Good morning. All right, on with the show. So, of course, I have a fun topic which will make everybody warm, fuzzy, and enjoy the heck out of it. Obstetrical trauma, which is one of those things that either really gives you the buzz or it gives you the willies. You choose. Okay. Big green button. Big green button doesn't work. There it goes. Okay. All right, so one of the things that's really nice about our place, and you get a lot of experience, is because we keep families together. We're the only place in the state of Arizona that does, we're pediatric verified and adult verified. We do OB, we do all the high-risk stuff, and we also have the level one burn center. So, one of the worst things is when a pregnant female comes in burned, traumatized, she's pregnant, and you go, oh crap. Unfortunately, we have a bunch of experience with that. So, I have no disclosures other than this statement. I would like everybody to read this statement, understand this statement, and believe this statement, that no pregnant woman should be allowed out of the house, get into a vehicle, participate in any risky behavior or activities for the duration of their pregnancy due to the profound increase of becoming a trauma patient. Every time I give this, there's usually somebody in the audience who's pregnant and throws something at me. But the fact is, people do things. It's called life, and being part of life has dangers. So, we all have to be willing to pay that price. So, OB trauma comes in many forms. We have the babies on the left, we have the baby on the right, which occasionally does happen. So, his baby looks a little different, but certainly every once in a while it is trauma. All right, when it comes to female anatomy and baby anatomy, they are intimately involved, as we know, and one of the things that we have to worry about is fetal position, fetal life, and fetal demise. Here comes the not fun part. Fetal demise is a reality, and all of a sudden we learn, long, long time ago, take care of mom, you take care of baby. But there's a lot to that with trauma. Everybody knows we're trying to do less scanning, less radiation, and every time I give a talk on radiation and cat scanning, I keep coming up with the same answer. You do what's right, radiation be damned. But the fact is, you have to do what's right, because if the signs and symptoms are there to scan a woman who's pregnant, guess what you should be doing? Scanning the woman, and we're going to get into that. So, education, because prevention is the key to trauma prevention. So, prevent it. Let's be educated, and wearing a seatbelt the right position is very uncommon in Phoenix. Wearing a seatbelt at all is uncommon in Phoenix. So, we get a lot of this, but you want to make sure that we educate the public, and part of our public outreach is not just child safety, child seats, but it's maternal safety. So, it is double jeopardy. Mom comes first, no ifs, ands, or buts, and we have people who still believe it's all about the baby. Those are called obstetricians. They are invited to our trauma room, but they have to stand behind the red line until invited in, and there is a reason. Because they have a mixed-up sense of priorities. If you look at the ATLS manual under OB trauma, it specifies, and we'd love to give it to them at least annually, maybe we should give it monthly, so they remember that it's mom first. You can't say that enough. It's a mantra, and is the baby always second, or is the baby concomitant with the mother? Again, treat the mother right. Baby's treated better. So, we know the different physiology, and I'm not going to go over this. I put this up here just for everybody's reminder, that maternal physiology is different versus when she's not pregnant. So, there are some issues there, including like kids, they don't fall off the cliff until way out there. So, you've got to be careful. They may not show you the signs and symptoms of shock as clearly as you'd like, because they're pregnant. They have that parasite growing inside of them, and that parasite changes everything, especially towards the latter part of the cycle. So, what do we do? What we do is our standards. Don't deviate. Practice like you do. Do like you practice. Do it every time the same way. You rarely go wrong, but it really is ATLS in the field, and what happens is sometimes EMS, again, needs education because they don't do the right priorities, the right timing, the right way. So, we have to educate them as well. So, as it's said in many, many, many trauma centers, in many, many trauma conferences, diesel fuel is the best medicine for trauma patients from the field. Jet fuel, diesel fuel, just get them to the damn trauma center, and that really pays dividends. So, if we get them left side down, we give them oxygen. Some people are even advocating doing field ultrasounds, and some communities have it. Some don't, but it's the ability to look early and find what's potentially bad. So, the trauma complications that we all look for, vaginal bleeding, sometimes preterm rupture of the membranes, that's where your OB comes in. We don't look for that. Placental abruption, guess whose responsibility that is? Ours. Not OB. That's ours. Ladies and gentlemen, this is our problem. That's a new finding, just a couple years old, that we realize this is all about our ability to diagnose this. We worry about pelvic fractures in the woman. Fetal deaths certainly do occur, and sometimes they come in without heartbeats. Fetal fractures, intracranial hemorrhages, and that indirect injury due to maternal hypoxia or hypotension. So, what do we do? Well, everybody says ultrasound. This is, again, where you tell your OBs, mind your business, because they want to do an ultrasound on everybody, but for different reasons. They want to look at the heartbeat, I'm all for it. They want to figure out the age of the fetus, I'm all for it. They want to tell me there's an abruption, tell them to go take a hike, and I'll show you why. Because they're wrong more than they're right, and that's even a public statement put out by their society. So, if I do nothing else today, it's to have everybody bring back the fact that ultrasound is not sensitive. It is not specific. CAT scan is. So, what do we do in the ED? We give some high-flow oxygen, we all know that. We watch their blood pressure, we monitor them for bleeding, we do a quick pelvic exam or at least an examination of that area to make sure nothing's leaking out. If we have to, we transfuse them, we watch the baby as close as we can, and then we start to worry. Because based on their signs and symptoms, their presentation, that's when you worry about the big ugly abruption. Because that's what it is, big and ugly. So, do they have uterine tenderness? A woman who comes in with any abdominal pain is getting a CAT scan. Because I can't tell the difference between muscular pain of their abdominal wall and pain from their uterus. It's impossible for me to tell. No crystal ball. And if anybody wants to share theirs with me, please do. Premature labor, the abdominal cramping, again, a very generic sign or symptom. And then fetal distress, of course, that we watch for. So, the clinical practice guideline in Canada says you have to look. An ultrasound is not sensitive for looking for this abruption. Fetal distress is fairly easy. We watch the heart rate. But when looking at the mom progressing over time, we have to do a better job. And at least in Canada, they have the right idea. It just hasn't spilled over to the U.S. yet. So, abruption, even minor trauma, can cause it. And this is one of those issues that we have to be more aware of. And I'll get into a story in a moment. So, abruptions, clinical impression, laboratory tests, fetal evaluation. And those laboratory tests also include the CAT scan. So, radiology must be included. Not just sonographic findings. So, here's an article we wrote because we had a few fetal demises. And we started to scratch our heads saying, what in the world are we missing? There's got to be a better way. And OB, nope. We're doing the right thing. Well, if you're doing the right thing, why do we have fetal demises? We should be all scratching our heads to do research on things that don't make sense. This was one of those things that popped up in our peer review. So, we did research on it. The ability of CT to diagnose placental abruption. We searched the world. We searched everywhere. We couldn't find anything on this. So, these are pictures from our article that just show the top left hand is a normal placenta. You can see the highlights. Right there. What lights up is good solid placenta. That's well perfused. Go to the right, top right. You can start to see little dark areas coming into those bright areas. Something isn't quite right. Little less flow. And then go to C, you see even less flow. And then in D, there's barely any flow. Nobody ever put out a grading system. Nobody ever commented on this before. We searched textbooks. We searched radiology and OB. Nobody had this. And all of a sudden, we started to correlate our CAT scans to our potential for fetal demise. And what we found was, this is the retrospective data, that we had missed this. No one ever put their finger on this to say, oops, mortality sucks. Plain and simple. Remember, I told you this was going to be a warm and fuzzy talk, right? So, we had to do a better job. So, that's when we started looking more critically, prospectively at these CAT scans. Came up with a grading system and all of a sudden, we decided, you know what? We're doing something right. We haven't had a fetal demise since from this. So, lo and behold, our OBs finally have something to go on. Our radiologists are proud that they have a scoring system created that gives people useful, objective information to the risk of abruption and the risk of a fetal demise. So, once you realize this, we look at the baby, we monitor the baby, we look at our CAT scan and we put the big picture together and go, this kid's getting out now. Knock on wood, no more fetal demise in our hospital from this. We need to share this because it's still happening around the country. When I go to different conferences, I ask people about this and they, oh yeah, we had one not too long ago. Maybe, maybe we can prevent it. So, we looked at all trauma patients greater than 26 weeks gestation. They went the CT abdomen and pelvis as part of their workup. We went for our grading system here. What we found was, radiation be damned, it comes in really handy to have this diagnostic ability to help the fetus, to help the mother and we have a happy family instead of a very unhappy family. So, anytime we have fetal distress or we see low grade or excuse me, high grade abruptions on CAT scan, kids coming out. So, we looked at our historical controls and again, we had a 40% fetal mortality. Nobody should have that, not now. So, we can all do better and now we do. So, uterine rupture, let's get into something a little more fun, more surgical. Compression injuries to the abdomen are common, whether it's a steering wheel or something else, intrusion. Did they have a prior C-section? Sometimes, you can't find the fundal height and you're like, oh, something's wrong here. Vaginal or internal hemorrhage and shock, you have to be suspicious. This may be where your FAST comes in because you'll see free fluid. Laceration with acute hemorrhage, a lot of fetal demise from this. And again, we'd like to prevent that the best we can and we got to get in there and help this. One of the hardest subjects is maternal arrest. This is one of those that makes you scratch your head going, I don't know what the literature says if it's accurate or not. And you know what? It's hard to know. So, just going over it, everybody does ACLS. Sure, we do it. Try and keep the mom alive the best we can, which again, helps the baby even if she's in arrest. If you have high quality CPR and you're getting circulation, you buy yourself a little bit of time. We do our ATLS protocol, stat C section, and here's really the best literature I could find. Gestational age greater than 26 weeks, less than five minutes in arrest, get that kid out. You have a probability of saving a life. The question ethically, morally, is when to call it. That's a tough one. Never easy. It's like a fireman who goes down, a police officer who goes down, a nurse or doctor you know who goes down. When do you call it? I'll leave that to you. So, the literature is pretty reasonable now when it comes to this. How often, meaning how long, should you do that CPR and when is a chance of getting that kid out viable? So, they said four minutes, no later than four minutes, gives you a chance to get the child out. So, we go for under five and we hope for the best. This is what every woman should be doing. Remember my personal bias. Laying in bed, bonbons, being served by her husband, her friend, her partner, whoever, and just take it easy. Don't do those high-risk behaviors. Don't become our trauma patient. Okay, if they want to go out for a run, they're safe, they're not in your cars, they want to go for a trip, they want to be safe, not get hurt, okay, I might be open to that, maybe. Just be aware of your surroundings, wear bubble wrap, wear a helmet, I don't know, be safe, wear an inner tube around you to kind of bounce off of things. This is not okay. Getting on the back of a motorcycle, getting to the gym, going crazy with martial arts, smoking, drinking, mountain climbing? I'm sorry, the answer is no. Don't ride a horse, don't inject drugs. In fact, go back to my premise, go stay at home. It's not a bad idea. We don't want to be doing this. This is the key. We want to avoid this at all costs. Yes, we want to be ready and available if this happens and if this is needed. I get it. We all are trauma centers, ready, prepared to do it if we have to. Prevention is the key and I implore everybody when you go back and think about how do we do outreach, how do we do injury prevention? Don't forget the maternal. We really focus on kids. We're all doing Stop the Bleed now. We all have our passions in our communities. I would encourage us to not forget maternal safety as well. It is two lives we're saving, not just one. Come on, it's a twofer. This is great. I'll take those odds any day, better than my wife playing craps today. Anyway, if you're not having fun at work, you're doing something wrong. One of the things when it comes to maternal trauma, it is no fun. We all sit there and everybody's a little bit more serious that day, but again, I encourage you to remember some of the steps I showed you because it really can make a difference in both maternal and fetal outcomes. It's something that's overlooked. It's something that's not well described in the literature other than one article right now, and a lot of people don't know about it. So maybe you guys will take it back to your place and encourage your OB and your trauma teams to think long and hard about using CAT scan and then grading your abruptions. It can help, and as I promised everybody, this was only a public service announcement. The only vaccine for obstetrical trauma is prevention. They even put up signs on the highway, pre-born babies feel pain, say no to maternal trauma. I like that. I really like that. I'm a big supporter of that. And just because we're saving time, I'm done early. Thank you for your attention.

obstetrical trauma

prevention

high-risk obstetric care

placental abruption

maternal safety