0071643192.pdf

■ Peritonitis

■ Free air under diaphragm on CXR or on CT

■ Injury to pancreas, diaphragm, aorta, bowel, or kidney with urine leaking

outside of Gerota’s fascia

■ Persistent blood from NGT, rectum, or vagina

PENETRATING

■ Injury with hypotension

■ Tenderness not related to the abdominal wall wound (peritonitis)

■ Evisceration of abdominal contents through wound

■ Positive DPL

■ Any GSW to abdomen which entered was believed to have entered peri-

toneum by evaluation of projectile trajectory

■ Local wound exploration that reveals violation of abdominal wall

■ Foreign body in abdomen

■ Diaphragmatic injury

■ Blood from NGT, rectum, or vagina

TRAUMA IN PREGNANCY

MECHANISMS

■ MVCs account for half of trauma in pregnancy. Failure to wear a seat belt

and placement of the lap belt over the pregnant abdomen increase the risk

of fetal death.

■ Abuseduring pregnancy is also common with the abdomen being the

most common site of injury. Pregnant women injured by a partner often

say that an accidental fall was the cause of the injury.

SYMPTOMS/EXAM

■ Changes in normal vital signs in pregnant patients may complicate the

evaluation of the injured pregnant patient:

■ Baseline heart rate increases by 10–15 bpm.

■ Baseline BP decreases in the first and second trimesters.

■ In the third trimester, supine hypotension may occur due to uterine

compression of the inferior vena cava. Positioning the patient in the

left lateral decubitus positionmay improve venous return.

■ The normal fetal heart rate is 120–160 bpm. An abnormal rate suggests

fetal distress.

■ The presence of vaginal discharge mandates a pelvic exam to access for

rupture of membranes (ferning, pH > 7).

■ Continuous fetal monitoring should be initiated in patients beyond 24 weeks

of gestation. Abnormal rates and decelerations after a uterine contraction

indicate fetal distress and may also be a marker of occult maternal distress.

DIAGNOSIS

■ Changes in normal laboratory values during pregnancy complicate inter-

pretation in the trauma patient:

■ Baseline hematocrit is decreased to 32–34%.

■ Baseline PCO 2 is decreased to 30 mmHg.

■ Baseline serum bicarbonate is decreased to 21 mEq/L.

■ Ultrasoundis the initial modality of choice both for evaluating for intra-

abdominal bleeding and for assessing gestational age and fetal viability.

TRAUMA

Initial Hgb may not reveal

significant bleeding as it takes

hours for volume to be

replaced by extracellular fluid.

Serial values will show a

trend.

Consider abuse in injured

pregnant patients, particularly

those with abdominal injury

who report a fall.

Fetal viability:

24 weeks gestation,

dome of uterus above

umbilicus

A PCO 2 of 40 mmHg during the

latter half of pregnancy

suggests hypoventilation.