Management and interventions
As previously mentioned, the physiologic changes created by pregnancy can be challenging for even the most experienced emergency teams to manage in pregnant trauma victims. There must be close communication and cooperation between emergency physicians and nurses, trauma surgeons, obstetricians and all members of the team who are caring for the patient. The primary goal of trauma intervention is maternal stabilization. Definitive treatment is instituted according to the type and severity of injuries and the patient's overall clinical condition.
If the patient is hemodynamically unstable due to hemorrhagic shock or obvious intra-abdominal injuries, she will be not be in the emergency department long enough for more than the most basic of assessments and diagnostic evaluations and will likely be taken to the operating room for damage control surgery.
Positioning
If possible, any patient over 24 weeks pregnant ( or with a fundus 4 cm above the umbilicus) should be placed in the left lateral decubitus (left side lying) position to avoid symptoms of hypotension caused by pressure of the uterus on the inferior vena cava. Her back should be at an approximate 15-30 degree angle. If a wedge is available, this can be used. If the patient is on a backboard, tilt it left. A patient with unstable blood pressure and a questionable c-spine status who is not on a backboard should be log-rolled with her neck stabilized or the uterus can be manually displaced to the left. Right lateral decubitus is an acceptable alternative. Some late third trimester patients cannot tolerate the supine position due to respiratory distress. These patients will require reverse Trendelenburg positioning in addition to the left lateral tilt.
Airway
High flow oxygen should be given to all patients until a respiratory assessment is completed. Due to the higher risk of aspiration and the greater likelihood of hypoxic decompensation in pregnancy, early intubation via rapid sequence intubation (RSI) is recommended when there is the question of airway compromise. All pregnant trauma victims should be considered a difficult intubation. Preoxygenation is extremely important due to the pregnant patient's tendency to desaturate during RSI. When possible, the most experienced provider should perform the intubation, preferably with the use of a video laryngyscope. If the patient cannot be intubated, preparations should be made for surgical cricothyroidectomy. There is significant literature recognizing the issue of failed intubation in obstetric anesthesia as a major cause of maternal morbidity and mortality (Vanden Hoek et al, 2010).
Breathing
Chest wall and/or lung injury is not tolerated well in later pregnancy due to alterations in respiratory function. If chest tube insertion is required, it must be placed 1-2 intercostal spaces above the normal landmarks for tube thoracostomy due to the elevation of the diaphragm.
Circulation
In addition to left lateral positioning, bilateral large bore IV placement should be initiated in order to facilitate fluid resuscitation with crystalloid and blood products if needed. Tachycardia and hypotension are late signs of hemorrhage and shock in pregnant patients and aggressive management of volume replacement should be instituted on arrival to the emergency department.
Disability
A basic neurological examination should be completed, especially if intubation or use of paralytics is considered. Management of pregnant patients with spinal cord injuries includes the use of high dose steroids as in other settings. Fluids and dopamine are safe for initial management of neurogenic shock, although there is potential for compromised uterine blood flow with the use of dopamine. Seizures should raise a concern for the presence of eclampsia.
Exposure/Environment
The patient should be completely examined for any signs of injury while she is unclothed. Hypothermia is a concern during this process as it is associated with an increased incidence of coagulopathy and worsening outcome. The patient must be kept warm during this time.
Focused interventions/FAST Exam/ Fetal Assessment
Once the primary survey has been completed, an nasogastric tube and foley catheter may be inserted. Due to the increase in nasal and oropharyngeal venous engorgement, the risk of bleeding during and after insertion of gastric tubes is high and should be anticipated. The increased risk of aspiration due to decreased gastroesophageal sphincter tone should also be considered for placement of a gastric tube.
A foley catheter may be placed to assess urinary output. Placement should only occur if there is definitive need due to the gravidas increased risk of urinary tract infections.
A FAST exam should be completed to assess for fluid in the pericardium, pleural cavity, pararenal retroperitoneum and peritoneal cavity. The sensitivity and specificity of FAST in pregnant trauma victims is similar to those in non-pregnant patients, making it a safe and effective screening tool.
Fetal Assessment should be initiated at this time. Even in the case of relatively minor injuries, any patient with a viable pregnancy should be seen by an obstetrician and a period of fetal monitoring, including ultrasound and cardiotocography, should be provided. Monitoring should be supervised under the direction of an obstetrician and appropriate trained nursing staff, and performed for at least 4-6 hours. Any abnormalities during this period of monitoring should extend the observation period to 24 hours.
If the patient is hemodynamically unstable due to hemorrhagic shock or obvious intra-abdominal injuries, she will be not be in the emergency department long enough for more than the most basic of assessments and diagnostic evaluations and will likely be taken to the operating room for damage control surgery.
Positioning
If possible, any patient over 24 weeks pregnant ( or with a fundus 4 cm above the umbilicus) should be placed in the left lateral decubitus (left side lying) position to avoid symptoms of hypotension caused by pressure of the uterus on the inferior vena cava. Her back should be at an approximate 15-30 degree angle. If a wedge is available, this can be used. If the patient is on a backboard, tilt it left. A patient with unstable blood pressure and a questionable c-spine status who is not on a backboard should be log-rolled with her neck stabilized or the uterus can be manually displaced to the left. Right lateral decubitus is an acceptable alternative. Some late third trimester patients cannot tolerate the supine position due to respiratory distress. These patients will require reverse Trendelenburg positioning in addition to the left lateral tilt.
Airway
High flow oxygen should be given to all patients until a respiratory assessment is completed. Due to the higher risk of aspiration and the greater likelihood of hypoxic decompensation in pregnancy, early intubation via rapid sequence intubation (RSI) is recommended when there is the question of airway compromise. All pregnant trauma victims should be considered a difficult intubation. Preoxygenation is extremely important due to the pregnant patient's tendency to desaturate during RSI. When possible, the most experienced provider should perform the intubation, preferably with the use of a video laryngyscope. If the patient cannot be intubated, preparations should be made for surgical cricothyroidectomy. There is significant literature recognizing the issue of failed intubation in obstetric anesthesia as a major cause of maternal morbidity and mortality (Vanden Hoek et al, 2010).
Breathing
Chest wall and/or lung injury is not tolerated well in later pregnancy due to alterations in respiratory function. If chest tube insertion is required, it must be placed 1-2 intercostal spaces above the normal landmarks for tube thoracostomy due to the elevation of the diaphragm.
Circulation
In addition to left lateral positioning, bilateral large bore IV placement should be initiated in order to facilitate fluid resuscitation with crystalloid and blood products if needed. Tachycardia and hypotension are late signs of hemorrhage and shock in pregnant patients and aggressive management of volume replacement should be instituted on arrival to the emergency department.
Disability
A basic neurological examination should be completed, especially if intubation or use of paralytics is considered. Management of pregnant patients with spinal cord injuries includes the use of high dose steroids as in other settings. Fluids and dopamine are safe for initial management of neurogenic shock, although there is potential for compromised uterine blood flow with the use of dopamine. Seizures should raise a concern for the presence of eclampsia.
Exposure/Environment
The patient should be completely examined for any signs of injury while she is unclothed. Hypothermia is a concern during this process as it is associated with an increased incidence of coagulopathy and worsening outcome. The patient must be kept warm during this time.
Focused interventions/FAST Exam/ Fetal Assessment
Once the primary survey has been completed, an nasogastric tube and foley catheter may be inserted. Due to the increase in nasal and oropharyngeal venous engorgement, the risk of bleeding during and after insertion of gastric tubes is high and should be anticipated. The increased risk of aspiration due to decreased gastroesophageal sphincter tone should also be considered for placement of a gastric tube.
A foley catheter may be placed to assess urinary output. Placement should only occur if there is definitive need due to the gravidas increased risk of urinary tract infections.
A FAST exam should be completed to assess for fluid in the pericardium, pleural cavity, pararenal retroperitoneum and peritoneal cavity. The sensitivity and specificity of FAST in pregnant trauma victims is similar to those in non-pregnant patients, making it a safe and effective screening tool.
Fetal Assessment should be initiated at this time. Even in the case of relatively minor injuries, any patient with a viable pregnancy should be seen by an obstetrician and a period of fetal monitoring, including ultrasound and cardiotocography, should be provided. Monitoring should be supervised under the direction of an obstetrician and appropriate trained nursing staff, and performed for at least 4-6 hours. Any abnormalities during this period of monitoring should extend the observation period to 24 hours.