Trauma In Pregnancy 1: Introduction

Trauma in the pregnant patient is scary, but thankfully not very common. About 1 in 15 pregnant women sustain some type of significant injury. About half are from car crashes (most commonly if unrestrained), and 25% each are from assault (frequently domestic) and falls. Unfortunately, trauma is the leading cause of non-obstetric fetal death.

What makes this type of trauma problematic is two-fold, literally. First, you have two patients. And second, neither one has “normal” physiology. The mother has made numerous adaptations to accommodate the pregnancy, and the fetus is essentially a small parasite, totally dependent on her.

Let’s look at the impact of some of the more important maternal adaptations:

  • Total blood volume increases by about one liter. This would seem to be good, but since it is mainly dilutional with no real increase in total RBCs, and this is coupled with a lower mean blood pressure. Trauma professionals can easily underestimate blood loss.
  • Going into the third trimester, the uterus can compress the IVC when the mother is lying supine. but it is quite frequently forgotten. One of the first maneuvers when you suspect an advanced pregnancy is to bump the patient to her left. Do this even if the blood pressure is normal.
  • The pelvic veins are huge. Disruption from pelvic fractures or penetrating injury can lead to massive bleeding.
  • The stomach is probably full, and under pressure from below. This increases aspiration risk in women who have decreased mental status or need intubation.

And don’t forget the fetus:

  • The fetal/placental/uterine complex is one large, non-compressible unit with multiple shear planes within it. Blunt force will stress those planes, and may result in disruption of the uterus from pelvic veins (massive bleeding), or separation of the placenta from the uterus (abruption).
  • The fetus is totally dependent on the mother for survival, but the placenta will protect the mother first, shutting down fetal circulation if she becomes hypotensive or hypoxic.
  • The baby was designed to come into this world at full term. We have developed the technology to sustain life in smaller and more premature babies. The magic number of weeks keeps slowly decreasing, but preemie survival without complications is a challenge.

Tomorrow, we’ll move on and get to the fun stuff, predicting outcome after trauma in pregnancy.

Platelet Transfusion In Patients Taking Anti-Platelet Drugs

These days, trauma professionals see quite a few patients who take antiplatelet agents for cardiovascular comorbidities. These drugs can be problematic when the patients sustain injuries that result in bleeding in problematic areas like the cranial vault.

Aspirin and clopidogrel are the most common medications, and they irreversibly inhibit platelet aggregation.  All exposed platelets essentially quit working for the remainder of their 10-day lifespan. Platelet aggregation improves slowly over time after cessation of the drug as new platelets are added to the circulation from the bone marrow.

But what can you do if you are concerned that your patient is bleeding after injury because their platelets are not working? It seems logical that you would just transfuse some new platelets. But you should know by now that not everything that makes sense really works. A group in France designed a study to test this premise in patients taking either aspirin or clopidogrel. They performed a prospective, observational study on patients presenting with potentially life-threatening hemorrhage.

The authors used the Verify Now device to measure platelet response to the two drugs. Patients who had normal platelet function in the first place (not compliant or not a responder to the therapy) were excluded. All patients had initial platelet counts greater than 100K/ml. They underwent platelet transfusion for management of hemorrhagic shock, intracranial hemorrhage, or an emergent neurosurgical procedure.

Here are the factoids:

  • Only 25 patients were enrolled during the three year study; 13 were receiving only aspirin, 8 clopidogrel only, and 4 combined therapy
  • Average transfusions were 1-2 apheresis packs of platelets (6-12 units)
  • For aspirin patients, all showed significant platelet dysfunction before transfusion, and all but one showed recovery of function post-transfusion
  • For clopidogrel patients, platelet function remained impaired; the percent of inhibited platelets decreased but remained above the study threshold for “normal” of 20%

Bottom line: This is a very small study, but drives home the point that clopidogrel and its relatives may be problematic in bleeding patients. The active metabolites of this drug class are not well understood. But they are most likely still circulating in the blood in patients actively taking them, and deactivate new platelets as soon as they are transfused (assuming that the transfused platelets have good function in the first place). 

This issue requires further study so we can really tease out the actions of the drugs and their effect on transfused platelets. Until then, carefully consider whether platelet transfusion will be helpful in your bleeding patients, and if it is even worthwhile giving them or waiting for them to finish prior to going to the operating room.

Reference: Is platelet transfusion efficient to restore platelet reactivity in patients who are responders to aspirin and/or clopidogrel before emergency surgery? J Trauma 74(5):1367-1369, 2013.

What Would You Do? The Elderly Patient With Subdural Hematoma – Final Answer?

I’ve spent the last several posts reviewing the sparse data that we have on the impact of subdural hematoma management in elderly patients. With this information, I had hoped to arrive at some answers as to what to do when certain common patient presentations are encountered.

Unfortunately, the data is not very good, and is structured to raise false hopes. Overall, it looks like about 30-40% of selected patients die in the postoperative period. And the percentage of patients who are discharged at their pre-injury level of independence is in the low single digits. In fairness, one paper did show an improvement from severely disabled to moderately disabled or recovered, although the authors obfuscated how many actually made it to the good recovery group.

The biggest problem with all of the literature we have is that the patients were selected for surgery based on the opinion of the neurosurgeon. This means that many patients who they felt would do poorly with operation were excluded. It is extremely likely that the inclusion of these patients would have dragged down the already poor numbers that were reported. But in fairness, we might have also found a few surprise saves among those patients; I guess we’ll never know.

So let me give you my take on the scenarios that I presented so many days ago. Remember, these are my opinions and are not meant to be gospel. Other trauma professionals will need to interpret the information themselves and make their own decisions.

Scenario 1 – An elderly female falls and sustains a modest subdural hematoma with no shift and a normal exam. Follow your established practice guidelines unless some of the factors in the following scenarios are present.

Scenario 2 – Same as above, but the patient presents 8 hours after the fall. The clock started ticking when the fall occurred. Since your practice guideline recommends monitoring for 6 hours and then a followup CT of the head, the initial CT is the followup scan. The patient could then be discharged if there are no alarming findings on initial CT and the neuro exam is normal.

Scenario 3 – Same as scenario 1 but the patient has advanced dementia. These patients were generally excluded from the studies, and they are not expected to do well. Frankly, they will likely be much worse after an operation and will require an even higher level of post-discharge care (if they make it that far) and more involvement of family. It is critically important that the trauma professionals have a frank talk with the family to make sure they understand the overwhelming likelihood that their loved one will never be as good as they were before the injury. Surviving an operation does not mean going back to their usual living situation. The family absolutely needs this information to make the best choice for their loved one.

Scenario 4 – Same as scenario 1 but the patient has a well documented “do not actively resuscitate” order in place. The patient and their family need the same talk as above so they can appreciate all of the risks and the few, if any, benefits of surgery. Only then can they make an informed if they want to consider temporarily rescinding their DNAR order to allow surgery.

Scenario 5 – Same as scenario 1 but the patient is 95 years old. The data showed that patients in their 80s tended to do even more poorly than younger patients. There were very few nonagenarians in the literature, but it can be expected they would do even worse than the octos. They and their families need the same depressing talk so they can make the right decision.

Bottom line: Communication is key. And good data is even more key, although we have too little of it. For now, all we can do is paint a somewhat depressing picture of generally poor outcomes in highly selected patients. Hopefully we’ll have better data some day and can slice and dice things a little better. This may eventually allow us to offer surgery to those patients who will actually benefit from it the most.

What Would You Do? The Elderly Patient With Subdural Hematoma – Part 4

In my last post, I discussed a paper that examined the fate of very well-selected elderly patients with traumatic subdural hematoma. Today, I’ll focus on one that was just published that took all comers, kind of. Hopefully, this will give us a better idea of what outcomes to expect after emergency craniotomies.

This work was conducted at the University of New Mexico, and was yet another retrospective review. They took all comers with age > 65 and acute subdural hematoma. However, criteria for proceeding to surgery were based on neurosurgeon discretion. Only 62 patients were identified during a 5 year period, and the Glasgow Outcome Scale score was the primary outcome.

Here are the factoids:

  • 60% of patients were taking preoperative anticoagulant or antiplatelet drugs
  • Perioperative mortality was 39%, and this increased to 44% at three months
  • Of the remaining 38 survivors, 4 were in a vegetative state,  26 were severely disabled, 6 had moderate disability, and 2 had a good recovery
  • By 6 months, 20 of the patients in the severely disabled category improved to either moderate disability or good recovery

The authors conclude that, although mortality was high, a significant number of patients (31%) made a meaningful recovery by 6 months. These were patients who had achieved a GOS score of 4 or 5.

Bottom line: Once again, read closely. If you look at the numbers at discharge, 39% were dead and 3% were recovered. The rest ranged from a vegetative state to varying degrees of disability and independence. 

Over the first three months  postop, the severe disability number shrank, with 5 dying, 3 moving to moderate disability, and 12 making a recovery. This continued to improve somewhat over the next 3 months, but the authors don’t clearly state how many were actually in the recovered group.

So the final numbers that we can tease apart show a 44% mortality and at least 25% recovered. These sound pretty good, right?

Unfortunately, the retrospective design and small numbers are heavily influenced by the selection process. Remember, the patients who received an operation were more likely to survive if the neurosurgeon was skilled in selecting his or her patients vs declaring them as having a “nonsurvivable injury.” We still don’t know the answer to our questions for all comers, but it’s probably quite a bit worse than these numbers. I would imagine that every one of those not operated upon died, and including them would skew these numbers tremendously towards nonsurvival.

So what’s a trauma professional to do? In my next post, I’ll try to bring it all together in a way that we can apply to our own patients.

Reference: Mortality and functional outcome in surgically evacuated acute subdural hematoma in elderly patients. World Neurosurg 126:e1234-e1241, 2019.

What Would You Do? The Elderly Patient With Subdural Hematoma – Part 3

In previous posts, I proposed several scenarios with elderly patients presenting with subdural hematomas and discussed the use of practice guidelines to help direct their care. The principal conundrum has been in knowing who will do well vs who will not.

Today, I’ll review a paper that examined functional outcome / salvageability in patients with subdural hematomas. It is from a Swiss group that retrospectively reviewed their experience over a six year period. Interestingly, they had specific criteria in place (fifteen years ago) that would limit craniotomy to study patients with:

  • A Karnofsky Performance Scale score of 80 or more and living independently. This scale evaluates the ability to carry out activities of daily living using a score of 0 to 100. Scores > 80 indicate that there may be some symptoms of disease, but daily activities can be carried out with some effort or less.
  • No known dementia
  • No comorbidities that had a survival time of less than 12 months.
  • Desire to proceed with surgery and consent to do so.

Patients with fixed, dilated pupils were excluded. Here are the factoids:

  • 42 patients older than 65 years presented during the study period, and 37 met inclusion criteria
  • 81% of patients had comorbidities and 43% were on some type of anticoagulant or platelet agent
  • Median GCS was 8, so these patients had significant head injury
  • One third (13) died in the perioperative period, and one quarter experienced nonlethal complications
  • Anticoagulation or antiplatelet agents did not appear to affect mortality
  • Final Glasgow Outcome Scale scores were favorable (4-5) in 40% and unfavorable to severely disabled (1-3) in 60%. However, these numbers were calculated using all 37 study patients, and did not exclude the 13 who died! I’m not sure how this works, exactly.

Bottom line: Read this one closely. The authors conclude that, although morbidity, mortality, and adverse outcomes are high, there is a good outcome in 41% of patients.

Really? This is why it is so important to read the whole paper. If you just browsed the abstract and its conclusion, you would have missed the fact that they only accepted independent patients with no dementia or critical comorbidities! The patient group was highly selected which biased them toward better outcomes. Furthermore, there were only 37 people in this retrospective study. 

Personally, I learned very little from this study. I cannot use it to guide me in answering the questions I posed with the original scenarios.  Tomorrow, I’ll review a more recent paper to see if we can find any more clues.

Reference: Age and salvageability: analysis of outcome of patients older than 65 years undergoing craniotomy for acute traumatic subdural hematoma. World Neurosurg 78(3/4):306-311, 2012.

Home of the Trauma Professional's Blog

Do you want to get a daily email every time there’s a new post? See what I’m up to.

Click here to get details and subscribe!

Request a Topic

Subscribe now to the Trauma MedEd Newsletter and get a free copy of my guide, "How To Keep Up With Your Literature"!