Anesthetic Management of Emergency C/S in a trauma patient with pulmonary contusions
Abstract Number: 178
Abstract Type: Case Report/Case Series
INTRODUCTION: There is an eight fold higher risk of difficult intubation in pregnant patients as compared to the general population. This risk is further increased in a pregnant trauma patient. We present the anesthetic management for C/S for placental abruption in a pregnant patient s/p MVA and with pulmonary contusions.
CASE REPORT: Patient is a 24y term G1P0 who was a restrained passenger in an MVA. No sig. PMH. Allergies: PCN. VSS. CT of cervical spine did not show any fractures, but this information was not documented in the chart prior to the procedure. Patient was transferred to OB with a cervical spine collar. In OB patient had stable vital signs with occasional cough with SpO2 = 96% on room air. Soon afterwards, the FHR tracings revealed sustained bradycardia. Placental abruption was suspected, and an emergency C/S was declared. After rapidly making difficult intubation equipment available, RSI and intubation with manual inline stabilization was done. On entry to uterus 30% abruption was seen. Tubes, ovaries, bowel, and bladder were without obvious injury. No hemoperitoneum was seen. During C/S, trauma team arrived to inform that a review of CT neck, chest, and CXR showed right pulmonary contusion, and no cervical spinal fractures. At end of case, copious amount of blood were suctioned from ETT, and patient was unable to maintain SpO2 > 90% with FiO2 of 40-50%. Decision was made to keep patient intubated and transfer to ICU for ventilation management. In ICU patient experienced vaginal bleeding, which was managed with methergine. She was extubated 6 hours later and transferred to L&D RR. In RR she complained only of sore throat and occasional hemoptysis. When the postpartum bleeding was deemed to be under control, and there were no respiratory issues, she was transferred to the floor.
DISCUSSION: The incidence of trauma in pregnant patients is approximately 8%, with 20% of these patients requiring emergency surgery. The most common type of injury (70%) is blunt trauma associated with MVAs. Major maternal trauma is frequently associated with placental abruption with a high risk of DIC. The anesthesiologist must be prepared to deal with not only the visible effects of trauma, but also the possibility of DIC. Additional IV lines are needed and blood/components must be readily available.
When intubation is required in patients with suspected cervical spine injury, options include: fiberoptic intubation, intubation with manual-in-line stabilization of the neck, intubation using an alternate device (ex: Glidescope), and intubation via a supraglottic device (ex: LMA Fastrach). The presence of coexisting pulmonary injuries can make ventilation and extubation more difficult.
Pulmonary contusions are the most common type of lethal chest trauma with a mortality rate of 14-40%. Pulmonary contusions may also progress to ARDS. The importance of avoiding fluid overload and the possible need for post-op ventilation must be kept in mind.