Trauma is an example of a multisystem, life-threatening illness. Like all life-threatening emergencies, the management of major trauma requires a systematic approach. Developing an understanding of such an approach and applying it to any life-threatening emergency will help to optimise care.
There are marked differences in the epidemiology of trauma in different countries. In the UK, there are an estimated 10 000 deaths from trauma each year – approximately 30 deaths each day, of which road traffic accidents are the most common cause.
Trauma occurs in up to 7% of pregnancies and is most commonly due to suicide (most common postnatally), road traffic accidents (equal frequency throughout pregnancy), domestic violence (more common before 18 weeks), falls (between 20 and 30 weeks) and burns.
The Confidential Enquiry into Maternal Deaths has highlighted suicide as a major cause of death recently and in the 2006–08 triennium there were 29 reported suicides. Of these deaths, 87% were by violent means, which is a less common method of suicide in the nonpregnant female. The most common methods involved hanging or jumping from a height, but self-immolation also occurred. The Enquiry reported 17 cases of road traffic accidents and 11 cases of murder, but of all the 344 deaths assessed, 34 of these women had suffered from domestic violence. The obstetrician is likely to be called to any case of trauma in the pregnant woman.
A survey of trauma deaths shows up to 33% to be preventable. These preventable deaths are largely the result of early hypoxia and hypovolaemia. Forty percent of deaths occur at the scene of the accident. Of those who survive major trauma, only 18% make a full functional recovery; many have minor disabilities, but 9% have moderate disability (usually orthopaedic, such as knee ligament injuries); and 3% have severe disability (usually neurological: spinal-cord injury, head injury). Abruption occurs in up to 70% of major trauma in pregnancy, while uterine rupture is much less likely, occurring in less than 1% of major injuries, but it is associated with a 10% maternal mortality rate. Fetal loss occurs in up to 40% of major, and 2% of minor, injuries. Fetal loss occurs in 35% traumatic abruptions and is invariable in traumatic uterine rupture. The seat belt advice, ‘Above and below the bump, not over it’ is regularly repeated in the confidential maternal death reports.
Analysis of trauma data shows a trimodal death distribution:
1. Instantaneous
Within seconds to minutes of the injury: deaths are due to a blocked airway, massive head injury, severe spinal-cord injury and exsanguination.
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