Critical Care Obstetrics part 52 pps

In order to avoid or limit permanent cerebral injury, specifi c cerebral resuscitation must be carried out in the head trauma victim.. In a recent review of preg-nant trauma deaths in Co

regulation described above Unfortunately, reperfusion of the injured area may occur in the presence of absent or diminished autoregulation Injury is either mechanically (through edema) or metabolically (through inappropriate substrate production) pro-duced through reperfusion [117]

In order to avoid or limit permanent cerebral injury, specifi c cerebral resuscitation must be carried out in the head trauma victim The sooner resuscitation is begun, the greater the chance injured, but living, neuronal tissue will survive [117 – 119]

Brain i njury m echanism in t rauma

Penetrating head injuries produce injury by obvious mechanisms With blunt head trauma, especially in deceleration events, move-ment of the brain occurs fi rst in one direction with a secondary

rebound movement in the opposite direction producing a coup – countercoup effect Closed head injuries can occur without signifi

-cant injury of the cutaneous tissues and calvarium through

bruising or contusion of the brain at coup or countercoup sites

Intracerebral hemorrhage from traumatic brain injury often results from severe contusion Subdural or epidural hematomas are produced by direct laceration or tearing of subdural or epidural vessels, respectively [6,116]

Primary m anagement of t raumatic b rain i njury

Initial management of suspected brain injury starts with the basic “ ABCs ” discussed previously Profound hypotension, defi ned as systolic blood pressure less than 60 mmHg in non - pregnant indi-viduals, may cause or contribute to altered consciousness Correction of hypotension is important While possible, hypo-tension as a result of the neurologic insult is uncommon Until proven otherwise, hypotension in the presence of head injury is usually from other causes Severe hypertension in the comatose trauma victim may be centrally mediated This “ Cushing response ” is also characterized by bradycardia and a diminished respiratory rate [113] Altered levels of consciousness may also be produced by alcohol or drug ingestion Toxicological assessment

is recommended in most trauma patients with altered levels of consciousness Conversely, an altered level of consciousness should never be totally attributed to alcohol or other drug inges-tion alone unless completely proven otherwise Finally, other medical conditions such as hypoglycemia may occasionally be seen coincidental with trauma

A baseline and ongoing mental assessment is necessary as a frame of reference in all trauma patients The “ A - V - P - U ” mini exam (Figure 37.1 ) is a brief primary survey tool In the secondary survey, more extensive evaluation, such as by the Glasgow Coma scale (GCS) is recommended (Table 37.2 ) [15,16] A score of 8

or less is indicative of the diagnosis of coma and is classifi ed as severe head injury [6,114,118] If the GCS is from 9 to 12, the injury is classifi ed as moderate GCS scores greater than 12 are classifi ed as minor head injuries [108,116] Once again, the GCS and other neurologic examinations need to be performed fre-quently so trends in neurologic response can be identifi ed A decrease in the GCS score of 2 or more points is indicative of

Head t rauma

Approximately 50% of all trauma deaths are associated with head

injury Over 60% of motor vehicle - associated trauma deaths

occur as a result of head trauma [6] In a recent review of

preg-nant trauma deaths in Cook County (Illinois), approximately

10% of maternal trauma deaths were directly due to head injury

[112]

Several aspects of cranial and cerebral physiology and

patho-physiology are very important in head trauma victims The brain

is one of the most carefully protected organs of the body; the

calvarium and cerebrospinal fl uid cushion the brain from minor

trauma However, in severe trauma, these two otherwise

protec-tive features may contribute to or precipitate brain injury The

brain has poor tolerance of diminished perfusion with little or no

metabolic reserve in brain tissues Global cerebral oxygen

con-sumption of at least 1.5 mL/100 g/min must be maintained to

prevent injury Oxygen delivery to the brain is determined by

blood pressure, blood oxygen content, blood fl ow distribution,

and relative perfusion pressure Because the closed space of the

calvarium is occupied by blood, cerebrospinal fl uid, and brain

volume, intracranial pressure is a function of all three

compo-nents, referred to as the Monro – Kellie doctrine Cerebral edema

results in increased brain volume, thereby producing elevated

intracranial pressure Traumatic collections of blood in the

cranial vault will similarly increase intracranial pressure Often,

both of these mechanisms are present in the head trauma victim

[113,114]

Cerebral a utoregulation in t raumatic i njury

Cerebral autoregulation is normally maintained over a wide

range of blood pressures Extremes of blood pressure, such as

hypotension found in the multiple trauma victim, taxes the

brain ’ s ability to autoregulate When coupled with cerebral

edema and/or intracranial bleeding, hypotension further

aggra-vates the inability of the brain to autoregulate When the injured

brain loses its ability to autoregulate, self - perpetuation of the

brain injury occurs Finally, because the cranium is a closed

system, propagation of elevated extravascular cerebral pressure

transmurally causes the driving pressure in the cerebral

circula-tion to be signifi cantly decreased In that fl ow is directly

deter-mined by a change in pressure, diminished cerebral perfusion

pressure (mean arterial blood pressure – intracranial pressure)

causes decreased effective cerebral blood fl ow Cerebral mass

lesions will therefore diminish cerebral perfusion pressure in

pro-portion to their size even in the face of normal blood pressure It

should thus be obvious that acute brain injury is often self -

perpetuating and when in evolution and is poorly tolerated by

the fastidious neuronal cells Cell death and permanent injury

may result The therapeutic goal of acute cerebral resuscitation is

to limit cell death by regulated reperfusion to non - functioning,

but still viable brain tissue ( ischemic penumbra ) The clinician ’ s

ability to accomplish this goal is often limited [115,116]

Another feature of brain injury is the concept of secondary, or

reperfusion, injury An initial insult produces the loss of

auto-at least 24 hours [120] Other criteria thauto-at differentiauto-ate mild con-cussion (less likelihood of sequelae) from the more severe classic concussion include the presence or absence of loss of conscious-ness itself, the duration of amnesia, and the presence of persistent memory defi cit Diffuse axonal injury (DAI), more commonly known as “ closed head injury ” , is produced by widespread global brain injury or the cerebral edema resulting from diffuse brain injury [118] Prolonged coma is the hallmark of DAI CT imaging will show cerebral edema without focal lesions Nearly 50% of coma - producing brain injuries are caused by DAI DAI is

classi-fi ed clinically into mild, moderate, and severe categories [121] Severe DAI carries a 50% mortality Long - term supportive care and control of intracranial hypertension are the only treatment for the condition Partial or complete recovery is possible, but permanent coma ( “ chronic vegetative state ” ) is often an inexo-rable consequence of severe DAI

Focal b rain i njury

Focal brain injuries are those in which damage occurs in a rela-tively local area Types of focal brain injury include contusions, hemorrhages, and hematomas Because focal injuries may produce a mass effect and damage underlying normal brain tissue, rapid diagnosis and treatment of focal brain injuries may improve outcome and recovery

Contusions are usually caused by deceleration coup – counter-coup trauma as previously described Although contusions can

occur anywhere, they are most commonly found in the tips of the frontal and temporal lobes In addition to producing defi cits from focal injury, delayed bleeding and edema can produce injury from mass effects [116] Prolonged observation is recommended

If neurologic deterioration is detected and is thought to be from

a mass effect, surgery may be indicated

Hemorrhages and hematomas can be functionally classifi ed into those occurring in the meningeal or parenchymal regions of the brain Parenchymal hemorrhage includes intracerebral hema-tomas, impalement injuries and missile (bullet) wounds Meningeal hemorrhage is further classifi ed as acute epidural hemorrhage, acute subdural hematoma, or subarachnoid hemorrhage

Acute epidural hemorrhage (AEH) usually occurs from tears

in the middle meningeal artery Although found in 1% or less of coma - producing acute brain injuries, AEH can be rapidly pro-gressive and fatal Figure 37.3 describes the usual sequence of events associated with AEH It is important to note that the patient with AEH may display an intervening period of lucidity prior to a rapid deterioration from massive rebleeding of the lesion [143] If surgically treated early, the prognosis is good (91% survival) [118] If not evacuated until hemiparesis and pupil fi xation, the prognosis is poor AEH is, in effect, “ the vasa previa ” of acute brain injury Rapid recognition and treatment yields markedly improved results

Subarachnoid hemorrhage (SAH) produces bleeding in the subarachnoid space Meningeal irritation occurs with the result-ing symptoms of headache and/or photophobia Because the

sub-deterioration [108] Irrespective of the GCS score, unequal pupils,

unequal motor fi ndings, open head injury with leaking

cerebro-spinal fl uid or exposed brain tissue, and/or the presence of a

depressed skull fracture also indicate severe head injury Finally,

if headache severity dramatically increases, pupillary size increases

unilaterally, or lateralizing weakness is noted to develop,

particu-lar concern is warranted

Appropriate immediate investigations of the head trauma

victim may include roentgenograms (X - ray), CT radiography,

and neurologic or neurosurgical consultation Sedation and/or

paralysis is delayed until the consultant examines the patient, if

possible Generally, all patients with moderate or severe head

injury should be radiographically evaluated for cervical spine

fracture Conversely, skull roentgenograms are often not helpful

[108] as physical examination or CT imaging provide more

reli-able information and higher - quality data CT imaging is a vital

tool in the evaluation of head injuries and except for women with

minor injuries, all head - injured patients require CT imaging

Severe injury dictates imaging as soon as possible However, it is

important to adequately monitor the victim while she undergoes

imaging Once C - spine fractures are ruled out, the 20+ week

gestation pregnant patient is placed in left lateral tilt during the

scanning [9] Head injuries can be simply classifi ed into the

cat-egories of diffuse brain injury, focal brain injury, and skull

frac-tures (Table 37.4 ) [6,8,116]

Diffuse b rain i njury

Diffuse brain injury can be classifi ed as a concussion or diffuse

axonal injury Concussion is produced from widespread brief

interruption of global brain function Although confusion,

head-ache, dizziness, etc., are often present in the recovering

concus-sion victim, any persistent neurologic abnormalities in the patient

with a presumed concussion must be investigated for other

eti-ologies Many authors feel that the patient with 5 minutes or

more of lost consciousness should be observed in the hospital for

Table 37.4 Classifi cation of acute head trauma

Diffuse brain injury

A Concussion

B Diffuse axonal injury

Focal brain injury

A Contusion

B Hemorrhage/hematoma

1 Parenchymal hemorrhage

2 Meningeal hemorrhage/hematoma

a Acute epidural hemorrhage/hematoma

b Subarachnoid hemorrhage/hematoma

Skull fractures

A Simple fracture

B Basilar skull fracture

C Depressed skull fracture

Basilar skull fractures may not immediately be apparent clinically Anterior basilar skull fractures may predispose to inadvertent placement of a nasogastric tube into the intracranial space [116] Skull fractures typical require cranial CT scanning and physical exam Skull X - rays are usually not helpful for the initial evalua-tion of head injury Attempt at precise delineaevalua-tion of skull frac-tures should not delay recognition and treatment of other head injuries

Head t rauma: g eneral p rinciples

Mainstays in the treatment of head trauma include maintenance

of brain perfusion, reduction of cerebral edema, elimination or reduction of hemorrhage, and prevention of infection Patients with evolving symptomatology or unremitting coma need to be evaluated immediately for potential neurosurgical intervention Maintenance of normal arterial blood pressure will aid the often impaired cerebral autoregulation seen with head trauma Normalization of blood glucose will help supply cerebral meta-bolic needs Hyperglycemia is to be avoided, as it is as undesirable

as hypoglycemia [114,120] Figure 37.5 outlines a general scheme for severe head injury triage and features of high - , moderate - , and low - risk lesions It should be noted that a lateralizing defect and GCS ≤ 8 requires immediate evaluation for surgical treatment Intracranial pres-sure (ICP) monitoring has been long advocated as a meapres-sure to improve outcome in traumatic brain injury There is clearly a split of opinion with regard to the indications and effectiveness

of ICP monitoring The current consensus recommendations propose ICP monitoring be used in comatose patients with GCS scores of 8 or less after resuscitation who also demonstrate patho-logic CT radiographic abnormalities In those patients with a GCS

of 8 or less without CT abnormalities, ICP monitoring is indi-cated if two or more of the following are present: age > 40 years, unilateral or bilateral posturing, and systolic blood pressure less than 90 mmHg at any time since injury [117,126,127] Abnormal intracranial pressure (ICP) is medically treated with controlled hyperventilation, mannitol administration, barbiturate coma, loop diuretics, volume restriction, and head - up positioning [117] When ICP monitoring is employed, measurements above

20 – 25 mmHg generally necessitate treatment strategies to lower ICP

Hyperventilation works to transiently decrease ICP by reduc-ing cerebral blood fl ow If used, hyperventilation should be undertaken to a P a CO 2 endpoint of 26 – 28 mmHg [128] , although the appropriate level for pregnancy is not established

Hyperventilation is not effective in “ prophylaxis ” against elevated

ICP [6,112,129] If hyperventilation is abruptly discontinued, ICP may rise rapidly Current data refute the long - held clinical practice of using aggressive hyperventilation for the treatment or prevention of intracranial hypertension In non - pregnant patients, sustained hyperventilation is associated with the least favorable outcome Hyperventilation ’ s impact is probably medi-ated through reduction in cerebral blood fl ow in normal brain parenchyma surrounding damaged neural tissue Hyperventilation

arachnoid space is much larger than the epidural space, bleeding

does not usually rapidly progress to death Although bloody

spinal fl uid is a hallmark of SAH, CT scanning has basically

replaced lumbar puncture in the diagnosis of SAH Evacuation is

sometimes not required If evacuation is not performed,

treat-ment is supportive Meningeal irritation can produce unwanted

cerebral artery vasospasm Cerebral artery vasospasm may be

diagnosed by clinical ascertainment of neurological defi cit, with

either empiric treatment and/or confi rmation via transcranial

Doppler velocitometry and/or cerebral arteriography Treatment

of cerebral artery vasospasm involves volume loading,

vasopres-sor - induced hypertension and calcium channel blocker therapy

with nimodipine Refractory treatment of vasospasm has been

advocated by the use of angiographically instilled papaverine and/

or calcium channel blocking agents or direct balloon angioplasty

[114,119,122] Clear - cut consensus on optimal treatment is still

pending [123]

Acute subdural hematoma (SDH) is one of the more common

causes of serious brain hemorrhage SDHs commonly occur from

rupture of bridging veins between the cerebral cortex and dura;

but, may also occur from direct laceration of the brain or cortical

arteries The clinical presentation of SDH often depends upon the

rapidity of expansion of the hematoma Rapidly expanding

hematomas carry a poorer prognosis than do stable, chronic

SDHs Early evacuation of rapidly growing SDHs may favorably

impact the 60% mortality that SDH carries [20,118,120] Others

advocate early (within 4 hours of injury) evacuation of subdural

hematomas greater than 1 cm in diameter that are associated with

a shift in midline brain structures Patients with subdural

hema-tomas of less than 5 mm with only mild or absent neurologic

symptoms may be candidates for expectant management

Intracerebral hematomas can occur anywhere in the brain

Symptoms and outcome depend upon the size and location

Intraventricular and intracerebellar hemorrhages portend poor

outcome With impalement injuries the missile or projectile

should be left in place until neurosurgical evaluation is obtained

Bullet wounds should be mapped as to entrance and potential

exit CT radiography may help the localization process of any

remaining missile fragments Non - penetrating bullet wounds

may result in signifi cant blunt trauma [118,125]

Skull fractures are relatively common and may or may not be

associated with severe brain injury Because skull fractures may

be an indicator that signifi cant energy dispersal occurred on the

cranial vault, most patients with seemingly uncomplicated skull

fractures should still be observed in the hospital with serial

neu-rosurgical evaluations

Skull f ractures

Different types of skull fractures have different clinical

consider-ations Linear non - depressed skull fractures that traverse suture

lines or vascular arterial grooves may be associated with epidural

hemorrhage, whereas depressed skull fractures may require

oper-ative elevation of the bony fragment On the other hand, open

skull fractures nearly always require early operative intervention

mannitol is used in severe head trauma, the benefi ts of its admin-istration far outweigh these risks [9,116] Diuresis with furose-mide or other loop diuretics may also be used Overhydration, especially with hypotonic solutions, should be avoided Head - up positioning at 20 ° may marginally reduce hydrostatic pressure Barbiturate coma has been utilized as a treatment of refractory intracranial hypertension The technique probably works by reducing cerebral oxygen consumption [118,119] Corticosteroids are not indicated for therapy of cerebral edema from trauma [120,131] Other less successful treatments of refractory intracra-nial hypertension include hypothermia, decompressive craniot-omy, hypertonic saline, and a variety of investigational neuroprotective agents Research is ongoing in this area of neurotrauma

Delivery c onsiderations in b rain t rauma

The best route of delivery in the patient with acute brain injury

is unknown [132] The original large series addressing the issue

in patients with non - traumatic brain injury was in 1974 by Hunt

et al [132] Regardless, limited data are available as to the

recom-is no longer recommended and should be avoided, if possible,

within the fi rst 24 hours following acute brain injury If used at

all, the technique is reserved for temporary treatment of severe

intractable intracranial hypertension The effects of normal

preg-nancy (compensated respiratory alkalosis) on CO 2 - mediated

regulation of cerebral blood fl ow are not known

Mannitol functions as a hyperosmotic diuretic Doses of 0.5 –

1 g/kg body weight are typically used as primary treatment of

intracranial hypertension [130] Frequent monitoring of serum

osmolality is needed, and mannitol should be withheld if

osmo-lality is greater than 315 – 320 mOsm/L Treatment may be directed

at maintaining ICP at less than 20 – 25 mmHg Alternatively,

cere-bral perfusion pressure - directed treatment (CPP = mean arterial

pressure – ICP) may be instituted using mannitol and peripheral

vasoconstrictors to increase mean peripheral arterial pressure At

present, there is no standard recommendation for CPP nor is

there a recommendation as to the most effective way for

achiev-ing a particular CPP treatment endpoint Mannitol can

theoreti-cally affect uteroplacental perfusion and/or fetal volume

homeostasis However, given the grave circumstances for which

Survey for other injuries General resuscitation Cranial computed radiography (CCR)*

Glascow coma scale (GCS) scoring

Intracranial pressure monitoring

may not be indicated unless

specifically warranted

Intracranial pressure monitoring**

CCR with defect

2 or more not present:

• >40 years of age

• Posturing

• Systolic BP <90mmHg

2 or more present:

• >40 years of age

• Posturing

• Systolic BP <90mmHg CCR without defect

Figure 37.5 Initial evaluation of the comatose

trauma victim * Neurosurgical consultation liberally indicated during the evaluation of the comatose trauma victim * * A lateralizing defect with GCS < 8 may necessitate expedited surgical exploration (sources as referenced in text)

fracture should be accomplished relatively early The underlying rationale is that outcome is improved in the stable head injury patient when the femur fracture is addressed within 3 – 5 days after the injury [136] Placement of pins to stabilize fractures does not appear to increase the incidence of acute respiratory distress syn-drome (previously held opinion was that embolic marrow show-ering occurred as a consequence of bone manipulation from hardware placement )

One serious manifestation of severe injury of extremities is acute, compartment syndrome (ACS) ACS is causes by tissue edema and/or bleeding increasing the intramural pressure within

a fascial compartment ACS is not an infrequent complication of traumatic skeletal injury Up to 17% of patients with a tibial fracture secondary to a motor vehicle accident may develop ACS [137] Clinical features of the diagnosis include severe pain, ten-derness, and swelling of the involved extremity Loss of distal pulses is a late fi nding Tonometry of an affected fascial compart-ment may be used to supplant clinical diagnosis Treatcompart-ment is by fasciotomy, and, outcome is improved if the diagnosis is made early [138]

As stated previously, published experience with the specifi c management of traumatic orthopedic injury in pregnancy is lacking However, the general principles discussed in this section may serve to provide a basis of management during pregnancy Multidisciplinary care is helpful in the management of complex cases

Spinal t rauma in p regnancy

Spinal cord injury has both immediate and long - term implica-tions for trauma victim As related earlier in this chapter, neck and back stabilization is paramount during the extraction, trans-port, and initial resuscitative phases of any patient with suspected neck or back injury Use of back boards and neck stabilization during intubation are crucial to the preservation of whatever potential function remains and for the prevention of further spinal cord trauma As with other traumatic injury, avoidance of systemic hypotension is associated with better neurological outcome after traumatic spinal injury

Suspected neck or back traumatic injury necessitates both cer-vical spine radiography and careful evaluation of the spine via CT radiography When specifi c radiographic screening techniques are utilized, the combination of three - view cervical spine X - ray and CT radiography have an over 99% negative predictive value

in ruling out signifi cant spinal injury [139,140] Identifi ed inju-ries need to be stabilized under the care of a skilled neurosurgeon Surgical strategy in these cases is beyond the scope of this text Opinion is divided regarding early (postresuscitation and imme-diate treatment of acutely life - threatening injuries) surgical repair

of spinal cord injury patients Another unanswered question is that concerning the use of corticosteroids Several randomized and non - randomized trials have been conducted in order to answer the question as to whether systemic corticosteroid admin-istration results in improved neurological outcome in traumatic spinal injury Opinion is divided over corticosteroid use in blunt

mended route of delivery in patients with traumatic or atraumatic

brain injury Individualized therapy and consultation with a

neu-rologist and/or a neurosurgeon are recommended

Rapid diagnosis, early neurosurgical intervention and

meticu-lous attention to support measures offer the best hope for a

favorable outcome in patients with severe brain injuries

Comanagement with consultants, appropriate and timely use of

cranial CT scans, and serial neurologic examination may reduce

mortality and morbidity in brain trauma Improvement in

mater-nal outcome offers the best hope for improved fetal outcome

Traumatic o rthopedic i njury

Very limited information has been published specifi cally on

frac-ture management complicating pregnant traumatic injury Just

as the care of a complicated pregnancy requires the expertise of

a qualifi ed obstetrician and gynecologist or maternal - fetal

medi-cine subspecialist, specifi c management of skeletal fractures is

beyond the scope of this text and warrants specifi c management

by the appropriately trained and credentialed orthopedic

special-ist However, several important points and issues may help the

obstetric provider care for the pregnant trauma patient with

mul-tiple fractures

In the initial assessment of the victim with orthopedic injury,

only acute extremity injury and unstable pelvic fracture with

fracture - related hemorrhage are typically immediate life -

threat-ening injuries which would require emergency department or

immediate operating room treatment [133] Acute extremity

hemorrhage is managed according to the site of hemorrhage and

degree of bleeding and the injury itself An unstable pelvic

frac-ture or dislocation may result in marked pelvic hemorrhage If

faced with a patient with an unstable bleeding pelvic fracture,

most orthopedic specialists recommend placement of an external

pelvic fi xator to reduce pelvic volume and to stabilize the pelvic

ring Hemorrhage is generally controlled so as to allow successful

resuscitation and focus on other injuries [134] Other chapters of

this book outline the importance of deep venous thrombosis

(DVT) prophylaxis: DVT prophylaxis is very important in the

patient with orthopedic injury

Orthopedic urgencies (after and/or not at the exclusion of

primary resuscitation and life - saving measures) generally include

management of amputation or devascularization, and

debride-ment of open fractures Necessity for amputation of the severely

mangled extremity is directly related to the age of the victim, the

degree of skeletal or soft tissue injury, the degree of systemic

hypotension/shock, and the degree of and duration of limb

isch-emia Re - attachment of a severed limb is possible and should be

considered as appropriate after primary stabilization has occurred

[135]

Open fracture debridement and fi xation will help relieve pain

and may improve long - term outcome Early, but non - immediate

fracture fi xation allows earlier mobilization Fixation and repair

of a femur fracture is usually not an immediate concern during

resuscitation of the trauma victim with a concomitant head

injury However, it is recommended that repair of the femur

3 Fildes J , Reed L , Jones N , Martin M , Barrett J Trauma: the leading

cause of maternal death J Trauma 1992 ; 32 : 643

4 Sachs BP , Brown DAT , Driscoll SG , et al Maternal mortality Massachusetts: trends and prevention N Engl J Med 1987 ; 316 :

667

5 Satin A , Hemsell DL , Stone IC , et al Sexual assault in pregnancy

Obstet Gynecol 1991 ; 77 : 710

6 American College of Surgeons, Committee on Trauma Advanced

Trauma Life Support , 7th edn Chicago : First Impressions , 2004

7 Vaizey CJ , Jacobson MJ , Cross FW Trauma in pregnancy Br J Surg

1994 ; 81 : 1406

8 American College of Surgeons Advanced Trauma Life Support for

Doctors – Faculty Manual , 7th edn Chicago : First Impressions , 2004

9 Kuhlman RS , Cruikshank DP Maternal trauma during pregnancy

Clin Obstet Gynecol 1994 ; 37 : 274

10 Scorpio RJ , Esposito TJ , Smith LG , Gens DR Blunt trauma during pregnancy: factors affecting fetal outcome J Trauma 1992 ; 32 :

213

11 Hoff WS , d ’ Amelio LF , Tinkhoff GH , et al Maternal predictors of

fetal demise during pregnancy Surg Gynecol Obstet 1991 ; 172 : 175

12 Dilts PV , Brintzman CR , Kirschbaum TH , et al Uterine and sys-temic hemodynamic inter - relationships and their response to

hypoxia Am J Obstet Gynecol 1967 ; 103 : 38

13 Greiss F Uterine vascular response to hemorrhage during

preg-nancy Obstet Gynecol 1966 ; 27 : 408

14 Hankins GDV , Barth WH , Satin AJ Critical care medicine and the obstetric patient In: Ayres SM , Grenuik A , Holbrook PR , Shoemaker

WC , eds Textbook of Critical Care , 3rd edn Philadelphia : WB

Saunders , 1995 : 50 – 64

15 Jennett B , Teasdale G , Braakman R , et al Prognosis of patients with

severe head injury Neurosurgery 1979 ; 4 : 283

16 Teasdale G , Jennett B Assessment of coma and impaired

conscious-ness: a practical scale Lancet 1974 ; 1 : 81

17 Baxt WG , Moody P The differential survival of trauma patients J

Trauma 1987 ; 27 : 602

18 Rutherford EJ , Nelson LD Initial assessment of the multiple trauma patient In: Ayres SM , Grenuik A , Holbrook PR , Shoemaker WC ,

eds Textbook of Critical Care , 3rd edn Philadelphia : WB Saunders ,

1995 : 1382 – 1389

19 Winchell RJ , Hoyt DB , Simons RK Use of computed tomography

of the head in the hypotensive blunt - trauma patient Ann Emerg Med

1995 ; 25 : 737

20 National Blood Transfusion Service Immunoglobulin Working

Party Recommendations for the use of anti - D immunoglobulin 1991 :

137 – 145

21 Pearlman MD , Tintinalli JE , Lorenz RP Blunt trauma during

preg-nancy N Engl J Med 1990 ; 323 : 1609

22 Goodwin TM , Breen MT Pregnancy and fetomaternal hemorrhage

after noncatastrophic trauma Am J Obstet Gynecol 1990 ; 162 : 665

23 Rose PG , Strohm PL , Zuspan FP Fetomaternal hemorrhage

follow-ing trauma Am J Obstet Gynecol 1985 ; 153 : 844

24 Bowman JM Management of Rh - isoimmunization Obstet Gynecol

1978 ; 52 : 1

25 Laml T , Egermann R , Lapin A , Zekert M , Wagenbichler P Feto

maternal hemorrhage after a car accident: a case report Acta Obstet

Gynecol Scand 2001 ; 80 : 480

26 American College of Obstetricians and Gynecologists Practice

Bulletin No 282 Prevention of RhD Alloimmunization Washington,

DC : American College of Obstetricians and Gynecologists , 1999

spinal injury [140,141] It does appear that corticosteroids are not

benefi cial in penetrating spinal injury (such as gunshot wounds)

[142] If used at all, therapy should be begun within 8 hours

fol-lowing injury

Several manifestations of autonomic instability may be seen in

the spinal injury victim The patient with recent cervical or

tho-racic spinal cord complete transection has a loss of sympathetic

outfl ow Vagal afferent and efferent innervation is preserved

through the intact vagus nerve, with the result being systemic

hypotension and bradycardia from unbalanced parasympathetic

stimulation Heat dissipation increases and oliguria may result

Initial treatment with isotonic fl uid resuscitation may not be

totally effective Vasopressors and/or pressor inotropes

(dopa-mine) may be required In the non - pregnant patient, a target

mean arterial blood pressure (MAP) of at least 85 – 90 mmHg is

optimal for best neurologic outcome [140,143] Since published

data are limited in pregnant populations, individualized guidance

using fetal heart rate monitoring in the potentially viable fetus

may be required

In the non - acute setting, incomplete transections above T5

through T6 may place the patient at risk from autonomic

dysre-fl exia Afferent stimulation from a hollow viscus often produces

marked catecholamine release with marked hypertension and

other sympathetic sequelae Uterine stimulation from labor,

bladder distention, constipation, or superfi cial stimulation of the

skin below the level of the lesion may produce this condition

[144,145] For the laboring patient, epidural or spinal anesthesia

may ameliorate the unopposed afferent stimulation Treatment

of hypertension via direct - acting agents or ganglionic blockade

may be necessary in patients who do not have epidural or spinal

anesthesia [140]

Long - term care of the patient with a catastrophic spinal injury

is beyond the aim of this chapter Severe impairment may result

in lifelong challenges for the spinal injury victim

Conclusion

Trauma during pregnancy poses a special and immediate

chal-lenge to the obstetrician and to the emergency room provider

Generally speaking, most diagnostic and therapeutic modalities

relating to trauma care should not be avoided or modifi ed during

pregnancy Co management, with input from obstetric and non

obstetric services, functions to insure appropriate care of the

pregnant trauma victim and her fetus

References

1 Laverly JP , Staten - McCormick M Management of moderate to

severe trauma in pregnancy Obstet Gynecol Clin North Am 1995 ;

22 : 69

2 Vainer MW Maternal mortality in Iowa from 1952 to 1986 Surg

Obstet Gynecol 1989 ; 168 : 555

with spontaneous hepatic rupture and abdominal compartment

syndrome J Trauma 2004 ; 57 : 171

49 Boehlen F , Morales MA , Fontana P , Ricou B , Irion O , Moerloos P Prolonged treatment of massive postpartum haemorrhage with

recombinant factor VIIa: case report and review of the literature Br

J Obstet Gynaecol 2004 ; 111 : 284

50 Boba A , Linkie DM , Plotz EJ Effects of vasopressor administration and fl uid replacement on fetal bradycardia and hypoxia induced by

maternal hemorrhage Obstet Gynecol 1966 ; 27 : 408

51 Katz VL , Dotters DJ , Droegemueller W Perimortem cesarean

delivery Obstet Gynecol 1986 ; 68 : 571

52 Katz V , Balderston K , DeFreest M Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol 2005 ; 192 :

1916

53 Morris JA , Rosenbower TJ , Jurkovich GJ , et al Infant survival after

cesarean section for trauma Ann Surg 1996 ; 223 : 481

54 Rothenberger D , Quattlebaum FW , Perry JF Jr , et al Blunt maternal

trauma: a review of 103 cases J Trauma 1978 ; 18 : 173

55 Kimball IM Maternal fetal trauma Semin Pediatr Surg 2001 ; 10 ( 1 ):

32 – 34

56 Crosby WM , Costiloe JP Safety of lap belt restraints for pregnant

victims of automobile collisions N Engl J Med 1971 ; 284 : 632

57 Pearlman MD , Klinich KD , Schneider LW , et al A comprehensive program to improve safety for pregnant women and fetuses in

motor vehicle crashes: a preliminary report Am J Obstet Gynecol

2000 ; 182 : 1554

58 National Conference on Medical Indications for Air Bag Disconnection , George Washington University Medical Center

Final Report 1997 Available at: http://dmses.dot.gov/docimages/

pdf24/29064_web.pdf

59 Moorcroft DM , Dunn SM , Stizel JD , Duma GG The Effect of

Pregnant Occupant Position and Belt Placement on the Risk of Fetal Injury Warrendale, PA : SAE International , 2004

60 Agran PF , Dunkle DE , Winn DG , Kent D Fetal death in motor

vehicle accidents Ann Emerg Med 1987 ; 16 : 1355

61 Lane PL Traumatic fetal death J Emerg Med 1989 ; 7 : 433

62 Stafford PA , Biddinger PW , Zumwalt RE Lethal intrauterine fetal

trauma Am J Obstet Gynecol 1988 ; 159 : 485

63 Bunai Y , Nagai A , Nakamura I , Ohya I Fetal death from abruptio

placentae associated with incorrect use of a seatbelt Am J Forensic

Med Pathol 2000 ; 21 ( 3 ): 207

64 Griffi ths M , Hillman G , Usherwood M Seat belt injury in pregnancy

resulting in fetal death A need for education? Case reports Br J

Obstet Gynaecol 1991 ; 98 : 320

65 Pearce M Seat belts in pregnancy BMJ 1992 ; 304 : 586

66 Pearlman MD , Viano D Automobile crash simulation with fi rst

pregnant crash test dummy Am J Obstet Gynecol 1996 ; 175 : 977

67 Rozycki GS , Shackford SR Ultrasound: what every trauma surgeon

should know J Trauma 1996 ; 40 : 1

68 Scalea TM , Rodriguez A , Chiu WC , et al Focused assessment with sonography for trauma (FAST): results from an international

con-sensus conference J Trauma 1999 ; 46 : 466

69 Rozycki GS , Gallard RB , Feliciano DV , Schmidt JA , Pennington SD Surgeon performed ultrasound for the assessment of truncal

injuries: lessons learned from 1540 patients Ann Surg 1998 ; 228 :

557

70 Rozycki GS , Feliciano DV , Schmidt JA , et al The role of the surgeon

performed ultrasound in patients with possible cardiac wounds Ann

Surg 1996 ; 223 : 737

27 Boyle J , Kim J , Walerius H , Samuels P The clinical use of the

Kleihauer – Betke test in Rh positive patients Am J Obstet Gynecol

1996 ; 174 : 343

28 Weiss HB , Songer TJ , Fabio A Fetal deaths related to maternal

injury JAMA 2001 ; 286 : 1863 – 1868

29 Fries MH , Hankins GDV Motor vehicle accident associated with

minimal maternal trauma, but subsequent fetal demise A nn Emerg

Med 1989 ; 18 : 301

30 Pearlman MD , Tintinalli JE , Lorenz RP A prospective controlled

study of outcome after trauma during pregnancy Am J Obstet

Gynecol 1990 ; 162 : 1502

31 Williams JK , McClain L , Rosemursy AS , Colorado NM Evaluation

of blunt abdominal trauma in the third trimester of pregnancy :

Obstet Gynecol 1990 ; 75 : 33

32 American College of Obstetricians and Gynecologists Obstetric

Aspects of Trauma Management Technical Bulletin No 251

Washington, DC : American College of Obstetricians and

Gynecologists , 1998

33 Pritchard JA , Brekken AL Clinical and laboratory studies on severe

abruptio placentae Am J Obstet Gynecol 1967 ; 97 : 681

34 Higgins SD , Garite TJ Late abruptio placentae in trauma patients:

implications for monitoring Obstet Gynecol 1987 ; 63 (Suppl): 510

35 Dahmus MA , Sibai BM Blunt abdominal trauma: are there

predic-tive factors for abruptio placentae or maternal - fetal distress? Am J

Obstet Gynecol 1993 ; 169 : 1054

36 Katz JD , Hook R , Baragh PG Fetal heart rate monitoring in

preg-nant patients undergoing surgery Am J Obstet Gynecol 1976 ; 125 :

267

37 Evrard JR , Sturmer WQ , Murray EJ Fetal skull fracture from an

automobile accident Am J Forensic Med Pathol 1998 ; 10 : 232

38 Hartl R , Ko K In utero skull fracture: case report J Trauma 1996 ;

41 : 549

39 Palmer JD , Sparrow OC Extradural hematoma following

intrauter-ine trauma Injury 1994 ; 25 : 671

40 Weyerts LK , Jones MC , James HE Paraplegia and congenital

frac-tures as a consequence of intrauterine trauma Am J Med Genet 1992 ;

43 : 751

41 Hall EJ Scientifi c view of low - level radiation risks Radiographics

1991 ; 11 : 509

42 Shepard TH Catalog of Teratogenic Agents , 7th edn Baltimore, MD :

Johns Hopkins , 1992

43 American College of Obstetricians and Gynecologists Guidelines for

Diagnostic Imaging During Pregnancy Committee Opinion No 299

Washington, DC : American College of Obstetricians and

Gynecologists , 2004

44 Ben - Menachem Y , Handel SF , Ray RD , et al Embolization

proce-dures in trauma, a matter of urgency Semin Intervent Radiol 1985 ;

2 : 107

45 Briggs GG , Freeman RK , Jaffe SJ A Reference Guide to Fetal and

Neonatal Risk – Drugs in Pregnancy and Lactation , 6th edn Baltimore,

MD : Williams and Wilkins , 2001

46 Martinowitz U , Kenet G , Segal E , et al Recombinant activated factor

VII for adjunctive hemorrhage control in trauma J Trauma 2001 ;

51 : 431

47 O ’ Neill PA , Bluth M , Gloster ES , et al Successful use of recombinant

activated factor VII for trauma - associated hemorrhage in a patient

without preexisting coagulopathy J Trauma 2002 ; 52 : 400

48 Dart BW , Cockerham T , Torres C , Kipikasa JH , Maxwell RA A

novel use of recombinant factor VIIa in HELLP syndrome associated

92 American College of Obstetricians and Gynecologists Committee

Opinion No 282 Immunization during pregnancy Washington, DC :

American College of Obstetricians and Gynecologists , 2003

93 Barone JE , Pizzi WS , Nealon TF Jr , et al Indications for intubation

in blunt chest trauma J Trauma 1986 ; 26 : 334

94 Wilson RF Thoracic injuries In: Ayres SM , Grenvik A , Holbrook

PR , Shoemaker WC , eds Textbook of Critical Care Philadelphia : WB

Saunders , 1995 : 1429 – 1438

95 Weaver WD , Cobb LA , Hallstrom AP , et al Factors infl uencing

survival after out of hospital cardiac arrest J Am Coll Cardiol 1986 ;

7 : 752

96 Feliciano DV Tube thoracostomy In: Benumof JL , ed Clinical

Procedures in Anesthesia and Intensive Care Philadelphia : JB

Lippincott , 1992 ; 305 – 314

97 Mattox KL Approaches to trauma involving the major vessels of the

thorax Surg Clin North Am 1989 ; 69 : 77

98 Mansour MA , Moore EE , Moore FA , et al Exingent post - injury thoracotomy Analysis of blunt versus penetrating trauma Surg Gynecol Obstet 1992 ; 175 : 97

99 Shoemaker WC , Carey JS , Yao ST , et al Hemodynamic alterations

in acute cardiac tamponade after penetrating injuries of the heart

Surgery 1970 ; 67 : 754

100 Shoemaker WC Algorithm for early recognition and management

of cardiac tamponade Crit Care Med 1975 ; 3 : 59

101 Rene G , Mattox K , Beall A Recent advances in operative

manage-ment of massive chest trauma Ann Thorac Surg 1973 ; 16 : 52

102 Sankaran S , Wilson RF Factors affecting prognosis in patients with

fl ail chest J Thorac Cardiovasc Surg 1976 ; 60 : 402

103 Paone RF , Peacock JB , Smith DLT Diagnosis of myocardiac

contu-sion South Med J 1993 ; 86

104 Mattox KL , Flint LM , Carrico CJ Blunt cardiac injury (formerly

termed “ myocardiac contusion ” ) (editorial) J Trauma 1992 ; 33 :

649

105 Frazee RC , Mucha P , Fainell MB , et al Objective evidence of blunt

cardiac trauma J Trauma 1986 ; 26 : 510

106 Biffl WL , Herzig D Thoracic trauma In: Fink MP , Abraham E ,

Vincent JL , Kochanek PM , eds Textbook of Critical Care , 5th edn

Philadelphia : Elsevier Saunders , 2005 : 2077 – 2087

107 Velmahos GC , Karaiskakis M , Salim A , et al Normal electrocardi-ography and serum troponin I levels preclude the presence of

clini-cally signifi cant blunt cardiac injury J Trauma 2003 ; 54 : 45 – 51

108 Barton RG Initial approach to the injured patient In: Abrams JH , Druck P , Cerra FB , eds Surgical Critical Care , 2nd edn Boca Raton,

FL : Taylor and Francis , 2005 : 63 – 80

109 Taskinen SO , Salo JA , Halttunen PEA , et al Tracheobronchial

rupture due to blunt chest trauma: a follow - up study Ann Thorac

Surg 1989 ; 48 : 846

110 Jones WG , Ginsberg RJ Esophageal perforation: a continuing

chal-lenge Ann Thorac Surg 1992 ; 53 : 534

111 Tilanus HW , Bossuyt P , Schattenkeck ME , et al Treatment of

oesophageal perforation: a multivariate analysis Br J Surg 1991 ; 78 :

582

112 Fildes J , Reed L , Jones N , Martin M , Barrett J Trauma: the leading

cause of maternal death J Trauma 1992 ; 32 : 643

113 Hayek DA , Veremakis C Intracranial pathophysiology of brain

injury Problems Crit Care 1991 ; 5 : 135

114 Deitch EA , Sarawati DD Intensive care unit management of the

trauma patient Crit Care Med 2006 ; 34 : 2294

71 Brown MA , Sirlin CB , Farahmand N , Hoyt DB , Casola , G Screening

sonography in pregnant patients with blunt abdominal trauma J

Ultrasound Med 2005 ; 24 : 175

72 Sirlin C , Casola G , Brown M , et al US of blunt abdominal trauma:

importance of free pelvic fl uid in women of reproductive age

Radiology 2001 ; 219 : 229

73 Goodwin H , Holmes J , Wisner D Abdominal ultrasound

examina-tion in pregnant blunt trauma patients J Trauma 2001 ; 50 ( 4 ):

689

74 Hoyt DB , Coimbra R , Winchell RJ Management of acute trauma

In: Townsend CM , Beauchamp RD , Evers BM , Mattox KL , eds

Sabiston Textbook of Surgery , 16th edn Philadelphia : WB Saunders ,

2001 ; 311 – 344

75 Baerga VY , Zietlow S , Scott P , Bannom M , Harsem W , Illstrup D

Trauma in pregnancy Mayo Clin Proc 2000 ; 75 ( 12 ): 1243

76 Poole GV , Martin JN , Perry KG , Griswold JA , Lambert J , Rhodes

RS Trauma in pregnancy: the role of interpersonal violence Am J

Obstet Gynecol 1996 ; 174 : 1873

77 Guth AA , Pachter I Domestic violence and the trauma surgeon

Am J Surg 2000 ; 179 : 134

78 Newberger EH , Barkan SE , Lieberman ES , et al Abuse of pregnant

women and adverse birth outcomes Current knowledge and

impli-cations for practice JAMA 1992 ; 267 : 2370

79 Parker B , McFarlane J , Soeken K Abuse during pregnancy: effects

on maternal complications and birth weight in adult and teenage

women Obstet Gynecol 1994 ; 84 : 323

80 McCormick RD Seat belt injury: case of complete transection of

pregnant uterus J Am Osteopathic Assoc 1968 ; 67 : 1139

81 Sandy EA , Koerner M Self - infl icted gunshot wound to the pregnant

abdomen: report of a case and review of the literature Am J Perinatol

1989 ; 6 : 30

82 Sakala EP , Kost DD Management of stab wounds to the pregnant

uterus A case report and review of the literature Obstet Gynecol Surv

1988 ; 43 : 319

83 Stone IK Trauma in the obstetric patient Obstet Gynecol Clin North

Am 1999 ; 26 : 459

84 Del Rossi AJ , ed Blunt thoracic trauma Trauma Quart 1990 ; 6 ( 3 ):

1

85 Awwad JT , Azar GB , Seoud MA , Mroueh AM , Karam KS High

velocity penetrating wounds of the gravid uterus: review of 16 years

of civil war Obstet Gynecol 1994 ; 83 : 59

86 Grubb DK Non - surgical management of penetrating uterine

trauma in pregnancy – a case report Am J Obstet Gynecol 1992 ; 166 :

583

87 Cornell WP , Ebert PA , Zvidma GD X - ray diagnosis of penetrating

wounds of the abdomen J Surg Res 1976 ; 5 : 142

88 Franger AL , Buschbaum HJ , Peaceman AM Abdominal gunshot

wounds in pregnancy Am J Obstet Gynecol 1989 ; 29 : 1628

89 Edwards R , Bennet B , Ripley D , et al Surgery in the pregnant

patient Curr Probl Surg 2001 ; 38 ( 4 ): 274

90 Hankins GDV Complications of beta - sympathomimetic tocolytic

agents In: Clark SL , Cotton DB , Hankins GDV , Phelan JP , eds

Critical Care Obstetrics , 2nd edn Boston : Blackwell Scientifi c , 1991 :

223 – 250

91 Caritis SN , Kuller JA , Watt - Morse ML Pharmacologic options for

treating preterm labor In: Rayburn WF , Zuspan FP , eds Drug

Therapy in Obstetrics and Gynecology , 3rd edn St Louis : Mosby Year

Book , 1992 ; 74 – 89

129 Muizelear JP , Maramou A , Ward JD , et al Adverse effects of prolonged hyperventilation in patients with severe head injury: a

randomized clinical trial J Neurosurg 1991 ; 75 : 731

130 Wakai A , Roberts I , Schierhout G Mannitol for acute traumatic

brain injury Cochrane Database Syst Rev 2005 ; 4 : CD001049

131 Dearden NM , Gibson JS , McDowell DG , et al Effect of high dose

dexamethasone on outcome from severe head injury J Neurosurg

1986 ; 64 : 81

132 Hunt HB , Schifrin BS , Suzuki K Ruptured berry aneurysms and

pregnancy Obstet Gynecol 1974 ; 43 : 827

133 Flynn WJ , Bone L Fractures in blunt multiple trauma In: Abrams

JH , Druck P , Cerra FB , eds Surgical Critical Care , 2nd edn Boca

Raton, FL : Taylor and Francis , 2005 : 81 – 86

134 Bone L Management of polytraum a In: Chapman M , ed Operative

Orthopedics Philadelphia : Lippincott , 2002 : 417 – 430

135 Court - Brown C , McQueen M , Tornetta P Orthopedic Surgery

Essentials Philadelphia : Lippincott , 2006 : 482 – 491

136 Giannoudic P , Veysi V , Pape HC , Smith M When should we operate

on major fractures in patients with severe head injuries? Am J Surg

2002 ; 183 : 261

137 Gulli B , Templeton D Compartment syndrome of the lower

extrem-ity Orthop Clin North Am 1994 ; 25 : 677

138 Besman A , Kirton O Pelvic and major long bone fractures In:

Fink MP , Abraham E , Vincent JL , Kochanek PM , eds Textbook of

Critical Care , 5th edn Philadelphia : Elsevier Saunders , 2005 :

299 – 300

139 Brohi K , Wilson - MacDonald J Evaluation of unstable cervical spine

injury: a six year experience J Trauma 2000 ; 49 : 76

140 Bottini A Spinal cord injury In: Abrams JH , Druck P , Cerra FB , eds Surgical Critical Care , 2nd edn Boca Raton, FL : Taylor and Francis ,

2005 : 245 – 267

141 Bracken MD , Shepard MJ , Collins WF , et al A randomized con-trolled trial of methylprednisolone or naloxone in the treatment of

acute spinal cord injury N Engl J Med 1990 ; 322 : 1405

142 Heary RF , Vaccaro AR , Mesa JJ , et al Steroids and gunshot wounds

to the spine Neurosurgery 1997 ; 41 : 576

143 Jallo G Neurosurgical management of penetrating spinal injury

Surg Neurol 1997 ; 47 : 328

144 Baker EB , Cardenas DD Pregnancy in spinal cord injured women Arch Phys Med Rehabil 1996 ; 77 : 501

145 Baker EB , Cardenas DD , Benedetti TJ Risks associated with

pregnancy in spinal cord injured women Obstet Gynecol 1992 ; 80 :

425

115 Robertson CS , Contant CF , Gokaslan ZL , et al Cerebral blood fl ow,

arteriovenous oxygen difference and outcome in head injured

patients J Neurol Neurosurg Psychiatry 1992 ; 55 : 594

116 Rabadi MH , Jordan BD Maternal head trauma during pregnancy

In: Hainline B , Devinsky O , eds Neurologic Complications of

Pregnancy , 2nd edn Philadelphia : Lippincott Williams and Wilkins ,

2002 : 75 – 85

117 Brain Trauma Foundation, American Association of Neurological

Surgeons , Congress of Neurological Surgeons, Joint Section on

Neurotrauma and Critical Care Guidelines for the Management of

Severe Traumatic Brain Injury: Cerebral Perfusion Pressure New

York : Brain Trauma Foundation , 2003

118 Bullock R , Ward JD Management of head trauma In: Ayres SM ,

Granuik A , Holbrook PR , Shoemaker WC , eds Textbook of Critical

Care Philadelphia : WB Saunders , 1995 : 1449 – 1457

119 Brain Trauma Foundation, American Association of Neurological

Surgeons , Joint Section on Neurotrauma and Critical Care

Intracranial pressure treatment threshold J Neurotrauma 2000 ; 17 :

493

120 Durbin CG Management of traumatic brain injury: have we learned

what works? Crit Care Alert 2001 ; 9 ( 6 ): 63

121 Judy KD Craniotomy In: Lanken PN , Hanson CW , Manaker S , eds

The Intensive Care Unit Manual Philadelphia : WB Saunders , 2001 :

979 – 986

122 American Nimodipine Study Group Clinical trial of nimodipine in

acute ischemic stroke Stroke 1992 ; 23 : 3

123 Schmid - Elaesser R , Kunz M , Zausinger S , Prueckner S , Briegel J ,

Steiger H Intravenous magnesium versus nimodipine in the

treat-ment of patients with aneurismal subarachnoid hemorrhage: a

ran-domized study Neurosurgery 2006 ; 58 : 1054

124 Gennarelli TA , Thibault LE Biomechanics of acute subdural

hema-toma J Trauma 1982 ; 22 : 680

125 Bullock R , Teasdale GM Surgical management of traumatic

intra-cranial hematomas In: Breakman R , ed Handbook of Clinical

Neurology – Head Injury Amsterdam : Elsevier , 1990 : 259 – 297

126 Brain Trauma Foundation, American Association of Neurological

Surgeons, Joint Section on Neurotrauma and Critical Ca re

Hyperventilation J Neurotrauma 2000 ; 17 : 513

127 Muizelear JP , Wei EP , Kontos HA , et al Mannitol causes

compensa-tory cerebral vasoconstriction and vasodilation on response to blood

viscosity changes J Neurosurg 1983 ; 59 : 822

128 Enevoldsen EM , Jensen FT Autoresolution and CO2 responses of

cerebral blood fl ow in patients with acute head injury J Neurosurg

1978 ; 48 : 689

Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

M Foley, J Phelan and G Dildy © 2010 Blackwell Publishing Ltd.

Cornelia R Graves

Tennessee Maternal - Fetal Medicine PLC, Nashville, and Vanderbilt University, Nashville, TN, USA

Introduction

Most burns are caused by exposure to a thermal, chemical, or

electrical source Recent studies have estimated that

approxi-mately 7% of women of reproductive age are seen for treatment

of major burns In the United States, most burns during

preg-nancy are due to industrial accidents [1] Unfortunately, a recent

proliferation of clandestine methamphetamine labs, especially

in rural areas, has emerged as a new cause of burns in this age

group [2]

Maternal and perinatal morbidity and mortality increase as the

total body surface area burned increases [3 – 5] (Figure 38.1 ) In

the non - pregnant population, recent advances in treatment have

reduced mortality rates and improved the quality of life in burn

survivors This has been translated into improved survival for

both mother and fetus Due to the complicated clinical nature of

the process, a multidisciplinary approach is required to achieve

the best results

Classifi cation

Burns are classifi ed by degree based on the depth of the burn into

the skin and also by the amount of surface area involved Partial

thickness injury includes fi rst and second degree burns; third

degree burns are full thickness

First - degree or superfi cial burns involve the epidermis only

The skin is erythematous and painful to touch The best example

of this type of burn is a sunburn These types of burns require

topical treatment only

Second - degree burns involve death and destruction of portions

of the epidermis and part of the corium or dermis A superfi cial

burn is typically characterized by fl uid - fi lled blisters A deep

partial - thickness burn may form eschar On initial evaluation, it

may be diffi cult to assess the depth of the injury These burns are painful, but enough viable tissue is left for healing to take place without grafting

Third - degree or full - thickness burns involve the dermis and the corium (dermis) and extend into the fat layer or further The skin has a thick layer of eschar and may or may not be painful depending on the amount of damage done to the surrounding nerves [3]

In addition to the thickness of the burn, the part of the body burned, concurrent injuries, and past medical history may also affect outcome

Estimation of total body surface area (TBSA) involved in a burn may be determined in two ways: “ the rule of nines ” or the Lund – Browder chart [6] The rule of nines divides the body into sections that allows for quick estimation of the burn area and is especially useful in emergency situations (Table 38.1 ) The Lund – Browder chart also divides the body into sections but is more accurate as it takes into account changes in body surface area related to patient age In both methods only second and third degree burns are estimated A chart specifi c to pregnancy has not been developed [6]

Minor burns involve less than 10% of TBSA, are no more than partial thickness in depth, and are otherwise uncomplicated Burns are considered major if the patient has a history of chronic illness, if the burn involves the face, hands, or perineum, if there

is concurrent injury, or if the burn is caused by electrical injury [7] Critical burns encompass greater than 40% of TBSA and are associated with major morbidity and mortality Severe burns involve 20 – 39% of TBSA; moderate burns involve 10 – 19% of TBSA [8]

Thermal b urns

Thermal injuries during pregnancy usually occur at home and are most often caused by fl ame burns or hot scalding liquids This type of burn commonly involves smoke inhalation injury The burn only involves the area of the body that was in direct contact with the cause of the injury Thermal burns are classifi ed based

on the degree of injury as described above [3,9]