(Poly)trauma during Pregnancy - sgar-ssar.ch · Prof. Marius Keel, MD, FACS General, Trauma and Orthopaedic Surgeon EBSQ Traumatology Emergency Physician Leitender Arzt für Becken-

Prof. Marius Keel, MD, FACS

General, Trauma and Orthopaedic Surgeon

EBSQ Traumatology

Emergency Physician

Leitender Arzt für Becken- und Wirbelsäulenchirurgie

Teamleiter Wirbelsäulenchirurgie

Universitätsklinik für Orthopädische Chirurgie

Inselspital, Bern

(Poly)trauma during

Pregnancy

El Kady, et al. Am J Obstet Gynecol 2004;190:1661-8

> Motor vehicle crashes

> Falls

> Suicide attempts

> Assaults

> Fires

> Guns

0.08

0.09

0.00

0.02

0.00

0.00

Per 1000 deliveries

Group 1: Women who deliverd at time of trauma hospitalization

0.67

0.30

0.05

0.25

0.01

0.06

Group 2: Women who were hospitalized for trauma up to 9 months preceding the obstetric delivery hospitalization

Occurrence Rates of Injuries of Pregnant Women

> Retrospective cohort study 1991-1999

> 10„316 deliveries with injuries at delivery (group 1; n=2494) or injury prenatally (group 2; n=7822) in 4„833„286 total deliveries (0.2%)

> Fractures, dislocations, sprains, strains

> Intracranial injuries

> Internal injuries (thorax, abdomen, pelvis)

> Injury to vessels

> Open wounds

> Superficial contusions, crush injuries

> Burns

> Nerve and spinal cord injuries

El Kady, et al. Am J Obstet Gynecol 2004;190:1661-8

Occurrence Rates of Injuries of Pregnant Women

0.21

0.01

0.05

0.02

0.06

0.17

0.02

0.02

0.81

0.16

0.14

0.02

0.42

0.63

0.04

0.04

Per 1000 deliveries

Group 1: Women who deliverd at time of trauma hospitalization

Group 2: Women who were hospitalized for trauma up to 9 months preceding the obstetric delivery hospitalization

Trauma-Management and Acute Surgery of Injured Pregnant Women

Pathophysiology

Damage Control

High qualified surgeon !

Obstetrician

„Life Saving Surgery“ and „Damage Control“

Who has the Lead ?

„Life Saving Surgery“ and „Damage Control“ of Two Patients !

Polytrauma during Pregnancy

>Trauma is the leading cause of maternal mortality and an important source of maternal morbidity.

> Initial treatment priorities for pregnant patient remain the same as for the non-pregnant patient.

>Best initial treatment for the fetus is the provision of optimal resuscitation of the mother and early assessment of the fetus.

Polytrauma

> Severity of injuries (ISS ≥17 pts.)

> Physiological status

Hypothermia

Acidosis

Coagulopathy

Lethal Triad

> Host defense

Keel et al. n=1191, 1.96-9.04; ISS≥17pts.

76%

25%

60%

32%

23%

58%

> Injury pattern

„Killers“ in Polytrauma

> Head injury (66%)


Coagulopathy- Dilution

- Consumption

Massive

transfusion

≥ 10 U PRBCs in

first 24 hrs

Ongoing bleeding

> Sepsis, MOF (13%)

> Hemorrhagic shock (21%)

35.5Hypothermia°celsius

Acidosis lactate mmol/l

Coagulopathy prothrombin time %

2.8

83

35.3

3.5

74

34.2

6.3

57

Lethal Triad

Mortality (36%): 28% 33% 67%

Hemorrhagic Shock and Mortality

I<750ml

-

-

n = 630

53%

II750-1500ml

>100/min.

-

n = 368

31%

III/IV>1500/2000ml

>120/min.

<90mmHg syst.

n = 193

16%


Priorities of Acute Treatment

1. Shock treatment

2. Control of hemorrhage

3. Treatment of coagulopathy

Hypothermia

Acidosis

Coagulopathy

Lethal Triad

4. Prevention of septic

complications

5. Organ-/limb saving

Primary survey ATLS

X-ray (thorax, pelvis)

FAST

Multislice CT (7-12mSv)

Resuscitation:

Preservation of

perfusion and

oxygenation

Vital functions?

Response?Life saving

surgery_

„in extremis“

Keel M, Labler L, Trentz O.

Eur J Trauma 2005; 31:212

Diagnosticworkup is not a

warmup !

Primary survey

X-ray (thorax, pelvis) + FAST

versus

Multislice CT

Effect of Whole-body CT during Resuscitation on Survival Huber-Wagner et al. Lancet

2009;373:1455-61

> Retrospective, multicentre study(DGU) of patients with ISS >=16 pts. and blunt trauma

> N=4621 (ISS: 29.7 pts.; SBP<90: 15%)

> Whole-body CT: n=1494 (32%)

> Non-whole-body CT: n=3127 (no CT 22%, selective CT 78%)

> Standardised mortality ratio (SMR, ratio of recorded to expectedmortality)

> Whole-body CT is an independentpredictor for survival

MSCT: The Focus on SelectionDeunk et al. Ann Surg 2010;251

MSCT: The Focus on Radiation

> Retrospective cross-sectional study

> N=1119

> Effective doses

> Head CT: 2 mSv

> Abdominal/pelvis CT: 31 mSv

> Lifetime attributable risk (LAR) of cancer

> Head CT: 0.23 cancer/1000 pat. (20 year old women); 1/8105 (40 y.); 1/12250

> Abdom. CT: 4/1000 pat. (20 y.)

Smith-Bindmanet al. Arch Intern Med 2009;169:2078-86

1. Surgical approach to airway for imminent asphyxia

3. Surgical control of hemorrhage

Pleural cavity

Peritoneal cavity

Pelvic fracture

Central amputation

Components of Life Saving Surgery

2. Decompression of cavities

Tension pneumothorax

Cardiac tamponade

Acute EDH

Keel, Labler, Trentz. Eur J Trauma Emerg Surg 2005; 31:212

Emergency Department Thoracotomy

Soreide et al. Scand J Surg 2007;96:4-10

Cothren et Moore. World J Emerg Surg 2006

Physiologic Disorders -Posttraumatic CHAOS

> Cardiovascular shock

> Homeostasis

> Apoptosis

> Organ dysfunctions

> Immune Suppression

Bone. Crit Care Med 1996; 24:1125

Pathophysiological Cascade

Endothelial/Parenchymal Cellular Damage

MODS/MOV

Neuroendocrine Reaction

Pain, Fear, Stress

Complement System Leucocytes-Endothelial-Interaction

PMN -„Respiratory

burst“

Coagulation Cascade

Acute Phase Reaction

Metabolic Disorder Kallikrein-Kinin-System

SIRS

AgTLymphocyte

Antigen Presentation

Antigen ToxinsTissue

Damage

Macrophage

TNF-a, IL-1b, IL-6, IL-8, IL-12, IL-18, MMF, HMG-1,

G-CSF, GM-CSF, PGE2, LTB4, TXA2, PAF

TH1: IL-2, IFN-g, TNF-b

Fractures BacteriaHypoxia/Hypotension

Keel, Trentz. Injury 2005; 36:691

CARS

Immuno-suppression

Infection

TH2: IL-4, IL-10, IL-13, TGF-b

Organ/Soft Tissue Injuries

21

Multiple Organ Dysfunction

Syndrome (MODS)

Host Defense Response

- reversible -

„Two Hit“ – Model Keel, Trentz. Injury 2005;36:691

Moore et al. J Trauma 1996;40:501

First Hits

-Hypoxia

-Hypotension

-Organ injuries

-Soft tissue injuries

-Fractures

Systemic Inflammatory

Response Syndrome (SIRS)

-Temperature

-Pulse

-Breathing

-Leukocytes

Crit Care Med

1992;20:864

Multiple Organ Failure (MOF)

Host Defense Failure Disease - irreversible -+Bacteria

Sepsis

Second Hits

Endogen (antigenic): - Hypoxia

- Hypotension, Azidosis

- Ischemia/Reperfusion

- Cellular detritus

- Contamination/Infection

Exogen (interventional): - Surgery with blood loss,

tissue damage, hypothermia

- Neglected/Missed injuries

- Prolonged diagnostic workup

- Massive transfusions

Hemorrhagic Shock and Morbidity

100

80

60

40

20

0

% infe

cte

d/n

on

-infe

cte

d p

atie

nts

infected noninfected

Hemorrhagic shock class

I II III IV

% p

atie

nts

with

SIR

S / s

ep

sis

100

80

60

40

20

0

no SIRSSIRS 3/4sepsis SIRS 2

I II III IVHemorrhagic shock class

> Inclusion: ISS ≥17 pts., survival >72 hrs

> N=972 (age: 40.2 y; ISS: 31.9 pts.; late mortality: 10.5%; blunt trauma: 91.4%)

> Hemorrhagic shock: I (n=582) – II (n=309) – III (n=56) – IV (n=25)

Lustenberger et al. Eur J Trauma Emerg Surg 2009

Systemic Inflammation and Risk Factors

Keel et al. n=413, 1.91-2.96

Eur J Trauma 2006;32:387

• SIRS3/4: 30%

• Multivariate:

-SIRS3/4: ISS,

head, thorax, abdomen,

pelvis, extremities, male

-Sepsis:Extremities, pelvis, male,

ISS, abdomen

27

Sepsis (%) +/-

27

28

34

29

32

23

25

21

22

24

21

• Sepsis: 25%

36

SIRS3/4 (%) +/-

32

33

42

37

37

24

29

26

26

28

26

Impact of Pregnancy on Trauma Mortality

John, et al. Surgery 2011;149:94.

> 1.46 million patients in The National Trauma Data Bank 2001-2005

> age 12-49; nonpregnant (n=214,394) and pregnant (HCG positive) (n=3„763

(1.72%)) women

> Pregnant women: younger, more minority groups, less severe injuries (ISS <9

pts.), lower proportion of severe head, abdominal or penetrating injuries

> Mortality for pregnant women 1.2% vs nonpregnant women 2.7%

> Multivariate analysis: Reduced mortality in younger pregnant women und

women with blunt trauma; no survival benefit in severely injured patients

> Survival advantage in premenopausal women with higher estrogen levels !

Deitch, et al. Ann Surg 2007;246:447.

> Estrogen and progesterone production by placenta throughout the gestation.

> Beneficial immunomodulatory and vasodilatory effects.

Angele, et al. Shock 2000;14:81.

Physiologic Alterations of Pregnancy

> Blood:

Plasma volume↑↑ and RBC(↑) – Hematocrit↓ (32%, physiologic anemia)

White-blood-cell↑ (15„000/mm3)

Fibrinogen↑

Prothrombin and partial thromboplastin times↓

Albumin↓, serum protein↓

pH↑

> Hemodynamics:

Cardiac output↑ (uterus and placenta receive 20% of CO in 3rd trimester; in supine position vena cava-compression 30%↓ of CO)

Heart rate↑ (10-15 beats/min. in 3rd trimester)

Blood pressure↓ (5-15mmHg in 2nd trimester, „Supine hypotensive syndrome“)

CVP↑ in lower extremities in 3rd trimester

ECG (shift leftward by 15°, flattened or inverted T waves)

Shock Tolerance during Pregnancy

>Better organ perfusion !

>Improved maternal tolerance to hemorrhage !

>Increased resistance to the „shock“ state in pregnant women !

> Respiratory system:

Tidal volume↑, residual volume↓ (diaphragmatic elevation)

PaCO2↓ (hypocapnia; values of 35-40mmHg may indicate impending respiratory failure during pregnancy)

Oxygen consumption↑

> GI-system:

Gastric emptying time↑

Early gastric tube decompression to avoid aspiration

> Urinary system:

Glomerular filtration rate↑, renal blood flow↑

Creatinine↓ und serum urea nitrogen↓

Dextrorotation of uterus lead to dilatation of right renal collection system

> Neurologic system:

Eclampsia mimic head injury (seizures, hypertension, hyperreflexia, proteinuria and peripheral edema)

Physiologic Alterations of Pregnancy

Anatomic Alterations of Pregnancy -Injury Pattern

ATLS Student Course Manual. 8th edition. Amercian

College of Surgeons Committee on Trauma 2008

> Uterus intrapelvic organ until 12th week of gestation

> Uterus reaches at umbilicus at 20 weeks

> Uterus reaches den costal marginat 34 to 36 weeks– uterus, fetus and placenta is more vulnerable

> As uterus enlarges, bowel is pushed cephalad – bowel lies in upper abdomen: bowel is protected in blunt abdominal trauma, more complex injuries in penetrating injuries

ATLS Student Course Manual. 8th edition. Amercian

College of Surgeons Committee on Trauma 2008

> Second trimester: uterus enlarges , small fetus remains mobile and cushioned by amniotic fluid – risk for amniotic fluid embolism and DIC


> Third trimester:

Uterus large and thin-walled

Fetal head within the pelvis –pelvic fracture result in skull fracture or intracranial injuries of fetus

Little elasticity of placenta: vulnerability to shearing forces with abruptio placentae

Decrease in maternal intravascular volume result in profound increase in uterine vascular resistance reducing fetal oxygenation despite normal maternal vital signs

Damage Control Concept

Stop the bleeding –

Life Saving Surgery

Damage Control Surgery (DCO)

> Surgical control of hemorrhage

> Angiographic control of hemorrhage (Transcatheter arterial embolisation (TAE))

> Massive transfusion protocols (MTPs)

> Correction of coagulopathy

> Correction of hypothermia

Mitigate the lethal triad –

Damage Control Resuscitation

Damage Control – History – US Navy

> …keeping afloat a badly damaged ship by procedures tolimit flooding, stabilize the vessel, isolate fires andexplosions and avoid their spreading…

History: DC – DCO

> Pringle-maneuver Pringle. Ann Surg. 1908; 48:541

> Intra-abdominal packing Feliciano, et al. J Trauma. 1981; 21:285

> Damage Control as approach Rotondo, et al. J Trauma. 1993; 35:375

> Early packing – outcome Garrison, et al. J Trauma. 1996; 40:923

> Timing of fracture treatment – DCO (Damage Control Orthopaedic Surgery) Pape, et al. Am J Surg. 2002; 183:622

Trauma – Care

Primary survey

X-ray (thorax, pelvis)

FAST

Multislice CT ?

Resuscitation:

Preservation of

perfusion and

oxygenation

Vital functions?

Response?

Early total

care+

Intensive

care unit

Day-1-

surgery

_„borderline“

Keel, Labler, Trentz.

Eur J Trauma 2005; 31:212

Physiologic

balance?

Scoring?

Ressources?

Secondary survey

X-ray (extremities)

Multislice CT

+

„responder“

?„transient

responder“

Damage control:

• Preemptive intervention

Life saving

surgery

_„in extremis“

Damage control:

• Preemptive intervention

• „Bail-out“ procedure

Assessment and Treatment of Pregnant Women

>For optimal outcome of mother and fetus:

–Primary survey and resuscitation of mother

–Assess fetus

–Secondary survey of mother

>ABCDE - Adjuncts (CVP, pulse oximetry, arterial blood gas)

>Uterine compression of vena cava reduces CO - Pregnant patient should be logrolled 15° to left and uterus displaced manually to left !

>Because of increased intravascular volume pregnant patient with significant blood loss without clinical shock signs - fetus in distress and placenta is deprived of vital perfusion.

>Dense uterine muscle, amniotic fluid absorb energy frompenetrating injuries - low incidence of severe visceral inj.

Assessment and Treatment of Fetus

>Causes of fetal death:

–Maternal shock and maternal death

–Placental abruption: 70% vaginal bleeding, uterine tenderness, frequent uterine contractions, uterine tetany, uterine irritability (cave minor injuries)

–Uterine rupture: rare, abdominal tenderness/rigidity, repound tenderness, profound shock, abnormal fetal lie, easy palpation of extrauterine location of fetus

–Direct fetal injuries: late pregnancy and serious maternal injuries (blunt trauma (dashboard, wheel, blunt instrument), penetrating injuries

>Adjuncts: Uterine ultrasonography, X-ray, Doppler ultrasound (fetal heart tones)

Assessment and Treatment of Fetus

>Fetal heart rate is a sensitive indicator of both maternal blood volume satus and fetal well-being: Continuous fetal monitoring 6 hrs. (<20-24 weeks of gestation) - with risk factors for 24 hrs.

–Maternal heart rate >110 beats/min.

–ISS >9 pts.

–Placental abruption

–Fetal heart rate >160 or <120

–Ejection during a motor vehicle accident, motorcycle or pedestrian collisions

Secondary Survey of Pregnant Women

>Abdominal CT

>Uterine contractions?

>Evaluation of perineum

>Presence of amniotic fluid in vagina

>Vaginal examination

>Decision for emergency cesarean section (obstetrician)

>At time of maternal hypovolemic cardiac arrest fetus already sufferd prolonged hypoxia - perimortem cesarean section may be successful if performed within4-5 min. of arrest

1. Bleeding Control - DC

“Open chimney”

Abbdominal/liver packing

Pringle maneuver

External fixation and

pelvic packing

or embolization

Repair

Vascular

exclusionResection

Source of Abdominal Bleeding

> Retroperitoneal bleeding (pelvis)

• Prevesical venous plexus

• Presacral venous plexus

• Fracture

• Small arteries: obturator/pudendal/gluteal

• Large–bore vessels

• Engorged pelvic vessels surround gravid uterus

> Intraperitoneal bleeding (pelvis)• Positive FAST in 39% - 97% intraperitoneal lesion

• Solid organ lesions (liver 10%, spleen 6%)

• Uterine rupture in pregnant women

Ruchholtz, et al. J

Trauma 2004;57:278

Kataoka, et al. J Trauma 2005;58:704

Lustenberger, et al. J Emerg

Trauma Shock 2011 (in press)

Characteristics

Early

Survivors

(n=34)

Non-

Survivors

(n=16)

All

(n=50)

Laparotomy 26 (77%) 14 (88%)34

(77%)

Cross-clamping

Aorta2 (6%) 8 (50%)

10

(20%)

Pelvic packing 23 (68%) 12 (75%)35

(70%)

Thoracotomy 0 7 (44%) 7 (14%)

Mortality4 (12%):

MOF 3,

head injury 1

16: hemorrhage

13, head injury

3

20

(40%)

Time to C-clamp (min)

39.5 2.2

Days till definitive pelvic stabilization

3.5 0.5

Age: 45 y

m:w=26:24

ISS: 42 pts.

12 years

Pelvic Clamp and Packing

AUC 95% CI p-value

BE at admission 0.856 0.751 – 0.961 <0.001

BE 1 h after admission 0.915 0.836 – 0.993 <0.001

Lactate at admission 0.784 0.651 – 0.917 0.001

Lactate 1 h after admission 0.825 0.705 – 0.944 <0.001

pH at admission 0.804 0.671 – 0.938 <0.001

pH 1 h after admission 0.905 0.819 – 0.992 <0.001

Pelvic Clamp and Packing

Abt, et al. Eur J Trauma Emerg Surg 2009

Fetomaternal Hemorrhage and isoimmunization

>0.01 mL of Rh-positive blood will sensitize 70% of Rh-negative patients, presence of fetomaternal hemorrhage in Rh-negative mother should warrant Rh immunoglobulin therapy within 72 hrs. unless the injury is remote from the uterus (isolated distal extremity injury)

> Multislice CT

> Retrograde

cystography

(intraop or preop)

> Explorative

laparotomy

2a. Reduction of Contamination (Diagnostics)

2a. Reduction of Contamination (Treatment)

> Treatment of hollow organ injuries:

Intraperitoneal lesions and unstable pelvic fracture: 31%

Demetriades et al. JACS 2002;195:1

2a. Reduction of Contamination (Treatment)

2b. Reduction of Contamination

> Débridement of open fractures

3. Decompression of Compartment Syndrome

> Imminent

> Manifest

4. Resection of Avital Tissue

Labler et al. Eur J Trauma Emerg Surg 2008

> Débridement of Morel Lavallé lesion

5. Fixation of Skeletal Instabilities

> Temporary fixation: External or internal fixators (LCP ?)

> Definitive fixation: Plate, Screws

> Reduction of trauma load

Case - Damage Control Surgery

-OP-time: 2:45

-Lactate: 2,1 mmol/L (initial: 3.2)

-Voluven 2200 mL; RL 8000 mL

-No RBC, FFP, Tc

Risk Factors for Early Mortality after Damage Control Surgery

Variable Odds Ratio (95% CI) p Value

INR >1.2 10.64 (1.32 - 83.33) 0.026

Base Deficit >3 mmol/L 4.85 (1.10 - 23.81) 0.040

AIS Head ≥3 4.27 (1.55 - 11.76) 0.005

Body Temperature <35°C 3.68 (1.15 - 11.76) 0.029

Lactate >6 mmol/L 2.96 (1.00 - 9.09) 0.050

Hemoglobin <7 g/dL 2.76 (1.02 - 7.46) 0.045

Frischknecht et al. J Emerg Trauma Shock 2011 (in press)

> DC procedures in 319 pat. (age: 39.3 y; ISS: 36.6 pts.; SBP <90

mm Hg: 8.7%)

> External fixator: C-clamp (10%), external fixator pelvis (2.5%),

external fixator extremities (60.5%)

> Packing: chest (4.7%), intraabdominal (25.7%), retroperitoneal (6.9%)

> Early mortality: 52/319 (16.3%)

> Late mortality: 22/267 (8.2%)

Damage Control Resuscitation (DCR)

> Permissive hypotension (Cave head injury)

> Minimizing crystalloid-based resuscitation strategies

> Massive transfusion protocols (MTPs): predifined blood products

- PRBCs

- FFP

- platelets

> Adjuncts to massive transfusion:

- Pharmacological adjuncts:

- fibrinogen

- rfVIIa,…

- Auto-transfusion/cell saverNunez et Cotton. Curr Opin Crit Care 2009;15:536-41

Hyperfibrinolysis and Hypofibrinogenaemia

Brenni et al. Acta Anaesthsiol Scand 2009

Fig. 2

Fig. 3

Fig. 4

-140/20 mmHg

-140 /min.

-Lactate 13 mmol/L

-Hb 10 g/dL

-1g tranexamic acid

-7 PRBC

-16g fibrinogen

-3500 ml colloids

-5500 ml crystalloids

3 hours:

rFVIIa (Novoseven®)

> Trial phase 2 (143 blunt trauma and

134 penetrating trauma, rFVIIa): In blunt

trauma significant reduction of RBC

after rFVIIa (trend in penetrating

injuries); no influence on mortality

Boffard et al. J Trauma 2005;59:8-15

CONTROLTM-„Clinical Trial on the Effect of rFVIIa

on Traumatic Blood Loss“: F7Trauma-1711-Study –multi-

center, randomized, double-blind, parallel group, placebo

controlled trial to evaluate the efficacy and safety of activated

recombinant factor VII (rFVIIa/NovoSeven®/ NiaStase®) in

severely injured trauma patients with bleeding refractory to

standard treatment. Trial Phase 3Global CONTROL Results Meeting

December 2008, Madrid

> Trial phase 3:

- 481 blunt trauma and 92 penetrating

trauma (576 randomized), rFVIIa (200

mcg/kg-1+3h 100mcg/kg)

- in blunt and penetrating trauma

significant reduction of RBC and

FFP after rFVIIa (1.3 U RBC and 2.7

U FFP)

- no influence on mortality or morbidity

>Symphysis ↑ (4-8mm)

>SI-joint ↑

>Vulnerable for open book injuries


> Retrospective 16 year period (1987-2002)

> 15 pregnant (1.1%) vs 1330 nonpregnant patients with pelvic or acetabular fractures: 1 mother died (6.7%)

> Conservative treatment n=11

> Operative treatment n=4

> 16 fetus: 12 survival, 4 died (25%)

Almog, et al. Am J Orthop 2007;36(11):E153-9

Pelvic Fractures During Pregnancy

23.7.2008

23.7.2008: Life Saving Surgery

24.7.2008: Damage Control Surgery

Keel, et al. J Trauma 2011 “LILS (Less invasive

lumbopelvic stabilization)”25.7.2008: Definitive Surgery

25.7.2008

6.10.2008

> Retrospective 6 year period

> 8 pregnant (1.5%) vs 818 nonpregnant patients with acetabular fractures

> Gestational age 5-26 weeks

> Infant delivery 27 weeks from time of surgery with normal Apgar score

> 4 PW - 3 Transverse + PW - 1 PC (car accidents)

> Intraoperative fluoroscopy 39 seconds

> CT: calculated radiation exposure dose to fetus 5 cGy

> Conclusion: minimal risk to baby - acceptable articular reduction

Porter, et al. J Orthop Trauma 2008;22(8):508-16

Operative Fixation of Acetbular Fractures in Pregnant Patient - Acceptable Reduction ?

>Limited use of intra- and postoperative X-ray

>Qualified specialist with experience in acetabular surgery (joint visualization)

Visualization of Osteochondral Acetabular Lesions - Perfect Reduction - no CT ?

> Free articular fragments

> Marginal impaction (defect)

> Central impaction (defect)

Pregnancy Outcomes after Orthopaedic Trauma ?

Cannada, et al. J Trauma 2010;69:694.

> Observational study 1995-2007 (12 years) - delivery at trauma

center during or after trauma admission

> 65 pregnant women with (6%) vs 990 without orthopeadic

trauma - surgical treatment for orthopaedic trauma 49%

> Gestational age 28 weeks (vs 31 weeks)

> Increased risk of preterm birth before 37 weeks (31% vs 3%)

> Increased Cesarean delivery (40% vs 25%)

> Increased risk of placental abruption (8% vs 1%), esp. pelvic

fractures (30%)

> Increased risk of perinatal mortality (fetal or neonatal death; 8%

vs 1%), esp. pelvic fractures (30%)

> Conclusion: Referral to medical center capable of handling both

primary injury and potential preterm birth



Rozycki. Editorial Comment. J Trauma 2010;69:698.

> Maternal shock

> Acidosis - hypoxia - hypothermia

> Medications

> Diagnostic radiation ?

> Surgery (opertive length, blood loss) ?

> Anesthesia (pre- or intraoperative hypotension, acidosis,

episodes of hypothermia; type of anesthetic) ?

Trauma-Management of Pregnant Patient

Cannada, et al. J Trauma 2010;69:694.

> Stage 4: Second Look„s and Schedulded Definitive Surgery

> Stage 5: Secondary Reconstructive Surgery

Damage Control Stages

> Stage 1: Indications

> Stage 2: Damage Control Surgery

> Stage 3: Resuscitation in ICU

Experience

Tactics

Dynamic

FlexibilityWindow of Opportunity

Days 4-10

Prevent Maternal and Fetal Death !

> Life Saving Surgery:

– Operative control of airway

– Decompression of cavities

– Surgical control of hemorrhage

– Team

– Tactic

- Time> Fast decision

making for Life

Saving Surgery,

DCS/DCO,

cesarean section

– Bleeding control

– Reduction of contamination

– Decompression of compartment syndrome

– Resection of avital tissue

– Fixation of skeletal instabilities

> Damage Control Concept

> Anticipate physiologic and anatomic alterations during pregnancy

> Fetal monitoring

> Cesarean Section

(Poly)trauma during Pregnancy - sgar-ssar.ch · Prof. Marius Keel, MD, FACS General, Trauma and Orthopaedic Surgeon EBSQ Traumatology Emergency Physician Leitender Arzt für Becken-

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