Advanced Trauma Life Support ATLS Student Course Manual 2018

INTIMATE PARTNER VIOLENCE 235
Because vaginal bleeding in the third trimester may
indicate disruption of the placenta and impending death
of the fetus, a vaginal examination is vital. However,
repeated vaginal examinations should be avoided. The
decision regarding an emergency cesarean section
should be made in consultation with an obstetrician.
CT scans can be used for pregnant trauma patients if
there is significant concern for intra-abdominal injury.
An abdomen/pelvis CT scan radiation dose approaches
25 mGy, and fetal radiation doses less than 50 mGy
are not associated with fetal anomalies or higher risk
for fetal loss.
Admission to the hospital is mandatory for pregnant
patients with vaginal bleeding, uterine irritability,
abdominal tenderness, pain or cramping, evidence
of hypovolemia, changes in or absence of fetal heart
tones, and/or leakage of amniotic fluid. Care should
be provided at a facility with appropriate fetal and
maternal monitoring and treatment capabilities. The
fetus may be in jeopardy, even with apparently minor
maternal injury.
Definitive Care
Obtain obstetrical consultation whenever specific
uterine problems exist or are suspected. With extensive
placental separation or amniotic fluid embolization,
widespread intravascular clotting may develop, causing
depletion of fibrinogen, other clotting factors, and
platelets. This consumptive coagulopathy can emerge
rapidly. In the presence of life-threatening amniotic
fluid embolism and/or disseminated intravascular
coagulation, immediately perform uterine evacuation
and replace platelets, fibrinogen, and other clotting
factors, if necessary.
As little as 0.01 mL of Rh-positive blood will sensitize
70% of Rh-negative patients. Although a positive
Kleihauer-Betke test (a maternal blood smear allowing
detection of fetal RBCs in the maternal circulation)
indicates fetomaternal hemorrhage, a negative test does
not exclude minor degrees of fetomaternal hemorrhage
that are capable of isoimmunizing the Rh-negative
mother. All pregnant Rh-negative trauma patients
Pitfall
Failure to recognize
the need for Rh
immunoglobulin
therapy in an Rhnegative
mother
prevention
• Administer Rh immunoglobulin
therapy to all
injured Rh-negative mothers
unless the injury is remote
from the uterus (e.g.,
isolated distal extremity).
should receive Rh immunoglobulin therapy unless the
injury is remote from the uterus (e.g., isolated distal
extremity injury). Immunoglobulin therapy should
be instituted within 72 hours of injury.
n TABLE 12-4 summarizes care of injured pregnant
patients.
Perimortem Cesarean
Section
Limited data exists to support perimortem cesarean
section in pregnant trauma patients who experience
hypovolemic cardiac arrest. Remember, fetal distress
can be present when the mother has no hemodynamic
abnormalities, and progressive maternal instability
compromises fetal survival. At the time of maternal
hypovolemic cardiac arrest, the fetus already has
suffered prolonged hypoxia. For other causes of
maternal cardiac arrest, perimortem cesarean section
occasionally may be successful if performed within 4
to 5 minutes of the arrest.
Intimate Partner Violence
Intimate partner violence is a major cause of injury to
women during cohabitation, marriage, and pregnancy,
regardless of ethnic background, cultural influences,
or socioeconomic status. Seventeen percent of injured
pregnant patients experience trauma inflicted by
another person, and 60% of these patients experience
repeated episodes of intimate partner violence.
According to estimates from the U.S. Department of
Justice, 2 million to 4 million incidents of intimate
partner violence occur per year, and almost one-half
of all women over their lifetimes are physically and/or
psychologically abused in some manner. Worldwide,
10% to 69% of women report having been assaulted
by an intimate partner.
Document and report any suspicion of intimate
partner violence. These attacks, which represent an
increasing number of ED visits, can result in death and
disability. Although most victims of intimate partner
violence are women, men make up approximately
40% of all reported cases in the United States.
Indicators that suggest the presence of intimate partner
violence include:
••
Injuries inconsistent with the stated history
••
Diminished self-image, depression, and/or
suicide attempts
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