Trauma in a Pregnant Patient
Reference: SOGC, Guidelines for the Management of a Pregnant Trauma Patient.
You are working as a rural emergency physician and EMS patches in announcing that they are 10 minutes away with a 28-year-old female at 36-week gestation. She was involved in a multi-vehicle accident, airbags were deployed and there was one death on scene. The nearest tertiary center is 3 hours away. Her vital signs are BP: 74/48, HR 127, O2 sat 92%, RR 33 and a GCS of 12. Her vitals remain the same despite 1 L of NS given with paramedics and O2 2 L Nasal prongs.
What are your initial steps before this patient arrives?
Pre-Primary survey: before the patient arrives do/prepare for the following:
Personal Protective equipment (PPE) for yourself and all staff involved
Ensure the trauma bay is cleared, stocked and the adult and neonatal crash cart is ready
Call for backup, mobilize your resources and assign clear roles (e.g. RT at the head of the bed, recorder, CPR staff, nurse in charge of delivering medications)
Ultrasound at the bedside
Fetal monitoring equipment at the bedside
Avoid hypothermia in any trauma patient
Warm IV Fluids
Increase the room temperature
Bair Hugger or equivalent
Call and inform OB and pediatrics of unstable pregnant trauma patient. Request their presence.
Call the blood bank for massive transfusion protocol: Ask for O negative blood
Check that all the equipment works
Every female of reproductive age should be considered pregnant until proven otherwise.
When you are faced with a trauma in a pregnant patient perform your usual ATLS algorithm with some adjustments:
Stabilizing the pregnant female is the priority, for a fetus >= 23 weeks place fetal monitoring equipment and consult OB stat.
Anti-D Immune Globulin if Rh-negative
If a Chest tube is required, it must be placed 1-2 spaces higher than usual i.e. 2nd or 3rd intercostal space
Nasogastric tube for decreased LOC to prevent aspiration of gastric fluids
Ensure O2 sat >95% for adequate fetal oxygenation
Left lateral position (increases preload to the heart)
After 20 weeks gestation, reposition the uterus to the left (increases preload to the heart)
O negative blood should be used for transfusion
No vaginal exam until placenta previa is ruled out
Tetanus vaccine is safe in pregnancy
Document domestic violence
Vasopressors decrease uteroplacental perfusion and should only be used if your patient is unresponsive to fluids