TRANSITION SERIES
Topics for the Advanced EMT
CHAPTER
43
Trauma in Special
Populations: Pregnancy
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.
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.
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.
The anatomy of pregnancy
Pathophysiology
• Complications of Trauma: Uterine
Contractions
– Most common complication.
– May progress to preterm labor.
– Monitor quality of contractions.
Pathophysiology (cont’d)
• Complications of Trauma: Preterm
Labor
– Occurs before 38th week of gestation.
– Fetus viable following the 24th week of
gestation.
Pathophysiology (cont’d)
• Complications of Trauma: Spontaneous
Abortion
– Occurs before the 20th week of
gestation.
– Common findings include abdominal
pain, cramping, vaginal bleeding.
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.
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.
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.
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
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.
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.
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.
Assessment Findings (cont’d)
• Questions should include:
– Due date, gestational age, fetal
movement, contractions, previous
obstetric history.
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.
Emergency Medical Care (cont’d)
• Determine breathing adequacy.
– High-flow via NRB with adequate
breathing.
– High-flow via PPV @ 10–12/min if
inadequate.
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.
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.
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.
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?
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.
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.
Case Study (cont’d)
• Primary Assessment Findings
– Peripheral skin cool and slightly
diaphoretic.
– Hemorrhage to proximal femoral shaft
fracture that is open.
Case Study (cont’d)
• Is this patient a high or low priority?
Why?
• What interventions should be provided
at this time?
Case Study (cont’d)
• Medical History
– Unknown other than patient is pregnant
• Medications
– Unknown
• Allergies
– Unknown
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.
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?
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
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.
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.
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.