Hi, I'm Britt Wells, I'm an orthopedic surgeon currently at St. Luke's Health System in Boise, Idaho. I was previously in the Dayton, Ohio area and worked very closely with Deb Myers at two different level three trauma centers. So Deb gave me the invite for this trauma panel. I really appreciate it. So let's talk about the 30 year old female. The scenario has already been presented. She was a restrained passenger that required extrication. She's 24 weeks pregnant, tender abdomen and pelvis. Fetal heart runs 120. The patient was hypotensive and tachycardic. And it was already laid out by Dr. Urbano that she did have a placental abruption and the decision was made to deliver that baby at the level three and then perform immediate transfer to a level one for additional care by OBGYN. And also probably neonatology. So this is the X-ray that I'm presenting here. This is the pregnant female with an open book pelvis. Just to briefly describe one of the classification schemes for pelvic injuries, the Young and Burgess classification is commonly used and these are divided with anterior posterior compression injuries, lateral compression injuries or vertical shear injuries. The scenario that we're presenting here is that this patient has an anterior posterior compression type three with wide diastasis of the pubic symphysis as you can clearly see and disruption of the left SI joint. Pelvic fractures in pregnancy are quite rare as Dr. Martin alluded to a little bit earlier. This was a paper that was published in 2007, American Journal of Orthopedics and they presented a case series of 15 patients and the outcomes are not great for these patients. There was 7% maternal mortality and 33% fetal mortality. So these are very serious devastating injuries potentially, especially for the infant. So let's talk a little bit about the emergent management of unstable pelvic fractures. Obviously we're going to institute ATLS protocol, ABCs with fluid resuscitation, packed red blood cells and I would also venture to say the TXA would have a very important role in care of this patient. Emergent stabilization of the pelvis, typically as we already mentioned, the patient received the pelvic binder in the field en route to the hospital. If pelvic binders are not available, simple bed sheets clamped in the front I think are very effective and the whole purpose of the binder of the sheets is to decrease the volume of the pelvis. Most of these bleeds are from the venous plexus and when you have an open book pelvis, you've got a large area of volume for bleeding to occur in and the whole purpose of the binder or the sheets is to decrease the volume of the pelvis to tampon out especially those venous bleeders. Other emergent stabilizations, depending on availability at your center, whether that's at the level three or the level one, could also include an emergent external fixator placement or a C-clamp, which is another version of an external fixator. And then you can also discuss other hemorrhage control if the binder or the external fixator is ineffective, which could include, depending on availability, interventional radiology to perform angioembolization, pelvic packing if the patient is already gonna be receiving a laparotomy for other intra-abdominal hemorrhage injuries such as a spleen, a liver, or in this case, emergency C-section to deliver this infant and also possible reboa. And then usually that would be a definitive fixation would occur later after the patient is stabilized. This is an algorithm, one proposed algorithm that looks at how we manage these pelvic fractures that have hemorrhage and are hypotensive. And you can see here, it's usually involving some form of stabilization with a sheet or a binder in the field, activate massive transfusion protocol, transfuse the patient and perform a FAST exam. If the FAST is positive, then that patient is probably gonna be going to the operating room for a laparotomy with either pelvic packing or pelvic angiography or possible reboa. If they're stable, then they could be transferred to the ICU with plans for a later definitive fixation. And Dr. Maynes, I'm not sure if you wanna kind of comment on the kind of the algorithm and the flow of patient care for these patients, but oftentimes it really depends, the definitive fixation of the pelvis is going to be after treatment, after the patient is stabilized. I think it really depends on what their other inter-abdominal injuries are or if they're gonna require an emergent laparotomy. So just a couple of comments. I mean, the mortality for hemodynamically unstable pelvic fractures is very high. And time to hemorrhage control is really one of the determining factors. So, and there's a wide variation around the country. So the level three here that we're talking about in this scenario actually has reboa and has used reboa and transported a number of patients with a zone three reboa in place. Now, it's not applicable if you've got intra-abdominal injury, potential torn thoracic aorta, reasons not to do that. But the times we've seen reboa used, it's been fairly effective. Now, 80% of major bleeding is venous in these pelvic fractures, 20% is arterial, but on both sides of that, they can bleed to death. I'm not a huge fan of pelvic packing if you've got reboa because reboa is much easier to work around with interventional radiology. And you don't have to remove the packing to actually see where the bleeding occurs. And you don't ever have to make that choice. We've had a few patients at our level one that have had reboa and that has not been adequate control. And they've gone on to do pelvic packing prior to going to IR, but that's a pretty rare situation. Your comments on that? Yeah, no, I would agree with that. I think pelvic packing is not very commonly performed in my experience. And I think reboa in this case would potentially be very effective. For this particular patient, this patient did not have a negative FAST exam. The bleeding was all intrauterine with a placental abruption. And I think Dr. Martin will be expanding upon this in quite further detail later. But I think the key was really to control the hemorrhage from the uterus by delivering the baby. So just to talk about pelvic binders and or sheet placement. I think oftentimes these are misplaced and they're placed too high up. What you have to realize is that this has to be placed at the level of the greater trochanters to really rotate that especially if it's an open book injury to rotate the pelvis internally to tamponade those venous bleeders. So a couple of things about pelvic binders. These are placed at the level of the greater trochanters. They're typically in place for the first 24 hours until some form of more definitive stabilization can be performed either an external fixator or definitive ORIF. And if it's left on more than 24 hours, these need to be removed to perform skin checks at least every 12 hours because they can cause skin necrosis. This is just a couple of different setups for external fixators. They can either be placed at the inferior iliac spine or a combination of anterior inferior and anterior superior iliac spine. And there's a variety of constructs that can be constructed to stabilize the pelvis whether that's more of a C-shaped clamp or whether it's a standard external fixator with multiple crossbars. One thing that I think we have to be aware of is if some form of laparotomy or in this case emergency section is gonna be performed, how does that play into the definitive fixation from an orthopedic standpoint? Obviously we'd wanna coordinate with our trauma surgeon and our obstetrician if they're gonna be having an emergency section. Are we gonna be performing concurrent or delayed pelvis ORIF? And also the plan for the incisions. Typically we would perform a fan and still type of incision which would be typical for a C-section also which would work very well for our purposes for a later definitive ORIF or if the patient is receiving a standard vertical laparotomy incision that can be extended distally and still provide adequate access to the pubic sensus for a definitive fixation later. I would comment if I've got this patient I'm not dinking with the fan and still I'm gonna open the belly, make a hole and try to make sure I see everything. Yeah, and I certainly would leave that up to the trauma surgeon's discretion but even with a vertical incision that can be extended and still provide access for our fixation purposes later. So that certainly would not burn any bridges for us. In this particular scenario, this is after the patient after the infant has been delivered and the patient is now receiving definitive fixation and you can see plate fixation of the pubic symphysis typically with three screws on either side of the pubic symphysis for a total of six screw construct and a sacroiliac screw at the left SI joint. Let's talk about the second patient which I think everyone agreed that this was a lower priority patient. They were hemodynamically stable, did not appear to have any other major injuries and appeared to have only an isolated periprosthetic fracture of the left hip. This patient was four weeks post-op from a left total hip. In this particular scenario, we were gonna say that she was on aspirin, 80 milligrams BID for VTE prophylaxis which is probably the most common prophylaxis protocol for total hip patients. GCS was 14, she was hemodynamically stable and the scenario that I devised was that she had a periprosthetic femur fracture on the left with a stable total hip stem which we would consider a Vancouver type B1 fracture. These are the x-rays. So she's had bilateral total hips but the left hip is the periprosthetic fracture. You can see there's a widely displaced fracture at the tip of the femoral stem. The stem is stable and that would be considered Vancouver B1. Just a little review for those of you that may not be familiar, the Vancouver classification system really is designed to look at the stability of the total hip stem. Type A would be either an avulsion of the greater or lesser trochanter which are stable fractures oftentimes treated non-operatively. A B1 is at or below the tip of a well-fixed femoral stem so that patient does not require a revision of her total hip stem. A type B2 is where the stem is unstable. The stem is displaced, either subsided or it's come loose from the femur approximately. A B3 is with bone loss and a type C is a fracture that's well below the tip of the femoral stem. So the scenario that I presented here was that this was a stable hip stem and I would venture to suggest that this patient probably could be adequately treated at the level three trauma center. I would say that most surgeons, most orthopedic surgeons would be able to fix a periprosthetic fracture that did not require revision of the total hip stem. If that stem was loose, I would agree with Dr. Rubano that that patient would probably require specialty care by a total hip surgeon because that would require a revision of the hip stem. But the scenario that I presented was that this was a stable stem and we just simply performed a plate fixation of this fracture with a combination of a locking plate, plus or minus cerclage cables, either around the stem or around the spiral fracture of the femur. So several questions arise in caring for this patient. Do all trauma patients require transfer to a higher level center? What is emergent? What can wait? A cardiac clearance oftentimes comes up as a question in these patients, especially older patients that may have a cardiac history with either valvular abnormality, CHF, et cetera, the use of TXA. I think it's also very important to discuss anticoagulation reversal. This patient was on aspirin and that patient would not require delay for surgery, but oftentimes patients are on the direct oral anticoagulants or on Coumadin. What are our VTE prophylaxis protocols postoperatively? And also discuss briefly about hip fracture clinical practice guidelines. So the question, do all trauma patients need to be transferred? I think this question really depends on what their other injuries are and what other specialties are available at the rural hospital. If they have a head injury or require a new certain neurosurgery consultation, that patient would most likely need to be transferred, whether we have OBGYN in the pregnant patient or if this patient needs a total hip revision. But I would say that many orthopedic injuries can be managed at the rural level three center. Complex injuries that may need to be transferred would include pelvic and or acetabular fractures, complex periarticular fractures, such as pilon, elbow, plateau, et cetera. Extensive polytrauma injuries with multiple long bone fractures probably needs to be transferred to a level one. And as we mentioned, periprosthetic fractures with a loose hip stem that require a revision of their prosthesis would require a specialty total joint surgeon care, which may or may not be available at the rural hospital. There was a nice paper that came out in clinical orthopedics related research last year that was really looking at what is the quality of care for patients at the rural hospital, especially at critical access hospitals. And the consensus of this study, at least for hip fractures, was that hip fracture surgical care at the critical access hospital actually had a lower rate of major medical and surgical complications. And that providers and patients living in isolated areas can be assured that their hip fracture management is going to be at the same level as potentially a level one or a non-critical access hospital. So I think we can take care of a lot of these patients at the critical access hospitals with excellent outcomes. Question arises, what needs to be, what is emergent and what can wait? I think the general consensus from an orthopedic standpoint is that the emergent cases include compartment syndrome, open fractures, open dislocations or open joint injuries, fractures or dislocations with neurovascular compromise, septic arthritis or other musculoskeletal infections with severe sepsis, necrotizing soft tissue infections, and unstable pelvic fractures that are hemodynamically unstable. Urgent cases, which we typically treat within 24 to 48 hours can include hip fractures, femur and other unstable long bone fractures and unstable periarticular fractures. Question, cardiac clearance and need for echo in a rural hospital. This is always something that comes up, I would say probably about 30% of the time, especially in the geriatric population. There was a nice paper that came out in the Journal of Orthopedic Trauma in April of last year. And it was talking about the unnecessary preoperative cardiology evaluation and echoes, which caused delay to surgery. And the conclusions of this particular paper is that echoes and cardiology consultation are often ordered and performed against current clinical practice guidelines. And the consensus was that these are expensive and they just lead to delays in surgery. If you ask an orthopedic surgeon, no patient needs an echo before surgery. And there've been many papers that suggest that echoes rarely if ever change any intervention from a cardiology standpoint for these patients. So I think the conclusion is that these should be used judiciously and according to clinical practice guidelines. Otherwise, I think we're just probably wasting money and causing surgical delays for these patients. So a polling question about TXA, how often and for what cases is TXA used at your institution? Give everybody a minute to respond to that. Okay. And I agree with your preoperative assessment, particularly on elderly patients. There are a handful of patients that really need serious consideration. And within our system, we've identified two subsets that really do poorly without careful hemodynamic monitoring, both intra and post-op. And those are patients with pulmonary hypertension and severe aortic stenosis. And certainly that subset of patients really deserves an aggressive but rapid workup because you don't want to delay surgery. You just want the anesthesiologist and critical care docs to know where they stand. They've got a relatively narrow sweet spot on their Starling curve and over and under resuscitation is a major problem in those patients. So I think that's the group with those kinds of comorbidities that really should be considered for pre-op echo. Yeah, I would completely agree with that. Okay, so we've got answers coming in. There's no clear consensus here. 41% are saying majority for MTP and OR cases. The second best answer was seldom for MTP OR cases. So comments. Interesting. Yeah, I would say that, and I'll get to my next slide here. Let's close that out. That in orthopedics, TXA really is having a huge upswing and we're using it very, very commonly in orthopedics. It's really become the standard of care and the gold standard for total joint arthroplasty. Almost every orthopedic surgeon that's performing a total joint is giving TXA. And there's been multiple studies that have shown it is safe and effective even in the highest risk patients, patients with history of coronary stents, patients with a history of prior DVT or PE, patients that have coronary artery disease, et cetera. It can be used safely in these patients. There's an increasing use in non-arthroplasty in orthopedic trauma cases. In my opinion, I think any potential case that has risk of a large amount of blood loss, I would say over 200 CCs, I think is certainly an indication to use TXA. It's cheap, it's effective, and it has a very low risk of complications. So why not use it? I would say I use it, especially in hip fractures. We use it almost with every hip fracture patient, whether that patient's getting an intramedullary nail or a hemi arthroplasty or total hip arthroplasty. It decreases blood loss and transfusion rates. And the typical protocol is one gram at the start of case and another gram at the close of the case. But there are many different protocols out there, even protocols for oral TXA or topical TXA. But the most common, I think, would be intravenous. Dr. Maines, any comments from a trauma standpoint? Yeah, we could spend a long time on TXA. TXA reverses hyperfibrinolysis and clearly is indicated if you're starting an MTP, TXA should go along with that. The CRASH-3 trial suggested one gram followed by one gram drip over eight hours. A lot of us think that that one gram drip over eight hours is really superfluous. It's all over at eight hours, one way or the other. And the military has actually gone to a two gram dosing for those patients. The TCCC, which looks at combat casualties, has a 2020 recommendation that the TXA dose be two gram by slow IV push. And what you've pointed out is that the safety profile for TXA is exceedingly high. So giving it in multiple situations has been shown to reduce blood loss and that sort of thing. Most of us as trauma facilities are familiar with adding it into the MTP, but you make some good comments about other uses for it. Yeah, we use it, we use it a lot. I think it's, I think it's a great medication. Another polling question regarding DOACs, the direct oral anticoagulants, Eloquus or Altopradaxa, what is your protocol? You can see the questions there, standard protocol, you know where the reversal medications are, don't know where they are, never seen the protocol, no idea where they are, varies by physician. And I think we're going to get a wide range of responses here. Looks like the most common response was standard protocol, know where it is, and drugs are located in the DED. I would say I'm not sure there's, you know, an exact standard protocol here and we'll discuss it, we'll discuss it a little bit on the next slide. There's been several papers, at least in the orthopedic literature, discussing is anticoagulation reversal even necessary prior to treatment, especially in more common cases such as a geriatric hip fracture. And I think the consensus is in many of these papers is that patients with an isolated hip fracture that are on an anticoagulant preoperatively, either Coumadin or a DOAC, may not require reversal. In fact, the studies have shown that the blood loss transfusion rates and complication rates are not significantly higher in patients that are not being reversed, that we probably can safely operate through the DOACs and even Coumadin, depending on the INR, without significant complications. So that's a topic that really requires quite a bit of discussion. The paper you quoted is from our system and we have a lot of variation in how that's managed, but we do have a system guideline for that. So let's go ahead. And there was another paper that was also looking at intervention for proximal femur fractures that were on direct oral anticoagulants and the complication rates were not significantly higher in patients that were on the DOACs and that we were able to operate through. So at least at St. Luke's, and I think this is becoming increasingly more common at other orthopedic institutions, that the need for reversal is not always necessary. What our threshold is currently at my hospital is that if the INR is greater than two, then we will reverse with IV vitamin K, usually 10 milligrams intravenous, not PO. PO takes way too long. That usually results in rapid correction of the INR within less than 12 hours and should almost eliminate the need for FFP. If the INR is less than two, we typically will operate on this patient without reversing and our transfusion rates, complication rates are not significantly increased. Regarding the DOACs, if you're going to be performing an elective case, you would hold and allow it to clear. For urgent cases, I think you can safely proceed without reversal with a goal in mind to get that patient to the operating room within 24 to 48 hours. If you have a truly emergent life-threatening hemorrhage, then I think you should consider reversal agents. These agents are available. Kcentrin and PCC can reverse all of the oral anticoagulants, but it is quite expensive, about 5,600 for a patient. There are specific antidotes for Eliquis and Xeralto and Dexanet Alpha, which is reported to be $22,000 per patient. Not many people are on Prodaxa, at least in my experience, more recently, but the cost is about 3,700 per patient. We do not delay any surgery for patients on aspirin or Plavix. That is a good comment. Few places have Andexa. It is very expensive. Its benefit over four-factor PCC for reversal does not seem to be a huge benefit. A lot of places are using four-factor PCC to reverse the 10A inhibitors. Praxvine is expensive, and some of our rural communities have coordinated with their family docs not to put patients on Prodaxa for anticoagulation and rather use one of the DOACs so it can be reversed with PCC if they need to. That is a very long discussion. Thanks for bringing that up. This is a cheat sheet that we use. This is usually more for elective cases, depending on the agent and whether it is going to be a low or high bleeding surgery and also depending on their renal function and creatinine clearance. For most of the urgent cases, we are operating through. Another polling question. What is the postoperative VTE prophylaxis protocol for orthopedics at your institution? Physician dependent, orthopedic group dependent, standard protocol for the entire hospital or unsure? Standard protocol. That is good to hear. I like protocols. For VTE prophylaxis, I am not sure there is an absolute right or wrong protocol because it does vary, but I think it is important to have a standardized protocol at your institution that everyone is following so it decreases confusion and gaps in treatment. So, at our institution, our VTE prophylaxis guidelines, we have SCDs on the nonoperative leg, intraoperatively and bilateral postoperatively. For total joint patients, it has really become the standard of care that aspirin 81 mg BID for up to 30 days has become the standard of care. Multiple studies have shown its efficacy compared to more potent agents and decreased post-op hematomas, wound drainage and infections. Other orthopedic fractures, I think it could be on a case-by-case basis, whether you may be using Lovinox or aspirin. For fractures below the knee, I think the risk is much lower and you could consider aspirin for higher energy injuries that are above the knee and the pelvis, acetabulum. You should possibly consider Lovinox. At St. Luke's, our hip fracture protocol is to have these patients on Lovinox for five days and then we transition them to aspirin for 30 days. And patients that are on preoperative anticoagulants, we usually restart those within 12 to 72 hours post-op. For elective cases, for urgent cases, we may not even stop those at all and just continue their DOACs or their anticoagulants without interruption. This is a paper that came out last year, I think it was in the this is a paper that came out in JBJS a couple of years ago that was looking at the protocol that we use and that was using aspirin for hip fractures after they've received five days of Lovinox in the hospital. I'd like to touch briefly, I know we're a little bit behind schedule here, on clinical practice guidelines in orthopedics. There have been some excellent papers published by the American Academy of Orthopedic Surgeons looking at the standard hip fracture protocols for hip fracture patients. We did actually publish a paper in AOSNOW in December of 2017 with our experience at St. Luke's developing a care map following the clinical practice guidelines and you can see some of the guidelines here. But they range from preoperative traction, which we usually do not use, the timing of surgery within 24 hours, VT prophylaxis, all the way through what type of procedure they're receiving, TXA, multimodal analgesia, etc. So we had a question from Vicki Bennett, very good question, what about weight-based dosing for Lovinox? We certainly use that if we're anti-coagulating with Lovinox. For the prophylaxis, the Western Trauma Association has guidelines recommending 40 BID for under 65 and 30 BID for over 65. And there's certainly a lot of controversy about that. We know that some of that is inadequate prophylaxis, so that's a much broader topic. We probably ought to talk about that one of these days with TCAA. So Dr. Wells, thank you very much. We're going to move on to the OB section of this. We have Dr. Martin, if you could introduce yourself and get going. Good morning, I'm Angela Martin. I'm a maternal fetal medicine specialist, or also known as a perinatologist, at the University of Kansas. And I'm going to jump right in since we're running a little bit behind here. All right, so trauma is unfortunately pretty common. It's the biggest non-obstetric cause of maternal mortality during pregnancy. It affects up to eight percent of pregnancies, which said in other ways, about one out of every 12 pregnant patients. Fortunately, the rate of fetal death from trauma remains very low, but the rate of preterm birth from trauma is not that uncommon. So this just kind of outlines the typical causes of trauma in pregnancy, and you can see that it's very similar to non-pregnant patients. Motor vehicle accidents cause the majority of trauma. Second most common is assault, and this includes domestic violence. And I want to particularly mention that because domestic violence is more common in pregnancy and more fatal in pregnancy compared to non-pregnant patients. And then you can see the breakdown there for the remaining more rare causes. All right, so our first polling question. How much blood flow does the term uterus receive per minute? Right, so pretty evenly split there. That's interesting. So it's actually 600 milliliters per minute. This is a pretty amazing statistic. The uterine blood flow increases in the late preterm and term period to 500 to 800 milliliters per minute. The cardiac output shifts to about 2% of the cardiac output going to the uterus in the non-pregnant state, to anywhere from 15% to 20% going to the uterus in the late preterm and term period. So pretty significant shift there in uterine blood flow. So we're going to jump right into the physiologic changes that happen in pregnancy that might be important for the trauma patient. So first, there's really significant cardiovascular changes even in the first trimester. The cardiac output has increased by as much as 20% in the first trimester. It continues to rise until the third trimester where it peaks at about 32, 33 weeks. At this point, it plateaus at about 30 to 50% above baseline. That increase in cardiac output is due to, number one, an increase in maternal heartbeat. That's only about 15 to 20 beats per minute above baseline. More significantly, there's an increase in the stroke volume due to the decreased afterload from decreasing vascular resistance from that progesterone effect. You also have an increase in the preload from a rise in the blood volume. The circulating blood volume increases to about five to six liters total, and the total intravascular volume increases to about 40 to 50% above that non-pregnant state. From a purely mechanical standpoint, the heart is rotated more towards the maternal left. There's pregnancy-related EKG changes that can be normal. So there's a 15 to 20 degree left axis deviation. There's transient ST and T wave changes as well. So as we already alluded to, these cardiovascular changes lead to a significant increase in blood flow to the pelvis. This clearly has implications for the trauma patient because if there is pelvic injury, you can have a really quick maternal assignation. The overall increase in the blood volume does allow for the patient to better tolerate blood loss, but I heard someone earlier mention the quote that kids are stable until they aren't. I think that could be said for the pregnant patient too, because they can tend to tolerate about 15 to 20% of their total blood volume blood loss before you start to see that reflected in their hemodynamic status. And then finally, it's worth mentioning that the gravid uterus can compress that inferior vena cava, so you get less venous return to the heart. All right. So going on to respiratory changes, in the first trimester, there's an increase in the tidal volume due to an increased respiratory drive, again, because that progesterone effect. This leads to a slight hyperventilation, and there's a chronic mild respiratory alkalosis in pregnancy. This is important to keep in mind when you're interpreting your ABGs, because an otherwise kind of mild acidotic patient could be moderate borderline severe in a pregnant patient. Physically, beginning around 20 weeks, you have an upward displacement of that diaphragm that leads to about a 20% decrease in the functional residual capacity. There's an increase in the diameter of the chest cavity and an upward displacement of the diaphragm, which has implications for the chest tube placement. There are experts that would suggest placing the tube about one to two intercostal spaces above the usual landmark of the fifth intercostal space. And then keep in mind, too, that pregnant patients always have a difficult airway. They desaturate pretty quickly in that supine position. There's normal edema related to pregnancy in the airway, and they just always have a very difficult airway. All right. So moving on here to other systems, so starting with the renal system, GFR and renal blood flow increase significantly during pregnancy. There's a physiologic fall in a serum creatinine. So typically, creatinine is less than one. That's normal in pregnancy. There's a physiologic mild hydronephrosis. There's dilation of the ureter. So the ureter is more prone to injury in pregnancy. Other intraabdominal anatomic structures are elevated and displaced as that uterus grows. So specific considerations related to trauma include elevation of the bladder, upward displacement of the bowel and stomach. So there's decreased risk of visceral injury with lower abdominal penetrating trauma, but increased risk with upper abdominal injuries. As I already mentioned, the difficult airway. Pregnant women are also at high risk of aspiration due to decreased lower esophageal sphincter tone and increased intraabdominal pressure. And then finally, hematologic changes. There's an increase in the coagulation potential with reduced anticoagulation fibrinolysis. So a normal fibrinogen in pregnancy is typically over 400. There's also a mild leukocytosis in pregnancy and a physiologic anemia because the total red cell mass only increases by about 20 to 30 percent, where the total blood volume, like we already discussed, increases by 40 to 50. All right, so obviously there's uterine changes that occur in pregnancy. In the first 12 weeks, the uterus stays in the pelvis and it's relatively protected from injury. After 12 weeks, it starts to rise intraabdominally and injury is a possibility. You know, dilated pelvic vasculature increases the risk of injury to these structures. And I'm going to mention it one more time, that uterine blood flow 500 to 800 milliliters per minute once you get to the late third trimester. All right, in the trauma bay, you know, if you have a patient and you're unsure of her gestational age, you can use the fundal height to help you estimate how far along she might be. So if you can barely palpate that fundus outside of the pelvis, you're looking at 12 to 14 weeks, halfway to the umbilicus, about 16 weeks. If you can palpate the fundus at the umbilicus, right around 20 weeks. And then by the time you get to the xiphoid process, you are 36 weeks or late preterm, early term. So when you're caring for the pregnant patient, the primary management goal is to stabilize the condition of the mother. The fetal outcomes are directly correlated with early and aggressive maternal resuscitation. Maternal shock and death are the leading cause of fetal death in cases of trauma. So fetal assessment should not delay the primary survey or resuscitation of mother. In a stable trauma patient, you know, you guys are familiar with this, the primary survey can be completed very quickly, sometimes in a matter of seconds. At that point, if the mom is stable, the fetal evaluation can begin. In the unstable trauma patient, resuscitation of the mother is critical to survival of the fetus, and delivery wouldn't be considered unless your resuscitation fails. And we're going to touch on delivery in the trauma bay a little bit later in this presentation. But during the initial primary survey, the obstetrician, if you are fortunate enough to be in a center that has one, can be standing nearby, available to hop in to assess that fetus when the time comes. You know, they might be looking for vaginal bleeding, and they're there in case the trauma surgeons have any questions. This management algorithm for trauma and pregnancy was published in the American Journal of Obstetrics and Gynecology back in 2013. So it's getting a little bit old, but it's still really good and really reinforces kind of maternal resuscitation first. All right. So I'm going to review things about the basic ATOS that you should bear in mind when you're dealing with it in a pregnant patient. Number one, if intubation is indicated, early intubation is recommended. Again, this is secondary to those physiologic changes we talked about. They're more prone to anoxia and that difficult airway due to the edema. So if you think that intubation is going to be indicated, it should be performed pretty early. Don't forget about your NG or OG tube for gastric decompression because of that aspiration risk. And then ideally, the oxygen saturation should be maintained over 95% in order to keep a favorable oxygen gradient to the fetus. So if you can't keep your oxygen saturation above 95%, you can consider an ABG. That partial pressure of oxygen should be about 70 or higher in the pregnant patient to maintain that favorable oxygen gradient from the maternal to the fetal placental unit. Okay. Polling question. Turning the patient from the supine to the left lateral position, and we'll say in the late third trimester early term, can increase cardiac output by approximately how much? So it's actually about 30%. That third answer there. Go on and talk about that a little bit. Okay. So turning the patient from supine to left lateral can increase that cardiac output by 25 to 30%. So this can be done by physically moving the patient on the left. You can get a wedge or a rolled up sheet or towel and put it under the right side of the board, or you can manually displace that uterus, which we'll talk about in a little bit when we start talking about chest compressions. Something else to keep in mind when you're considering that circulation is that, again, those vital signs, the heart rate and blood pressure, they're not going to start changing immediately and blood loss could be, you know, 15 to 20% before you start seeing significant changes in their vital signs. All right. So transfusion. So if transfusion is indicated, transfusion protocols and targets are similar to the non-pregnant individual, except for that fibrinogen. So a fibrinogen level over 200 or 300 in actively bleeding pregnant patients is desirable because again, pregnant patients have a higher baseline fibrinogen. Some people do say that a fibrinogen level over 200 in a pregnant patient is considered the minimum level necessary for adequate coagulation. Fibrinogen levels less than 100 are really concerning and suggestive of DIC and or placental abruption. And often those two things go hand in hand. I felt like this was a good time to address TXA in pregnancy as well. So TXA is known to pass through the placenta. It does appear in studies in the umbilical cord at a concentration that's about equal to that found in mother's blood. However, because just like Dr. Mains has already discussed, TXA does confer some survival benefit. Most experts do recommend that if it is indicated, you know, based on your ATLS guidelines, that it should be given in pregnancy. Because remember our main goal for fetuses to survive is maternal survival as well. At the very least, if TXA is not given as the massive transfusion protocol started, it should be given after cord clamp at delivery if that is indicated. In the OB literature, in the setting of postpartum hemorrhage, it's been shown to reduce blood loss, reduce the need for hysterectomy, and even reduce maternal mortality. All right, moving on now. So the 2015 American Heart Association guidelines on spontaneous cardiac arrest in pregnancy recommends the same hand position for chest compressions in the pregnant and non-pregnant adult because of the absence of data supporting a different approach of pregnancy. So these guidelines suggested a more cephalad hand position in pregnancy, or sorry, previous guidelines recommended a more cephalad position in pregnancy, but that has been removed. So hand placement should be the same in pregnancy as it is outside of pregnancy. The updated guidelines in part were based on MRI studies that found that there was no significant upward shift of the heart in the third trimester in pregnancy relative to the non-pregnant state. And this is where I want to mention that tilt again. So we already talked about how the left lateral tilt can significantly increase cardiac output, but there are studies to show that the force of chest compressions are actually a lot less effective if the patient is tilted. And that might decrease her chance of survival. So if you are performing chest compressions, instead of physically tilting your patient, you should perform manual displacement of that uterus that's shown here in these images. Okay. So you've done your primary survey, and mom is stable enough for the obstetrician to hop in if he or she is there to do what we call a fetal FAST scan. So this is kind of, again, after mom is deemed stable enough, kind of between your primary or secondary survey, some centers consider this to be an adjunct to the primary survey, but someone will jump in and evaluate that fetus. So if it's not an obstetrician, most likely the ultrasound will be used to obtain cardiac rate of the fetus. Is it present or not? And what is that rate or roughly what is that rate? Normal is 110 to 160. So there's a wide range there for normal fetal heart rate. So you want to attain that first. Another important thing is, is there one, two, three, how many fetuses are in there? You know, obviously singleton is a lot easier to manage than twin, triplet, et cetera. And then, you know, if you are comfortable with this, you can also try to evaluate for fetal position. If delivery is indicated, it's nice to know, are you going to reach in and find a head or feet? Placental location and kind of brief evaluation of the placenta can be performed. Again, if you're not used to kind of looking at placentas on ultrasound, this is really limited. And we'll talk about why in just a second. Fluid volume. Again, most people will be able to tell if there's no fluid in there. Number one, your ultrasound is going to be pretty hard if there's no fluid, no fluid for those ultrasound waves to travel. But, you know, no fluid versus roughly normal is also important. And then if you have no idea how far along the patient is, and that fundal height is really difficult to palpate, you can consider, consider trying to measure one of the femurs. A femur length of at least four centimeters is most likely a viable fetus. And then after this time, it's a good time to start your electronic fetal monitoring. Again, if you're in a center that has ability to do this, so if you have a fetal monitor after the primary survey, before the secondary survey is ongoing, you can hook the baby up to that external fetal monitoring. Okay, placental abruption. So I'm going to shift a little bit and talk about placental abruption here. So it's a really common complication of trauma. And in fact, in women who have pelvic fractures, like our patient, or really severe mechanisms of trauma, you know, motor vehicle accidents where the car rolls over, the risk of abruption is really high, about 40%. And abruption is caused because the placenta is not elastic and amniotic fluid is not compressible. So uterine distortion related to acceleration, deceleration, or direct trauma to the uterus can result in sheer stress at the uteroplacental interface. And that's what causes the abruption or the separation. Placental abruption is a clinical diagnosis. And I'm going to say that again, you can't really rely on any blood work or radiologic exam because abruption is a clinical diagnosis. So it's based on are there uterine contractions or abdominal pain. That uterus is going to be consistently hard, it's going to have increased tone, and the patient will have abdominal pain. Most of the time there is vaginal bleeding associated with abruptions. I say most of the time because a small percentage of them, probably 10 to 15%, will be concealed, meaning the bleeding is occurring behind that placenta, but it's not coming through the cervix. But most of the time it's associated with bleeding. So if you have vaginal bleeding, a really, really firm uterus with resting tone. And then the last part is fetal bradycardia. So if you can get a heart rate and it's significantly less than that 110, if you have those three things, you most likely are dealing with a fetal abruption. The ultrasound is nice, but a really acute bleed is often isoechoic with that placenta. So you might just see a really enlarged placenta, and that's going to be hard to recognize unless you're really reading ultrasounds frequently. A low fibrinogen is the most sensitive laboratory change for abruption, but early on that fibrinogen might not be less than 100. It might still be relatively normal or just mildly low. The KB stain, which looks for fetal cells and maternal circulation, again, is not always positive right off the bat. And sometimes that takes a while for that to come back. So it's really a clinical diagnosis here. All right. So external fetal monitoring is the most sensitive clinical tool we have for detecting placental abruption after a trauma. So for women who mom is stable, fetus is relatively stable, you need to put them on the external fetal monitoring machine. Again, if your facility has that capability, if not, she should be transferred because some abruptions are a little bit slower and moms don't present hemodynamically unstable. Babies initially look okay, and then the abruption will present itself once the fetus has lost enough blood, or once there's enough blood in the uterus to cause pain. And so all pregnant women that have a major trauma should be monitored for a minimum of four hours. And what should be going on is the external fetal monitoring to keep an eye on that fetal heart rate, because if you have a significant abruption, that heart rate will change. You can also monitor for contractions because a lot of times if an abruption is going to occur, or I should say almost all of the time, if an abruption is going to occur, the mom will begin having uterine contractions. And then you can continue to examine the mom as well, do serial abdominal exams. So that four-hour rule applies to any pregnant patient that has direct abdominal trauma, or just a really major mechanism like a car rollover, something like that. A minimum of four hours of external fetal monitoring. And if your facility isn't capable of doing that, the patient should be transferred to a center that is. So after that four hours, the patient can be discharged if there's no uterine contractions of at least six contractions in an hour. So if you have one or two an hour, that can be normal. But if you have six contractions an hour or more, that patient should be continued to be observed for even longer. She has to have no vaginal bleeding if she's going to be discharged after that four hours. The fetal heart rate tracing has to be reassuring. So the fetal heart rate has to be normal. And she can't have significant abdominal pain. So in this slide here, you can see the top, that patient is contracting. So the bottom is the tachometer that's measuring uterine pressure or abdominal pressure. And so you can see she's having regular contractions. So that woman would need to be need to continue to be hospitalized for a minimum of 24 hours. And then the bottom fetal heart tracing is something, you know, very concerning. So that the heart rate, the fetal heart rate is on top, starts off pretty normal. There's a few decelerations. And then you have what I would call a terminal bradycardia. So that heart rate goes down to the 60s, which is a very low fetal heart rate. You know, this is what I would expect our patient to have if she had been on continuous monitoring in the trauma bay. The fetal heart rate could have very well done something like this because she did have an abruption. So I mentioned that ultrasound is not a super sensitive tool. The specificity or the sensitivity rather for diagnosing placental abruption on ultrasound ranges from 20% to 60%, depending on the study and expertise of the person reading the ultrasound. So the image on the left there is an acute abruption. And it basically just looks like a really thick placenta. But that is in fact a placental abruption. As the bleed, you know, starts to go away and resolve over time, it does become hypoechoic. But that is much later in the process. Okay, I'm going to spend hopefully just a minute here talking about diagnostic imaging. So most of the time, diagnostic imaging is number one safe. And number two, the information you're going to obtain from your diagnostic imaging is almost always going to, you know, have more benefit than the risk to the fetus because of the radiation. So your role really is to give reassurance to the patient, the family, other providers who might be nervous in ordering these tests. Of course, if the imaging that you need, if ultrasound is something that can be done and would be helpful, that's great. Ultrasound would be your first line because it is perfectly safe. But if a CT is indicated, the CT should be done. So as a general rule, anything less than 50 milligray units or five rads is considered safe. But I want to reassure you that there's plenty of room for air there because most of the time we don't start seeing risks till we get up to 100 milligray units. So to get a little bit more specific, the risk to the fetus depends on gestational age. So in the first two weeks after conception, this is often before the patient has even missed a period, it's really an all or none effect. So if you have over 100 milligray units, most likely the blastocyst won't be able to implant. So the patient will go on to have a period and that will be it. Versus if it's not over 100 milligray units or the patient does not miscarry, the blastocyst will implant and there'll be no risk to ongoing pregnancy. Between two and 16 weeks, there is a risk of tratigenicity. But again, the threshold appears to be over 100 milligray units in that two to 16 week timeframe. You also have to consider developmental delay from radiation to the developing fetal brain, but this is extremely rare. The threshold for intellectual disability appears to start around 120 milligray units and not until about eight weeks. Once you get over 16 weeks, the threshold goes up to about 200 milligray units. There have been no cases of severe intellectual disability identified from children who survived the atomic bomb that were exposed before eight weeks or after 25 weeks. So again, this is really extremely rare and we're talking risks that don't start until over 100 milligray units and then once you get further along over 200 milligray units. So if you look at the chart here on this slide, you can see all of these studies have well below 100 milligray units and all of them even have below the 50 milligray units that we consider 100% to be safe. The one thing that is increased with radiation exposure to the fetus is various types of cancers. So most specifically would be like leukemias, things like that. So the estimated relative risk for fetal childhood cancer after exposure to one 50 milligray unit exam is about two. So that takes the risk for about one in the 30, one in 3,000 to one in 1,500. So you can tell patients that that risk goes from, you know, very, very rare to still rare. So just keep in mind that contrast is generally safe in pregnancy. We already have kind of gone over lab changes here. So I'm not going to go over that again since we're a little bit short on time. So I do want to mention RhoGAM because this is important for the trauma patient. So the Klinehart-Bettke test is the, or the KB stain is the most common test used to look for fetal cells in the maternal circulation. Every single Rh negative pregnant trauma patient should receive at least one dose of RhoGAM. So that's 300 micrograms of RhoGAM within 72 hours of the event in order to prevent maternal alloimmunization. The typical 300 microgram dose of RhoGAM is adequate to protect against maternal alloimmunization from about 15 milliliters of fetal red blood cells. That's about 30 milliliters of whole blood because the fetal hematocrit is about 50 percent. So your KB stain is able to estimate how many red blood cells are in the maternal circulation. And if your KB stain estimates that there's more than 15 milliliters of red blood cells or more than 30 milliliters of whole fetal blood in the maternal circulation, you need to give an additional dose of RhoGAM. All right, so we're going to touch a little bit on that dreaded perimortem cesarean section in the trauma bay. So the general rule that everyone follows is that it should be performed if the return of spontaneous circulation has not occurred within four minutes of maternal cardiopulmonary collapse. So the goal is to initiate your surgery at four minutes with delivery by five minutes. Chest compression should be continued during the cesarean delivery and delivery needs to be performed at the location of the arrest because if you take time to transport that patient to the OR, you're going to delay the time to delivery and potential, you know, increase the risk to the fetus. So almost always we recommend a vertical abdominal incision, like Dr. Baines has mentioned. This is to allow access to the upper abdomen to those trauma surgeons when we're done. So the OB team can quickly sew up the uterus and kind of get out of the way for the trauma surgeons to continue to resuscitate and perform their necessary surgeries. After delivery, don't forget about your pitocin to help prevent uterine acne. And then again, if TXA has not already been administered, administer TXA after delivery of that fetus. So when we're thinking about the benefit of perimortem cesarean delivery, you know, when you think about chest compressions, chest compressions can produce about 30% of normal cardiac output in the non-pregnant patient. There's a few studies to show that chest compressions in the pregnant patient might only produce about 10% of that normal cardiac output. You know, displacing that uterus off to the side manually, like we talked about, can be helpful, but delivering that infant is going to significantly improve your cardiac output, sometimes by as much as 60% right away. So you're going to get a huge improvement in your maternal resuscitative efforts by delivering that infant. You're also going to get about a 500 milliliter auto-transfusion, which is, which can be helpful. And then again, the fetal benefit is going to be survival. You know, most centers do consider periviability or, you know, they do consider chance of survival right around that 22-week mark. And so that's just something to keep in mind if you are delivering a fetus around that gestational age. I want to point out that, although we talk about that four-minute rule or five-minute rule, you know, delivery by five minutes, it's, it's not an absolute. There are various scenarios where I would recommend just going ahead with the delivery before that four-minute mark. There's no need to kind of wait around for those four minutes. And those are listed there. So if there's no chance of maternal survival and you have a viable fetus, don't wait four minutes because that baby, if the mom is not confusing that uterus, that baby's hypoxic and you're going to increase the chance of a neurodevelopmental delay or some sort of sequelae there. If your CPR is ineffective, if you feel like you can't resuscitate mom because, you know, maybe she has twins and she's full term, you know, please go ahead and deliver those babies. And then if the cause of arrest is unlikely to be reversed within four minutes, again, just proceed with that delivery. And then the other thing is that if you have a patient in the late third trimester or a term patient, there's so much benefit to the mom because of those cardiovascular changes after delivery. And you have a baby without very much risk of prematurity at all, or no risk of prematurity at all if they're term, there's no reason to wait four minutes. You can go ahead and proceed with delivery kind of right away. All right. So mortality and pregnancy trauma. So I already mentioned that trauma is the leading cause of non-obstetric death during pregnancy. Among women that are hospitalized because of a trauma, there's a 4% mortality rate, 20%, 27% of all maternal deaths are trauma related. And then again, pregnant women are significantly more likely to die from violent trauma compared to the non-pregnant patient. Specific fetal considerations include miscarriage and fetal death. The risk of this depends on the timing and severity of maternal injury. Placental abruption is the most common cause of fetal death related to trauma. And fetal death is overall very low, estimated at 3.7 fetal deaths due to maternal trauma per 100,000 births. So very low rate of fetal death related to trauma. Preterm labor is common after trauma, but it frequently resolves spontaneously. There is about a twofold increased risk of preterm delivery and a twofold increased risk of delivering a low birth weight baby, even if that baby is delivered months after the trauma. Finally, there is a risk of direct fetal injury, but this is extremely low and typically related to penetrating injuries. If there is a uterine rupture related to trauma, again, fortunately, very rare, but this always has occurred outside of the hospital setting and there's nearly a 100% fetal mortality rate and a really significant maternal morbidity and often mortality from that as well. And then just briefly want to touch on outcomes after perimortem cesarean delivery. So if you are performing that delivery in the trauma bay, there's some good news there. Over 50% of moms do survive the hospital discharge. There was a study that kind of retrospectively went back and looked at some perimortem cesarean deliveries, and they found that the delivery itself was thought to be beneficial for the resuscitation and up to 50% of those cases. And it was not harmful to the mom in any of those cases. If the delivery occurred within 10 minutes, the mom had a higher chance of survival and 10 to 15% of moms that survived did have a poor neurologic outcome. For the neonate, the survival rate's even higher, over 60%. Those that were delivered within 14 minutes of the arrest did better compared to those that did not. Those that did not survive had an average arrest to delivery time of about 22 minutes. And that's really delayed when we're thinking about our goal of four to five minutes. 21% of the neonatal survivors had poor neurologic outcome. All right. So to summarize, trauma's really common in pregnancy. Management considerations and labs need to be interpreted in relation to normal physiologic changes. Don't forget about that respiratory alkalosis. The initial goal is to assess maternal airway, breathing, circulation. Again, make sure mom is stable first before you jump in for that fetus. We've all been saying trauma's a team sport. So trauma and OB teams should work together for the best outcomes. So Dr. Maynes, do you have anything else you want to add? Well, yeah. So we're a little bit behind. So we're going to reduce the break to five minutes here and just start it in a minute or so. But I do have a comment. For those of us who are dumb trauma surgeons and face this situation rarely, I've had this situation in the past, pulling the trigger to do a laparotomy and C-section is a very hard decision. What do you think about liability and what do you think about making the wrong decision if you've got maternal and fetal distress in this situation? Yeah, that's a really great question. You know, I hope that the talk today kind of showed you that it's that delivery generally can only do good. You're going to improve. If you have a mom that is hemodynamically unstable, especially, you know, if you're doing chest compressions, you are only going to improve your efforts, your resuscitative efforts if you deliver. I think that, you know, you have to look at it too. There's going to be some liability if you end up not delivering and you lose the mom or the baby. So if you deliver that baby and do your very best in resuscitating mom and baby, I think that you've done some good. Yeah, I think once, you know, if you're in a trauma center that doesn't have OB, you've got a trauma surgeon having to deal with this, you basically revert to crisis standards of care. And that means you do the best you can with the resources you have. I've actually had this situation, 38-week pregnant mom stabbed in a bar brawl, placental abruption. Her blood pressure was 60, fetal heart rate was 60. I did a vertical laparotomy, vertical incision in the uterus, pulled out the baby, packed the uterus, went back to the back table and intubated the baby and did a line and then went back to mom. And, you know, flights are on the way, but this is a very stressful situation, really hard to pull the trigger to do that. I think your comments here have been very helpful. Great. Well, yeah, thank you. And yeah, you guys have to make some really difficult decisions. I've learned a lot just by listening this morning. So thank you for everything you guys do.

trauma management

pregnant patients

physiological changes

early intubation

airway management

TXA

placental abruption

diagnostic imaging

perimortem cesarean sections

fetal well-being

Trauma University