Trauma in Pregnancy
plasma volume increase 40% dilutional anemia
blood loss up to 2000 mL may not be apparent
cardiac output increases
BP, peripheral, pulmonary resistance decrease
Uterine circulation lacks autoregulation
decrease in FRC(fetal red cells), more sensitive to atelectasis aortocaval
fundal height - viable fetus => 24 ~ 25 weeks
Obstetrician presence
fetal assessment
normal fetal heart rate (120-160)
Bradycardia in fetus => hypoxemia
Cardiotrophic monitoring
abruptio placentae = separation between placenta and uterus
"FAST"?
"FHR(fetal heart rate?)"? hypovolemic
Blunt trauma
FAST, DPC, CT
- pelvic fracture, most common cause of fetal death, hemorrhagic shock => 25% fetal mortality
- penetrating trauma
most from GSW(gun shot wound)
low velocity stab wound rarely the cause
Cesarian section
T&C(type and crossmatching) spine injury? exsanguination?
Perimortem, 5 min within maternal death => fetal survival rate 70%
Morris et al.
Radiation / Pregnancy
high risk during organogenesis
avoid exposure > 5 ~ 10 rads
radiation badges?
Roger FB et al Arch Surg 1999
- factors associated with fetal death
Blunt Trauma
High ISS(injury severity score), low GCS(glasgow coma scale)
Shock(< style="font-style: italic;">
Cases
Cardiotrophic monitoring(CTM)?, resuscitate
UA, biopsy for rectal/anal cancer, gangrene resected, myopia?
=> circumferential biopsy
Colon cancer, LAR, liver metastasis
gastrohepatic junction, liver tumor in R lobe
open RFA, percutaneous RFA?
CEA, MONO%, prokin, globulin, A/G
Rectal bleeding, pain with stools
=> polyp and fissure at 12 o'clock
aortic cholecystitis, cholengitis
treated with antibiotic
cholengitis => stone? from gallbladder? increase in bilirubin
into the common duct, stasis, stone got stuck in duodenal, => passed the stone
horseshoe abscess fistula?
terminal ileum stricture
Crohn's, PTT?
Finding a fistula
- collect pt's urine(with barium in it)
- aliquot spin with centrifuge and X-ray it
Neurological sign of fistula => contrast/air in the bladder
strictural plasty? lateral atelectasis?
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The space between the diaphragm, which separates the chest cavities from the abdominal cavity, and the transverse colon is called the "subphrenic space". If there is an abscess developing in this space, this is called a subphrenic abscess. As there is a right and a left chest cavity, there can be from an anatomical point of view a right-sided and a left-sided subphrenic abscess.
Plain abdominal X-ray films may show the abscess cavity with gas in it from gas producing bacteria. Chest X-rays often show abnormalities in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well as an immobile diaphragm.
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Atelectasis is defined as a state in which the lung, in whole or in part, is collapsed or without air.[1] It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.
Causes
The most common cause is post-surgical atelectasis, characterized by splinting, restricted breathing after abdominal surgery. Smokers and the elderly are at an increased risk. Outside of this context, atelectasis implies some blockage of a bronchiole or bronchus, which can be within the airway (foreign body, mucus plug), from the wall (tumor, usually SCC) or compressing from the outside (tumor, lymph node, tubercle). Another cause is poor surfactant spreading during inspiration, causing an increase in surface tension which tends to collapse smaller alveoli.
[edit] Symptoms
- cough, but not prominent
- chest pain (rare)
- breathing difficulty
- low oxygen saturation
[edit] Diagnosis
- chest X-ray
Post-surgical atelectasis will be bibasal in pattern.
[edit] Treatment
As per the underlying cause. Post-surgical atelectasis is treated by physiotherapy, focusing on deep breathing and encouraging coughing. Atelectasis does not require antibiotics. Ambulation is also highly encouraged to improve lung inflation.
--------------------------------------------------------------------------'Aortocaval compression' is a blanket term which describes compression of the inferior vena cava and the aorta by the gravid uterus in women at term (1, 2, 3, 4). On assuming the supine position, 46% of women at term develop brachial and femoral hypotension; a further 31% develop femoral hypotension in the absence of brachial hypotension (10). This has implications for both mother and fetus. Maternal hypotension as measured by a reduction in brachial artery blood pressure, occurs as a result of a diminution in venous return. It is most pronounced in hypovolaemic states, either actual, as occurs with haemorrhage, or relative, as occurs following sympathetic blockade. Acute fetal distress can be caused by: 1. hypoperfusion of the uteroplacental unit secondary to maternal hypotension, or 2. occult aortic compression (in the presence of a normal maternal brachial arterial blood pressure) causing a reduction in iliac arterial flow (8)
The effect of the full lateral position on aorto-caval compression
The efficacy of left lateral displacement was demonstrated in 1972 . The full left or right lateral position completely relieves aortocaval compression.
Elevating the mother's right hip 10-15cm completely relieves aortocaval compression in 58% of term parturients.
Caval Compression
The principal site of venous obstruction in the supine hypotensive syndrome is at the pelvic brim. In the majority of patients, the compensatory mechanisms are sufficient to maintain arterial blood pressure.
When caval compression occurs, blood is diverted into the vertebral and azygos system. This system constitutes a 'protected' conduit for blood returning from the lower part of the body.
As the vertebral veins distend, so the volume of the subarachnoid and epidural space is reduced. This reduction in the volume of the epidural space can enhance the spread of recently-administered epidural solutions.
--------------------------------------------------------------------------Obstetrics (from the Latin obstare, "to stand by") is the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (the period shortly after birth). Many obstetricians are also gynaecologists
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Hypoxia is a pathological condition in which the body as a whole (generalised hypoxia) or region of the body (tissue hypoxia) is deprived of adequate oxygen supply. Low oxygen content in the blood is referred to as hypoxaemia. Hypoxia in which there is complete deprivation of oxygen supply is referred to as anoxia.
| Hypoxemia Hypoxemia, or reduced oxygen in the blood, can be caused by:
|
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Placental abruption (Also known as abruptio placenta) in biology, is the separation of the placental lining from the uterus of a female. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Abruption placenta is also a significant contributor to maternal mortality.
Symptoms
- contractions that don't stop
- pain in the uterus
- tenderness in the abdomen
- vaginal bleeding (sometimes)
Pathophysiology
Trauma, hypertension, or coagulopathy, can lead to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina occurs 80% of the time, though sometimes the blood will pool behind the placenta.
Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.
Abruptions are classified according to severity in the following manner:
- Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta.
- Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus.
- Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring.
- Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation.
Main Entry: hy·po·vo·le·mia
Variant(s): or chiefly British hy·po·vo·lae·mia /-väl-
-m-
/Function: noun
: decrease in the volume of the circulating blood
- hy·po·vo·le·mic or chiefly British hy·po·vo·lae·mic /-
-mik/ adjective--------------------------------------------------------------------------
Main Entry: ex·san·gui·na·tion
Pronunciation: (
)ek(s)-sa
-gw-n
-shnFunction: noun
: the action or process of draining or losing blood
- ex·san·gui·nate /ek(s)-
sa-gw-nt/ transitive verb -nat·ed -nat·ing--------------------------------------------------------------------------
Type & Crossmatch
| Blood Typing | Defining red cell blood group antigens by reaction with reagent antibodies in an agglutinating or hemolytic assay. |
| Minor Crossmatch | React recipient red cells with donor serum or plasma to detect antibodies that could destroy recipient red cells. Not of concern with packed cell transfusions. |
| Major Crossmatch | React donor red cells with recipient serum or plasma to detect antibodies that would destroy transfused cells. Should be done in addition to typing in a previously transfused patient. |
| Recipient blood type | Donor must be | |||||||
|---|---|---|---|---|---|---|---|---|
| AB+ | Any blood type | |||||||
| AB- | 0- | A- | B- | AB- | ||||
| A+ | 0- | 0+ | A- | A+ | ||||
| A- | 0- | A- | ||||||
| B+ | 0- | 0+ | B- | B+ | ||||
| B- | 0- | B- | ||||||
| 0+ | 0- | 0+ | ||||||
| 0- | 0- | |||||||
| Recipient blood type | Donor must be | |||
|---|---|---|---|---|
| AB | AB | |||
| A | A or AB | |||
| B | B or AB | |||
| 0 | Any blood type | |||
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In animal development, organogenesis is the process by which the ectoderm, endoderm, and mesoderm develop into the internal organs of the organism. The germ layers in organogenesis differ by three processes: folds, splits, and condensation. Developing early during this stage in chordate animals are the neural tube and notochord. Vertebrate animals all differ from the gastrula the same way. Vertebrates develop a neural crest that differentiates into many structures, including some bones, muscles, and components of the peripheral nervous system. The coelom of the body forms from a split of the mesoderm along the somite axis.
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Focused abdominal ultrasound for trauma (FAST} is a a rapid, bedside, ultrasound examination performed by surgeons and emergency physicians to screen reliably for hemoperitoneum or pericardial tamponade after trauma. With this technique it is possible to identify the presence of free intraperitoneal or pericardial fluid, which in the context of traumatic injury, is usually due to bleeding. FAST is less invasive than diagnostic peritoneal lavage and less costly than computed tomography, but achieves a similar accuracy.[1]
[edit] Interpretation
In hemodynamically unstable patients, a positive FAST result suggests hemoperitoneum and laparotomy should be performed in most cases. In hemodynamically unstable patients with a negative FAST result, a search for extra-abdominal sources of bleeding should be performed. In hemodynamically stable patients, a positive FAST result should be followed by a CT scan to better define the nature of the injuries.[2]
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An example of the ISS calculation is shown below:
| Region | Injury Description | AIS | Square Top Three |
| Head & Neck | Cerebral Contusion | 3 | 9 |
| Face | No Injury | 0 | |
| Chest | Flail Chest | 4 | 16 |
| Abdomen | Minor Contusion of Liver Complex Rupture Spleen | 2 5 | 25 |
| Extremity | Fractured femur | 3 | |
| External | No Injury | 0 | |
| Injury Severity Score: | 50 | ||
The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates slinearly with mortality, morbidity, hospital stay and other measures of severity. It's weaknesses are that any error in AIS scoring increases the ISS error, many different injury patterns can yield the same ISS score and injuries to different body regions are not weighted. Also, as a full description of patient injuries is not known prior to full investigation & operation, the ISS (along with other anatomical scoring systems) is not useful as a triage tool.
The Glasgow Coma Score (GCS) is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below:
Best Eye Response (4)
1. No eye opening
2. Eye opening to pain
3. Eye opening to verbal command
4. Eyes open spontaneously
Best Verbal Response (5)
1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
Best Motor Response (6)
1. No motor response
2. Extension to pain
3. Flexion to pain
4. Withdrawal from pain
5. Localising pain
6. Obeys Commands
Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as E3 V3 M5 = GCS 11. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.
• Teasdale G., Jennett B., Lancet 1974; 81-83.
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Main Entry: re·sus·ci·tate
Pronunciation: ri-
ss--ttFunction: transitive verb
Inflected Form(s): -tat·ed; -tat·ing
: to revive from apparent death or from unconsciousness <resuscitate a nearly drowned person by artificial respiration>
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Myopia, or nearsightedness, is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed.
Those with myopia typically can see nearby objects clearly but distant objects appear blurred. The opposite defect of myopia is hyperopia or "far-sightedness" or "long-sightedness" — this is where the cornea is too flat or the eye is too short.
Mainstream ophthalmologists and optometrists most commonly correct myopia through the use of corrective lenses, such as glasses or contact lenses. It may also be corrected by refractive surgery, such as LASIK. The corrective lenses have a negative dioptric value (i.e. are concave) which compensates for the excessive positive diopters of the myopic eye.
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Antemortem trauma is an injury that is sustained before the person died and therefore shows clear signs of healing that are recognizable on the bone after death. This could help in the identification of that person, by comparing medical X-rays of possible victims with those of the skeleton.Postmortem trauma is an injury to the skeleton that has been sustained after death. Postmortem trauma is distinctly different from antemortem trauma, as there will be no signs of healing. Furthermore, with exposure to the environment, bones dry out. When dry bones get broken, they break differently than fresh bones. There will also be differences in colour of broken areas on bone if they are broken postmortem. These differences will lead a forensic anthropologist to conclude that the break is postmortem. A trained anthropologist will be able to recognize the difference between postmortem trauma and antemortem trauma to the skeleton.
Perimortem trauma is trauma that is sustained at or about the time of death. Perimortem trauma is a little tricky to distinguish, but if you are analyzing trauma to a bone, and you have concluded that it is not antemortem trauma (because you see no signs of healing), and you conclude that it is not postmortem trauma (because you see differences in colour (staining) of the broken area with the surrounding area, and the break doesn't look as if it was broken when the bone was dry), then the only option left is perimortem. This process of elimination method is known as the "perimortem problem", as perimortem trauma is not cut and dry (pardon the expression). It takes a skilled anthropologist to determine what kind of trauma has been done to a bone.--------------------------------------------------------------------------
Globulin is one of the two types of serum proteins, the other being albumin. This generic term encompasses a heterogeneous series of families of proteins, with larger molecules and less soluble in pure water than albumin, which migrate less than albumin during serum electrophoresis.
It is sometimes used synonymously with Globular protein. However, albumin is also a globular protein, but not a globulin. All other serum globular proteins are globulins.
Protein electrophoresis is used to categorize globulins into the following four categories:
- Alpha 1 globulins
- Alpha 2 globulins
- Beta globulins
- Gamma globulins (immunoglobulins)
Serum albumin, often referred to simply as albumin, is the most abundant plasma protein in humans and other mammals. Albumin is essential for maintaining the osmotic pressure needed for proper distribution of body fluids between intravascular compartments and body tissues. The human version is human serum albumin. Bovine serum albumin, or BSA, is commonly used in molecular biology laboratories.
Albumin is negatively charged. The glomerular basement membrane is also negatively charged; this prevents the filtration of albumin in the urine. In nephrotic syndrome, this property is lost, and there is more albumin loss in the urine. Nephrotic syndrome patients are given albumin to replace the lost albumin.
Because smaller animals (for example rats) function at a lower blood pressure, they need less oncotic pressure to balance this, and thus need less albumin to maintain proper fluid distribution.
Functions of albumin
- Maintains osmotic pressure
- Transports thyroid hormones
- Transports other hormones, particularly fat soluble ones
- Transports fatty acids ("free" fatty acids) to the liver
- Transports unconjugated bilirubin
- Transports many drugs
- Competitively binds calcium ions (Ca2+)
- Buffers pH
[edit] Causes of albumin deficiency (hypoalbuminemia)
- Cirrhosis of the liver (most commonly)
- Decreased production (as in starvation)
- Excess excretion by the kidneys (as in nephrotic syndrome)
- Excess loss in bowel (protein losing enteropathy)
- Mutation causing analbuminemia (very rare)
- Acute disease states (referred to as a negative acute phase protein)
Main Entry: sta·sis
Pronunciation:
st-ss, stas-sFunction: noun
Inflected Form(s): plural sta·ses /
st-sz, stas-z/: a slowing or stoppage of the normal flow of a bodily fluid or semifluid
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A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure. It is also sometimes called a "stricture" (as in urethral stricture).
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The partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT or APTT) is a performance indicator measuring the efficacy of both the intrinsic and the common coagulation pathways. Apart from detecting abnormalities in blood clotting, it is also used to monitor the treatment effects with heparin, a major anticoagulant.
Methodology
Blood is collected, by a phlebotomist, with oxalate which arrests coagulation by binding calcium. This specimen is delivered to the laboratory. In order to activate the intrinsic pathway, phospholipid, an activator (such as silica, celite, kaolin, ellagic acid), and calcium (to reverse the anticoagulant effect of the oxalate) are mixed into the plasma sample . The time is measured until a thrombus (clot) forms. This testing is performed by a Medical technologist.
The test is termed "partial" due to the absence of tissue factor from the reaction mixture.
[edit] Interpretation
Values below 25 seconds and over 39 s (depending on local normal ranges) are generally abnormal. Shortening of the PTT has little clinical relevance, as most thrombosis patients have normal coagulation studies. Prolonged APTT may indicate:
- use of heparin (or contamination of the sample)
- antiphospholipid antibody (especially lupus anticoagulant, which paradoxically increases propensity to thrombosis)
- coagulation factor deficiency (e.g. hemophilia)
To distinguish the above causes, mixing studies are performed, in which the patient's plasma is mixed (initially at a 50:50 dilution) with normal plasma. If the abnormality does not disappear, the sample is said to contain an "inhibitor" (either heparin, antiphospholipid antibodies or coagulation factor specific inhibitors), while if it does correct a factor deficiency is more likely. Deficiencies of factors VIII, IX, XI and XII and rarely von Willebrand factor (if causing a low factor VIII level) may lead to a prolonged aPTT correcting on mixing studies.
--------------------------------------------------------------------------strictureplasty is achieved with a longitudinal incision across the short stenotic segment into the prestenotic and poststenotic intestine. For strictureplasty, the longitudinal enterotomy is converted into a transverse closure. Recurrence rates are not substantially increased after strictureplasty, even though inflamed intestinal tissue is left in situ. Resection and strictureplasty are complementary techniques and not used in lieu of each other. Inflammatory changes at the margin of resection are acceptable and are compatible with a safe anastomosis. Consequently, frozen-section histologic evaluation of the margins of resection is not necessary.
