• Dr. Nour Khatib, MDCM CCFP(EM) MBA

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

  • Neonatal warmer

  • 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

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