, and bradycardia are signs of fetal distress. The most sensitive clinical finding for placental abruption after trauma is uterine irritability, which is defined as more than three uterine contractions per hour. 5 Fetal distress and demise can occur quickly and abruptly, so vigilant monitoring is necessary. Tocolytic agents are generally not recommended for use in pregnant trauma patients, unless recommended by an obstetrician. Tocolytic agents have numerous adverse effects, including fetal and maternal tachycardia, which may complicate trauma evaluation. For pregnant patients at >20 weeks of gestation, obtain an obstetric US to assess fetal size and gestational age, cardiac activity heart rate, and fetal activity. A normal fetal heart rate is between 120 and 160 beats/min. If fetal cardiac activity is absent, then direct the remainder of treatment efforts solely at maternal resuscitation. US may show evidence of placental abruption (Figure 256-1). However, the sensitivity for placental abruption is only about 25%, although specificity is >90%. 17 US has many limitations: uterine rupture or fetal-placental injuries can be undetected; fetal distress is not monitored; and sensitivity for placental abruption is low. 5,17  IMAGING Attempt to minimize fetal exposure to ionizing radiation; however, do not withhold imaging that is necessary to appropriately manage the mother. The risk of injury to the fetus from radiation is much lower than the risk of a missed or delayed diagnosis of maternal injury. 18,19 See Chapter 99 and Tables 99-8 and 99-9 for detailed discussion of the teratogenic effects and radiation doses. One potential benefit of obtaining an abdominopelvic CT scan is the ability to detect placental abruption, with a reported sensitivity of 86% and specificity of 98% for abruption. 20 Fetal radiation exposure can be decreased by shielding the maternal abdomen and pelvis, performing modified studies, and using dose-reducing techniques. IV iodinated contrast is safe both in pregnancy and breastfeeding; oral contrast material is safe as well.

sensitivity of 86% and specificity of 98% for abruption. 20 Fetal radiation exposure can be decreased by shielding the maternal abdomen and pelvis, performing modified studies, and using dose-reducing techniques. IV iodinated contrast is safe both in pregnancy and breastfeeding; oral contrast material is safe as well. 21,22 IV gadolinium for MRI should not be given during pregnancy, but gadolinium is considered safe during breastfeeding.21-23  LABORATORY TESTING Perform a qualitative urine pregnancy test on all female trauma patients of childbearing age. Obtain a CBC, comprehensive metabolic panel, type and screen (or type and cross [if indicated]), coagulation profile including fibrinogen to assess for disseminated intravascular coagulation, and additional laboratory studies as clinically indicated. If available, perform a Kleihauer-Betke analysis on pregnant women who are >12 weeks of gestation. 3 Fetal maternal hemorrhage occurs when fetal red blood cells enter into the maternal circulation, which is assumed in the setting of maternal trauma. The Kleihauer-Betke test provides a quantitative determination of the presence of fetal hemoglobin in maternal blood. Acid elution is applied to an aliquot of maternal blood, and then both maternal and fetal red blood cells are counted under the microscope. The percentage of fetal red blood cells is used to determine the amount of fetal-maternal hemorrhage.  THERAPEUTIC INTERVENTIONS Administer Rho(D) immunoglobulin to all Rh-negative pregnant women with abdominal trauma. If as little as 0.1 µL of Rh-positive fetal blood enters an Rh-negative mother’s circulation, the mother can develop Rh antibodies, endangering the current pregnancy and subse quent pregnancies. 24 Rho(D) immunoglobulin is given to the Rh-nega tive pregnant mother to prevent antibody formation that could occur if her fetus is Rh positive. The dose depends on the gestational age: 50 micrograms IM for gestation ≤12 weeks and 300 micrograms IM in the second and third trimes ter. Total fetal blood volume at 12 weeks of gestation is approximately 4.2 µL. A 50-microgram dose of immunoglobulin is effective for up to 5 µL of fetomaternal hemorrhage. A 300-microgram dose protects for up A B FIGURE 256-1. A. Placental abruption. Transabdominal long-axis scan shows an anterior placenta with a contained marginal abruption (arrow). [Image used with permission of L. Sens and L. Green, Gulfcoast Ultrasound.] B. Placental abruption. Transabdominal scan, sagittal plane, demonstrating retroplacental hematoma (H) in an 18-week pregnancy. The placenta (P) is located on the posterior wall. A myometrial contraction (M) of the anterior wall is evident. Tintinalli_Sec21_p1669-1766.indd 1682 8/1/19 12:20 PM