1、,Chapter 19Trauma in Pregnancy,Trauma in Pregnancy孕妇创伤,Overview概要,Dual goals in managing pregnant trauma需要处理两个或以上的病人Physiological changes of pregnancy孕妇生理改变Response to hypovolemia对血溶积减少的反应Types of injuries most commonly associated常见伤势Initial assessment and management初步检查及处理Trauma prevention in pregn
2、ancy预防孕妇创伤,2,Trauma in Pregnancy-,Trauma in Pregnancy孕妇创伤,Unique challenges挑战Vulnerability of pregnant trauma patient孕妇于创伤时之弱点Potential injuries to unborn child对胎儿的伤害Dual roles双重角色Provide care to mother照顾母体Provide care to fetus照顾胎儿,3,Trauma in Pregnancy-,Trauma in Pregnancy,Leading cause of morbidit
3、y and mortality为孕妇发病率及死亡率的主要原因67%of pregnancies experience some trauma 6-7%孕妇曾遇上创创1 in 12 injured experience significant trauma 1-2%遭遇严重创伤Major causes主要原因Motor-vehicle collisions交通意外Falls高处堕下Abuse and domestic violence虐待及家庭暴力Penetrating injuries穿刺性创伤Burns烧伤,4,Trauma in Pregnancy-,Pregnant Patient,In
4、creased risk for trauma创伤的风险增加Fainting spells,hyperventilation,excess fatigue commonly associated with early pregnancy孕妇初期较易头晕,呼吸过速,易疲倦Balance and coordination affected by changes throughout pregnancy怀孕过程可影响其平衡力及身体协调,5,Trauma in Pregnancy-,Fetal Development,6,Trauma in Pregnancy-,Viability Assessmen
5、t,7,Trauma in Pregnancy-,阴道出血,肚脐,耻骨联合,流产,可被见,宫高,Physiologic Changes,8,Trauma in Pregnancy-,肠蠕动,血色素,心输出量,血量,血压,心率,血含二氧化碳量,Physiologic Changes孕妇生理的改变,Respiratory system呼吸系统Diaphragm elevated due to uterine size日渐长大的子宫令横隔膜上升Decreased thoracic volume肺容量下降Relative alkalosis血液相对为碱性 Predisposed to hyperven
6、tilation较易出现呼吸过速,9,Trauma in Pregnancy-,Vital Signs in Pregnancy孕妇生命表征的改变,Do not mistake normal vital signs for signs of shock.切勿把正常的生命表征当作休克Normal pulse:1015 beats faster 正常脉搏:快10-15次Blood pressure:1015 mmHg lower 血压:低10=15 mmHg3035%blood loss before significant blood pressure change失血量达30-35%才出现休克
7、Be alert to all signs of shock.注意出现休克征状Frequent ITLS Ongoing Exams反复ITLS”复检”捡查,10,Trauma in Pregnancy-,Response to Hypovolemia血溶积减少的反应,Vasoconstriction and tachycardia血管收缩及心跳过速 Reduction of uterine blood flow by 2030%子宫血流量减少20-30%Fetal heart rate and blood flow decreases 胎儿心跳速率及血流量下降 Fetus becomes h
8、ypoxemic 胎儿出现血氧过低High-flow oxygen is essential.给予高浓度的氧气 Maternal shock has 80%fetal mortality rate 孕妇出现休克,胎儿死亡率可达80%,11,Trauma in Pregnancy-,Trauma in Pregnancy,ITLS Primary and Secondary Surveys初步检查及进一步检查Optimize maternal and fetal outcomeHigh-flow oxygen rapidly administered尽快给予高浓度氧Fetal hypoxia o
9、ccurs before maternal hypoxia胎儿会比母体早缺氧Fluid administration must be prompt必需正确输液Fluid volume needed is greater输液量较多Frequent Ongoing Exams反复ITLS”复检”捡查Mortality of fetus related to maternal treatment 胎儿死亡率与母体处理有关,12,Trauma in Pregnancy-,Supine Hypotension仰卧血压低,Venous return decreases 30%in supine posit
10、ion with 20-week or larger uterus.下腔静脉于仰卧时受压 引致心脏血液回流受阻,通常20周以后出现Acute hypotension 急性血压低Syncope昏厥Fetal bradycardia 胎儿心跳过慢,13,Trauma in Pregnancy-,Supine Hypotension,Transport position运送时之卧式Tilt or rotate backboard 2030o to patients left 将脊板左倾20 30度Elevate right hip 46 inches with towel于盆腔下垫上4-6吋毛巾Ma
11、nually displace uterus to left 将子宫移向左侧,14,Trauma in Pregnancy-,Supine Hypotension,Transport positionBetter stabilized with vacuum backboardMore comfortable than standard backboard 固定于真空脊板较比一般脊板舒适,15,Trauma in Pregnancy-,Evaluation of Uterine Size,16,Trauma in Pregnancy-,17,Relatively minor abdominal
12、 traumacan cause fetal death.,Maternal death is most common cause of fetal death.胎儿死亡的原因最主要是母体死亡,Trauma in Pregnancy-,Pregnant Trauma Arrest 孕妇创伤性心跳停上,Treated same as for other victims急救法与普通伤者相同Defibrillation settings are same相同去颤法电量Drug dosages are same相同药物剂量Fluid volume needed increases需要较大量静脉输液4
13、liters normal saline rapid infusion during transport 送院时输液4公升If mother unsalvageable:如孕妇不能挽救Continue CPR继续 CPRNotify hospital of possible cesarean section通知院方:准备接生/剖腹接生,18,Trauma in Pregnancy-,Types of Trauma创伤种类,Motor-vehicle collisions交通意外Penetrating injuries穿刺性创伤Domestic violence家庭暴力Falls高处堕下Burn
14、s烧伤,19,Trauma in Pregnancy-,Motor-Vehicle Collisions撞车,6575%of pregnancy-related trauma交通意外占孕妇创伤65-75%1%injured when minor vehicle damage如车辆轻微破烂,少于1%孕妇受伤Seatbelts significantly decrease mortality 安全带可减低死亡率 Has not shown any increase in uterine injury 未证实会增加子宫受伤机会,20,Trauma in Pregnancy-,Motor-Vehicl
15、e Collisions,Maternal death母体死亡,Head injuryMost common头部受伤为最常见Uncontrolled hemorrhage 不能制止的内出血Second most common 第二常见Assess pelvis检查盆骨,Fetal injury胎儿受伤,21,Trauma in Pregnancy-,Fetal distress胎儿衰竭Fetal death胎儿死亡Placental abruption 胎盆剥落Uterine rupture子宫破裂Preterm labor早产,Abdominal Trauma腹部创伤,Physiologic
16、 changes生理改变Decreased sensitivity敏感度降低Gradual stretching续渐绷紧Hormonal changes荷尔蒙改变Uterus very vascular子宫大量有血液供应 Clinical presentation临床表现Guarding,rigidity,rebound response absent 可没有防卫性收缩,硬实,回缩痛等反应Abdominal trauma requires ED evaluation 所有腹部创伤都需要送院,22,Trauma in Pregnancy-,Penetrating Injuries 穿透性创伤,G
17、unshot wounds and stabbings枪伤及刺伤Entry below fundus从子宫下穿入Uterus absorbs force,protects maternal organs子宫承受力量,保护母体内脏High fetal mortality rate胎儿死亡率:4070%Lower maternal mortality rate减低母体死亡率:410%Entry above fundus从子宫上穿入Bowel injury due to displacement肠脏受伤,23,Trauma in Pregnancy-,Domestic Violence家庭暴力,10
18、%experience abuse during pregnancy 10%孕妇曾于懐孕期受虐待Proximal and midline injuries近端及中线部位受伤Face and neck most common 面部及颈为最常见 Low birth weight出生体重较轻Abused by spouse or boyfriend:7085%(U.S 被配偶 或 男友虐待:70-85%,24,Trauma in Pregnancy-,Falls高处堕下,Injury from falls高处堕下受伤Increase with progression of pregnancy 受伤机
19、会随着怀孕期增加Center of gravity altered中心改变Proportionate to force and body part impacted 与受力及身体撞击点有直接关系Pelvic injuries盆骨受伤Placental separation胎盆分离Fetal fractures胎儿骨折,25,Trauma in Pregnancy-,Burns烧伤,Fluid volume needed increasesMortality and morbidity死亡率及发生率Maternal mortality same as non-pregnant死亡率与非孕妇相同F
20、etal mortality increases with 20%BSA 烧伤面积 20%会増加胎儿死亡机会,26,Trauma in Pregnancy-,Trauma Prevention预防,Proper seat-belt use正确使用安全带Report domestic violence举报家庭暴力Counseling for domestic violence辅导Patient education病人教育Multiple changes associated with pregnancy 孕妇身体多方面改变Physiological,anatomical,emotional 生理
21、,解剖,情绪,27,Trauma in Pregnancy-,Summary总结,Trauma in Pregnancy孕妇创伤Knowledge of physiological changes生理上的改变Hypotension and hemorrhage easily overlooked 血压低及出血容易被忽视Rapid evaluation and interventions to stabilize 快速评估及处理Aggressive oxygen administration尽怏施氧Aggressive fluid resuscitation尽怏输液Prevent supine hypotension预防仰卧引致的血压低Fetal care depends on maternal care胎儿依赖母体,28,Trauma in Pregnancy-,Discussion,29,Trauma in Pregnancy-,
