Trauma in Special Populations: Pregnancy

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.

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.

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.

5. The anatomy of pregnancy

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

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

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

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.

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.

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.

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

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.

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.

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.

16. Assessment Findings (cont’d) • Questions should include: • Due date, gestational age, fetal movement, contractions, previous obstetric history.

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.

18. Emergency Medical Care (cont’d) • Determine breathing adequacy. • High-flow via NRB with adequate breathing. • High-flow via PPV @ 10–12/min if inadequate.

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.

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.

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.

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?

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.

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.

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

26. Case Study (cont’d) • Is this patient a high or low priority? Why? • What interventions should be provided at this time?

27. Case Study (cont’d) • Medical History • Unknown other than patient is pregnant • Medications • Unknown • Allergies • Unknown

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.

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?

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

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.

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.

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.