Your radio going off as a very distraught paramedic hurriedly relates that they?re about 2 minutes out with a motor vehicle collision victim who looks sick and is tachycardic, hypotensive, and having agonal respirations. He relates that the husband is frantically screaming that she?s due next month to have a baby girl. As your team gears up for the patient about to enter your trauma room, you realize that the ambulance is going to arrive much faster than your obstetrician on call (who is coming from home). You fully appreciate that the opening moves of this drama are going to be entirely up to you.
How do you plan to approach the management of this patient?
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Last Updated on January 26, 2023
STat call to OB and Surgery, Draw trauma labs, Intubate, insert large bore IV’s, port CXR, FAST exam and if + then straight to OR for Csection and exploratory lap.
?uterine rupture/placental abruption/other intrabdominal trauma, prepare for perimortem C-section and/or possible thoracotomy, place a call to pediatrics, get the warmer and neonatal intubation set ready to go, have O neg blood on standby, have adult intubation tray ready, ultrasound on and at bedside, recruit another ED physician if possible to assist
Before arrival, gather team, remind them that resuscitation of mom is essential, baby is a secondary thought (people get wrapped around the axle about pregnancy, but if mom does bad, so does baby). Prepare baby warmer if we have one for perimortem csection, get a kit (if we have one) available, but a 10 blade, bandage scissors, and 2 hemostats at a minimum. Simple things first, 2 large bore IV/O2/Monitor, if truly agonal, intubation and ventilate (slightly increase rate over baseline 2/2 pregnancy), O Neg PRBC 2 units, AB FFP as well. I am trying to avoid pressors to prevent placental ischemia, but if the initial blood doesn’t improve BP, I will. Chest exam/distal extremity pulses, HEENT, FAST Ultrasound if I have access, and a quick look at baby as well for FHT. Portable Chest for tube placement. Head to toe exam for other injuries. If patient arrests, standard ACLS, and perimortem c-section. Change undergarments.
Activate trauma team, prepare emergency obstetric kits in case i have to to do emergency (peri mortum?) ceaseran , and get most experienced person to be around to perform the precedure if indicated. Get emergency blood 0 negative ready. Prepare the staff and equipment..make sure everybody ready to receive. Get the obstetric registrar or anybody equivalent or better trained. probably inclined the bed by 15 to 30% in anticipation of CPR and to facilitate venous return
Quickly examine habitus for any sign of blunt trauma particularly to abdomen, chest and head. Administer oxygen, place leads and FHR monitor. if decelerations present, turn patient on their left lateral decubitus to relieve possible compression of ivc. Start large infusion of iv fluids with phenylephrine for peripheral vasoconstriction to increase preload/afterload since patient is hypotensive. Call for STAT US to r/o placenta abrupta/obtain Amniotic Fluid Index and do a quick sterile vaginal examination to check for cord prolapse, bleeding or amniotic pooling for possible rupture of membranes. Confirm with amnisure test/nitrazine to decide whether to prep patient for a possible emergency cesarian to minimize risk of amniotic fluid embolism if leak is suspected. If agonal breathing persists do quick CXR to r/o hemothorax or aortic rupture.
We have to manage the patient as ATLS protocol such as
Primary survey
A-Airway
B-Breathing
C-Circulation
D-Disabality
E-Exposure and Event
And then go to Secondary survey ( detailed Head to toe exam and AMPLE ) if there is no life threatening issues in ABCDE
But as in this particular case, if the patient arrest breathing ,we should do emergency post-motem CS to save the life of the baby.
Focus on primary survey of mother just as I would any other patient – specifically airway, breathing, circulation, disability and exposure. Activate the trauma team – as well as call OB and paediatrics.
I will anticipate a difficult airway given the patient is a trauma (C-spine precautions) and pregnant. Any chest tubes I place I would put a couple interspaces higher. I would also roll patient 30 degrees left, or manually displace uterus off IVC. I would consider the uterus as a source of bleeding. I would give O negative blood. If patient codes, I would be prepared to preform a perimortem C-section.
Upon receipt of this message, summons troops: anesthesia, surgery, nursery, sonography pastoral care. Notify administration and nursing leadership of the impending demand for services. Secure an OR, and have the OR or L&D team bring Ceserean supplies to trauma bay. Designate family care leader. P
Upon ambulance arrival, repeat rapid trauma assessment; incl vaginal exam.
Doppler or bedside ultrasound to document fetal life /viability
IF this verifies near-dead mother with viable (36 wk?) fetus, the next step is immediate point of care cesarean. Goals: salvage of healthy infant, with improved resucitation of the woman.
[If the fetus is, reliably, without heart tones then proceed with resucitation of the woman; remember leftward tilt (affects maternal venous return regardless of any need for placental perfusion)]
If you are going to do the cesarean, someone needs to be the trauma team leader.
If a surgeon is available to do the cesarean, then you will continue as team leader.
Continue maternal CPR during cesarean.
ACLS: good quality CPR, ventilation, etc, but expedite the advanced airway although de-emphasized in 2010 guidelines.
IO or IV access x2, incl central venous access if immediately achievable while collecting supplies for cesarean.
Foley catheter
Leftward tilt of the bed.
Clean cesarean, extricate infant. Clean and rapid uterine repair; closures focus on hemostasis, consider packing open abdomen for the time being.
Preparation:
I’d invest few seconds to overhead-call the Trauma team, NICU/PICU on-call team (or at least the PEM attending) & to make sure the most senior OB on-call staff is coming STAT.
I’d arrange -with the help of my charge nurse- to get a full neonatal resuscitation set with warmer (if not sure it’s single fetus, I’d ask for 2 sets & 2 warmers with extra staff), to get O-ve PRBCs, platlets & FFPs (6 units each) from the blood bank & alert them to be ready to provide more products if needed, & to make sure thoracotomy & laparatomy trays are ready to go in our resuscitation bay.
1ry survey:
I’d cover the ABCDE components simultaneously with my team making it clear for every body in the room that the priorities are still the same & resuscitating the mother is resuscitation to the fetus as well..
A= immediately I’d ascertain the patency of the airway by asking the patient to state her name while inspecting for any immediate or delayed threat to the airway protection e.g. low LOC / facial truama or burn / neck trauma or burn / signs of inhalation injury ..etc. if the airway is obstructed or there are anticpated threats to its protection, I’d intubate this patient utilizing RSI but after ruling out / releiving possible tension pnemothorax. For RSI meds we got propofol & Roc. as category B but if you aren’t comfortable with them you can always use etomidate & Sux. (category C). A quick check for pupils size & reaction & any laterlizing signs before administering paralytics will help the neurosurgon. Difficult airway is the rule in such case due to C-collar / immobilization, gravid Uterus, large breasts plus short apnea time & for these reasons I’d go with my video laryngoscopy as 1st line & using LMA / I-LMA and cricothyrotomy kit as my rescue airway tools. In such hypotensive patient, a push-dose of phenylephrine will bridge your RSI but beyond that you’ll have to balance blood products & fentanyl infusions to maintain both the hemodynamics & a good level of sedation.
B= first of all assess for tension pneumothorax since this patient is gasping by inspection of chest & trachea / auscultation & percussion / use of U/S “loss of lung sliding”. after ruling out or releiving tension pneumothorax & if the patient still not intubated, I’d get a stat blood gas & I’ll have zero-tolerance for hypoxemia &/ any mid-range PCO2 levels – not borderline or frank hypercarbia – & if any is present, I’d intubate the patient right away. if chest tube insertion is indicated, I’d go 2 ICS higher. as part of extended FAST the lungs could be scanned for hemothorax & small pneumothorax as well.
C= First of all I’d put roll of towels below the long back board to releive the IVC compression but if she is still hypotensive in the setting of trauma is RED flag signaling significant blood loss & hence 2×16 f IVs should be immediately in with 2L of NS or LR running by pressure bag. I’d have a low threshold to IOs (esp. humerous) in case the IVs were difficult to obtain in timely fashion. Meanwhile, I’d assess & try to control any obvious external bleeding. Once the 2L of crystalloid are in, the blood products will follow. After assessing the abdomen for signs of perotinitis & fundal hight, the pelvis should be assessed for stability ONCE & if unstable a sheet / binder / C-clamp should be applied immediately to reduce the size & hence the blood pool in there. I’ll add a quick look @ the FHT to my usual E-FAST looking for the source of bleeding. For a hypotensive trauma patient, vasopressors are of little use and it is essential to replace the loss & control the bleeding either in ER or OR. I’d tell my team in advance that if this patient arrested, another pre-assigned experienced team member will take over leading the code before, during & after a perimortum C- section that I’ll -with the help of 1or 2 other members- prepare for & perform to salvage the baby if there is NO ROSC by the 2nd rhythm check. ACLS therapies – including DC shock- are category C with exception of amiodaron which is D.
D= I’ll try to obtain my GCS, pupils exam & gross laterlization signs before intubation. if the patient had siezure any time in the course the possibility of eclampsia should always be considered & investigated esp. if there are no past history of epilepsy & No signs of head trauma.
E= In addition to the usual back & PR exams, I’ll do PV exam with nitrazine paper test to assess for amniotic fluid leak or dilated cervix.
Adjuncts= CXR with shielding should be done & pelvis- if indicated -. a CTG monitor should be attached..