Advanced Trauma Life Support ATLS Student Course Manual 2018

ASSESSMENT AND TREATMENT 233
To optimize outcomes for the mother and fetus,
clinicians must assess and resuscitate the mother
first and then assess the fetus before conducting a
secondary survey of the mother.
Primary Survey with Resuscitation
Mother
Assessment and Treatment
Ensure a patent airway, adequate ventilation and
oxygenation, and effective circulatory volume. If
ventilatory support is required, intubate pregnant
patients, and consider maintaining the appropriate
PCO 2
for her stage of pregnancy (e.g., approximately
30 mm Hg in late pregnancy).
Uterine compression of the vena cava may reduce
venous return to the heart, thus decreasing cardiac
output and aggravating the shock state. Manually
displace the uterus to the left side to relieve pressure
on the inferior vena cava. If the patient requires spinal
motion restriction in the supine position, logroll her
to the left 15–30 degrees (i.e., elevate the right side
4–6 inches), and support with a bolstering device, thus
maintaining spinal motion restriction and decompressing
the vena cava (n FIGURE 12-5; also see Proper Immobilization
of a Pregnant Patient on MyATLS mobile app.)
Because of their increased intravascular volume,
pregnant patients can lose a significant amount of
blood before tachycardia, hypotension, and other
signs of hypovolemia occur. Thus, the fetus may be in
n FIGURE 12-5 Proper Immobilization of a Pregnant Patient. If
the patient requires immobilization in the supine position, the
patient or spine board can be logrolled 4 to 6 inches to the left
and supported with a bolstering device, thus maintaining spinal
precautions and decompressing the vena cava.
distress and the placenta deprived of vital perfusion
while the mother’s condition and vital signs appear
stable. Administer crystalloid fluid resuscitation and
early type-specific blood to support the physiological
hypervolemia of pregnancy. Vasopressors should be
an absolute last resort in restoring maternal blood
pressure because these agents further reduce uterine
blood flow, resulting in fetal hypoxia. Baseline
laboratory evaluation in the trauma patient should
include a fibrinogen level, as this may double in late
pregnancy; a normal fibrinogen level may indicate early
disseminated intravascular coagulation.
Pitfall
Failure to displace
the uterus to the left
side in a hypotensive
pregnant patient
Fetus
prevention
• Logroll all patients appearing
clinically pregnant (i.e.,
second and third trimesters)
to the left 15–30 degrees (elevate
the right side 4–6 inches).
Abdominal examination during pregnancy is critically
important in rapidly identifying serious maternal
injuries and evaluating fetal well-being. The main cause
of fetal death is maternal shock and maternal death. The
second most common cause of fetal death is placental
abruption. Abruptio placentae is suggested by vaginal
bleeding (70% of cases), uterine tenderness, frequent
uterine contractions, uterine tetany, and uterine
irritability (uterus contracts when touched; n FIGURE
12-6A). In 30% of abruptions following trauma, vaginal
bleeding may not occur. Uterine ultrasonography may
be helpful in the diagnosis, but it is not definitive. CT
scan may also demonstrate abruptio placenta (n FIGURE
12-6A and C) Late in pregnancy, abruption may occur
following relatively minor injuries.
Uterine rupture, a rare injury, is suggested by
findings of abdominal tenderness, guarding, rigidity,
or rebound tenderness, especially if there is profound
shock. Frequently, peritoneal signs are difficult to
appreciate in advanced gestation because of expansion
and attenuation of the abdominal wall musculature.
Other abnormal findings suggestive of uterine rupture
include abdominal fetal lie (e.g., oblique or transverse
lie), easy palpation of fetal parts because of their
extrauterine location, and inability to readily palpate
the uterine fundus when there is fundal rupture. X-ray
evidence of rupture includes extended fetal extremities,
abnormal fetal position, and free intraperitoneal air.
Operative exploration may be necessary to diagnose
uterine rupture.
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