1. 43
Trauma in Special Populations: Pregnancy

2. Objectives
Review the incidence rates at which pregnant females are traumatized.
Review normal anatomy and physiology.
Discuss complications that can occur from trauma in pregnant females.
Review assessment findings and discuss treatment strategies.
Discuss the objectives.

3. Introduction Trauma can at times be complicated.
The pregnant patient can be one of those complications as the Advanced EMT must care for two patients now.
Everything that the Advanced EMT does for the mother affects the baby that is yet unseen.
Pregnant patients who are involved in trauma pose a special challenge in that Advanced EMTs must care for two patients at one time.
Trauma to a pregnant woman, whether severe or minor, can have significant effects on both:
Maternal health
Fetal health

4. Epidemiology
Trauma occurs in about 6%-7% of pregnancies, and is the leading cause of death for pregnant women.
MVCs account for 50% of injuries.
41% of fetuses die when the mother suffers a life-threatening injury.
Up to 17% of pregnant women are victims of abuse.
Review the basic statistics.

5. The anatomy of pregnancy
Review the changes in the female due to pregnancy.
Not only structural changes, mention changes to:
Blood volume
Respiratory rate
Blood chemistry
GI function
Loosening of the hip joints
Vena cava compression

6. Pathophysiology Complications of Trauma: Uterine Contractions
Most common complication.
May progress to preterm labor.
Monitor quality of contractions.
Discuss presentation and progression.

7. Pathophysiology (cont’d)
Complications of Trauma: Preterm Labor
Occurs before 38th week of gestation.
Fetus viable following the 24th week of gestation.
Discuss presentation and progression.

8. Pathophysiology (cont’d)
Complications of Trauma: Spontaneous Abortion
Occurs before the 20th week of gestation.
Common findings include abdominal pain, cramping, vaginal bleeding.
Discuss presentation and progression.

9. Pathophysiology (cont’d)
Complications of Trauma: Abruptio Placentae
Results mostly from blunt trauma.
Separation of placenta from uterine wall.
With or without external hemorrhage.
Abdominal pain, uterine tenderness, vaginal bleeding, hypovolemia.
Discuss presentation and progression.

10. Pathophysiology (cont’d)
Complications of Trauma: Uterine Rupture
Due to blunt force trauma.
Most fatal complication to mother and fetus.
Presents with maternal shock and palpable fetal parts in abdomen.
Discuss presentation and progression.

11. Pathophysiology (cont’d)
Complications of Trauma: Penetrating Trauma
Great fetal risk of injury.
Penetration in upper abdomen results in bowel and abdominal injuries.
Penetration in lower abdomen results in direct fetal injuries and death.
Discuss presentation and progression.

12. Pathophysiology (cont’d)
Complications of Trauma: Pelvic Fractures
Result from blunt trauma to abdomen.
May sustain significant hemorrhage.
Bladder, urethral, intestinal injuries
25% fetal mortality rate
Discuss presentation and progression.

13. Pathophysiology (cont’d)
Complications of Trauma: Hemorrhage and Shock
Can result from most any injury previously discussed.
Frequent cause of death to mother and fetus.
Mother may lose 30% blood volume before becoming symptomatic.
Discuss presentation and progression.

14. Pathophysiology (cont’d)
Complications of Trauma: Cardiopulmonary Arrest
Significant threat to fetus.
Poor likelihood of fetal survival with maternal death.
Continue with resuscitative efforts if mother in 3rd trimester.
Discuss presentation and progression.

15. Assessment Findings Follow normal assessment steps.
Pay attention to abdomen and uterus
Uterus should be palpable above iliac crest after the 12th week. It will continue to grow and move upwards throughout the pregnancy.
When contractions occur uterus should feel taut and round; if asymmetric, consider uterine rupture.
The prehospital assessment and management of the pregnant trauma patient are focused on identifying, ensuring, maintaining, and supporting the vital functions of the patient's airway, breathing, and circulation.
Unlike other traumatic emergencies, two patients must be considered by the Advanced EMT.
The best way to help both the mother and fetus involved in trauma is to take a proactive approach and to treat the mother aggressively.
All pregnant women who have suffered an injury, regardless of the severity of the injury, should be evaluated by a physician in the emergency room.

16. Assessment Findings (cont’d)
Questions should include:
Due date, gestational age, fetal movement, contractions, previous obstetric history.
The prehospital assessment and management of the pregnant trauma patient are focused on identifying, ensuring, maintaining, and supporting the vital functions of the patient's airway, breathing, and circulation.
Unlike other traumatic emergencies, two patients must be considered by the Advanced EMT.
The best way to help both the mother and fetus involved in trauma is to take a proactive approach and to treat the mother aggressively.
All pregnant women who have suffered an injury, regardless of the severity of the injury, should be evaluated by a physician in the emergency room.

17. Emergency Medical Care
Spinal immobilization considerations
Tilt backboard to left side after 20 weeks of gestation.
Assess and maintain the airway.
Vomiting common with pregnant mothers.
Review and discuss the slide.
Initial goal is to still properly manage the:
Airway
Breathing
Circulatory mechanisms
Remember that you are treating two patients, what you do for one (or not do), you are doing for both.

18. Emergency Medical Care (cont’d)
Determine breathing adequacy.
High-flow via NRB with adequate breathing.
High-flow via 10–12/min if inadequate.
Review and discuss the slide.
Initial goal is to still properly manage the:
Airway
Breathing
Circulatory mechanisms
Remember that you are treating two patients, what you do for one (or not do), you are doing for both.

19. Emergency Medical Care (cont’d)
Assess circulatory components.
Check pulse, skin characteristics.
With vaginal bleeding, absorb blood but don't pack vagina.
Control external major bleeds normally.
Start at least one large-bore IV en route to the hospital and run fluids according to patient presentation or local protocol.
Remember the mother can lose a significant amount of blood prior to showing frank signs of hypoperfusion.
The best method of caring for the fetus is by anticipating injuries and shock and aggressively managing the mother.

20. Emergency Medical Care (cont’d)
Perform a visual exam of vagina.
Assess for crowning or bleeding
Provide full immobilization.
Treat any minor injuries, time allowing.
Discuss as needed.

21. Case Study
You are dispatched to a single car MVC, in which the lone driver lost control on a wet road and struck a utility pole at a significant speed. FD is on scene still trying to disentangle the patient from the car. As you draw toward the car window, you can see a young adult female who is unresponsive and obviously pregnant.
Discuss the case study.

22. Case Study (cont’d)
Based on the scene size-up, what are some conditions you suspect the patient may have?
What will be your assessment approach to her?
With an MOI of a frontal impact, the patient could have experienced an “up and over” pattern of injuries (head trauma, brain trauma, neck trauma, chest and upper abdomen trauma), or the “down and under” pattern (lower extremity fractures, hip fractures/dislocation, and abdomen/lower chest trauma).
The fetus may suffer from:
Uterine rupture
Abruptio placentae
Hypoperfusion
Keeping with traditional assessment, the Advanced EMT should provide manual cervical immobilization while establishing the patient's mental status.
The Advanced EMT should then evaluate the quality of the airway, breathing, and circulatory components of the primary survey before making an ultimate decision about the patient's stability.

23. Case Study (cont’d) Scene Size-Up Scene safe from personal hazards.
Standard precautions taken.
Patient extricated from auto.
22–24-year-old female, 160 lbs, 3rd trimester.
MOI is blunt trauma from frontal MVC.
Consider notifying aeromedical transport for transport to trauma facility.
Discuss the case progression.

24. Case Study (cont’d) Primary Assessment Findings
Patient moans to noxious stimuli.
Airway open, breathing shallow, breath sounds present bilaterally.
Carotid and radial pulses present & tachycardic.
Discuss the case progression.

25. Case Study (cont’d) Primary Assessment Findings
Peripheral skin cool and slightly diaphoretic.
Hemorrhage to proximal femoral shaft fracture that is open.
Discuss the case progression.

26. Case Study (cont’d) Is this patient a high or low priority? Why?
What interventions should be provided at this time?
The patient should be considered a high priority due to:
The change in mental status.
The fact the patient is likely displaying some early indications of shock (tachypnea, tachycardia, potential change in mental status).
Open hemorrhage to leg from femur fracture.
The patient should be placed in a supine position with cervical immobilization maintained manually.
A primary survey should be completed along with the application of oxygen, probably by non-rebreather mask.
Finally, the external bleed should be managed with direct pressure.

27. Case Study (cont’d) Medical History Medications Allergies
Unknown other than patient is pregnant
Medications
Unknown
Allergies
Discuss the case progression.

28. Case Study (cont’d) Pertinent Secondary Assessment Findings
Patient is unresponsive to noxious stimuli now.
B/P 82/60, heart rate 140, respirations 32.
Physical assessment reveals abrasions and contusions to lower abdomen.
LLQ and RLQ both firm to palpation.
Discuss the case progression.

29. Case Study (cont’d)
What are two different explanations as to why the mother has a change in mental status?
How would you characterize the blood flow and oxygenation to the fetus at this time?
The mental status could be changed due to hypoxemia from breathing inadequately, it could also be from poor perfusion to the brain secondary to hypovolemic shock.
Both blood flow and oxygenation are probably depressed at this time to the fetus.
The normal compensatory mechanisms for the mother operate largely at the expense of the fetus.
So while blood flow is redirected to the mother and oxygen extraction from the blood stream occurs highest in the mother's organs, the fetus is robbed of blood flow and oxygenation.

30. Case Study (cont’d)
What patient positioning modifications will you make for this pregnant patient?
If the patient starts to improve, what would be the expected findings for:
Mental status
Heart rate
Skin findings
The patient should be immobilized, but the backboard should be tilted to the left so that the gravid uterus is not compressing the vena cava and contributing to poor preload of the right ventricle (supine hypotensive syndrome).
With patient improvement, the mental status should improve, the heart rate should drop back to a normal rate, and the skin should lose some pallor. In addition, muscle tone should improve as would the pulse oximeter.

31. Case Study (cont’d) Care provided:
Patient cervical spine manually immobilized.
High-flow oxygen via mask initially, PPV while en route due to respiratory failure.
Full spinal immobilization, board tilted to left.
Discuss the care provided.

32. Case Study (cont’d) Care provided:
Patient transported and large-bore IV inserted.
IV fluids to increase blood pressure.
Patient reassessed during transport without change in condition, hemorrhage controlled.
Discuss the care provided.

33. Summary
The Advanced EMT must remember that the pregnant patient may have unique injury patterns and presentation findings following trauma.
The care provided must equally support the mother's immediate needs as well as promote good perfusion, oxygenation, and nutrient delivery to the fetus.
Review as appropriate.