resuscitation fluid is blood. ATLS guidelines suggest starting resuscitation
with crystalloid solution and adding blood if there is no response after a
40 cc/kg bolus of crystalloid fluid. (d)The patient is too unstable to be trans-
ferred for a CT scan. If the patient’s BP normalizes, then the trauma team may
elect for a CT scan. If the patient remains hypotensive despite resuscitation,
then definitive measures need to take place, such as an exploratory laparo-
tomy to stop the hemorrhage. (e)Once the FAST examination is positive,
repeating it will not add valuable information. If the patient remains
hypotensive, definitive management is a priority.
163.The answer is e.(Rosen, pp 256-265.)Trauma occurs in up to 7% of
all pregnancies and is the leading cause of maternal death. It is important
tofocus the primary examination on the patient and evaluate the fetus
in the secondary examination. The ABCs are followed in usual fashion.
Once the patient is deemed stable, the fetus should be evaluated. Fetal eval-
uation focuses on the fetal HR and fetal movement. Minor trauma to the
patient does not rule out injury to the fetus. Therefore, it is important to
monitor the fetus. Cardiotocographic observation of the viable fetus is
recommended for a minimum of 4 hoursto detect any intrauterine
pathology. The minimum should be extended to 24 hours if, at any time
during the first 4 hours, there are more than three uterine contractions per
hour, persistent uterine tenderness, a non-reassuring fetal monitor strip,
vaginal bleeding, rupture of the membranes, or any serious maternal injury
is present.
(a)Cesarean section in the OR may take place if the patient is stable
but the fetus is unstable and greater than 24 weeks gestation. This decision
should be made by the obstetrician. (b)Cesarean section in the ED, or per-
imortem cesarean section, is performed if uterine size exceeds the umbili-
cus, fetal heart tones are present, and maternal decompensation is acute.
(c)Radiation from CT scanning in the setting of pregnancy is a concern.
Shielding of the uterus in head and chest scans allows for an acceptable
radiation exposure level. Abdominal and pelvic CT scanning incurs greater
radiation exposure and the risks and benefits of these studies should be
discussed with the patient. Other diagnostic procedures can be used in the
setting of blunt abdominal trauma, such as ultrasound, DPL, and MRI.
(d)Minortrauma does not exempt the fetus from injury and direct impact
is not necessary for fetoplacental pathology to occur. The mother with no
obvious abdominal injury or even normal laboratory values still requires
monitoring.
174 Emergency Medicine