Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult

Indication and Timing

Tracheostomy is performed in patients requiring prolonged mechanical ventilation aiming at avoiding the potential detrimental effect of a sustained translaryngeal intubation (e.g. laryngeal oedema, mucosal ulcerations). Potential benefits of tracheostomy in critically ill patients are improved comfort and reduced need for sedation, easier clearance of secretions and oral hygiene, and a possible faster weaning from mechanical ventilation. Controversy exists over optimal timing (early, tracheostomy placement compared with later time points) in patients with respiratory failure. Among the published randomised controlled trials, two large studies did not report a significant advantage of an early tracheostomy compared to a late procedure for the primary outcomes of incidence of ventilator-associated pneumonia and all-cause of mortality at 30 days from randomisation. In non-head injured blunt trauma patients with prolonged respiratory failure, tracheostomy placement after 7–10 days seems appropriate. This timing would avoid the potential procedural complications of an unnecessary procedure in patients with a possible shorter period of mechanical ventilation. Further investigations are needed for giving proper indication and timing of tracheostomy in selected populations (e.g. traumatic and non-traumatic neurologic injuries)