Intubation should occur if the patient is unable to maintain an adequate airway, has an oxygen saturation below 94 per cent or has a GCS under 9. Aim to keep the ETCO2 reading around 30-35 mmHg in the absence of a head injury. This is normal physiology for a pregnant woman. Blood gas analysis should be used to assist setting ventilation parameters (if available). ETCO2 monitoring (if available) should also be used to assess respiratory status and adequacy of ventilation.
Always have emergency airway equipment available by the bedside.
Notify radiology staff if available of the arrival of a pregnant trauma patient. Remember that in an emergency situation the optimal resuscitation, imaging and treatment of the mother will ensure the optimal chance of fetal survival.
Most diagnostic procedures pose no substantial risk to the mother or fetus, and necessary investigations should not be delayed or avoided because of concerns for the pregnancy. Radiation risks are greatest in the early stages of pregnancy (less than eight weeks); however, it is highly unlikely that the fetal-effective dose from diagnostic or most interventional procedures will exceed 100 mSv, which is the dose range at which the possibility of fetal complications is more concerning.
CT scanning of the abdomen and pelvis may increase the total radiation dose to the fetus and therefore should be used only after a risk-benefit analysis. However, in a critically injured patient, fetal outcomes are directly related to maternal outcomes, and the best care for the mother is also the best care for the unborn child.
If it appears that the patient will require transfer to a MTS, the decision to conduct a CT prior to retrieval must be carefully considered.
Consider need for FAST if available and if staff trained in its use are present or available. In haemodynamically stable patients, FAST can be delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed.
Ultrasound may be used to: assess a large organ injury; determine the presence of peritoneal fluid or blood; calculate gestational age and fetal heart rate; assess fetal wellbeing, fetal movement and placental location; and calculate amniotic fluid volume. However, ultrasound has a low sensitivity for placental abruption and should not be used to exclude this diagnosis.
Use of antiemetic’s should be considered early, to anticipate and prevent motion sickness and reduce the known risk of aspiration especially if transfer and retrieval is likely. All antiemetic’s are safe after 8 weeks gestation, prior to this time or if gestation is unknown Ondansetron should be avoided (however evidence regarding any risk associated with Ondansetron use before 8 weeks gestation is incomplete). Effective management of vomiting, reflux and risk of aspiration is a clear priority in managing patients with trauma in early pregnancy.
Analgesia should be carefully considered for a pregnant patient suffering a traumatic injury. The drug of choice will be based on clinical signs, the need for analgesia and whether the drug crosses the placenta into the fetal circulation. Short-acting agents are generally preferred, avoiding continuous infusions.
Most opioids are considered safe for use in therapeutic doses for short periods of time during pregnancy, and many are used routinely for labour analgesia despite crossing the placenta. In most circumstances, opioids would be considered an appropriate choice for analgesia in a pregnant trauma patient. Non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated in pregnancy and should be avoided.
Advice should be sought from a pharmacist or pregnancy medication advice service where concerns exist.
Monitoring the heart rate, respiration rate, blood pressure and oxygen saturation should take place at 15/60 intervals or less if indicated. All monitoring should be maintained until the retrieval team arrives.
A baseline ECG should be taken if time permits and facilities exist prior to transfer. Additionally, fetal monitoring should be commenced if capacity exists and gestation is 24 weeks or longer.
A urinary catheter should be inserted in pregnant trauma patients and their urine output measured hourly. A urinalysis should be performed also to check for blood and protein. The desired urine output for adults is 0.5–1.0 mL/kg/hr.
All patients should be kept nil orally in the initial post-resuscitation phase of injury.
If a base of skull fracture is suspected, and with any maxillofacial injuries, insertion should be avoided until the patient is transferred to the specialist centre. Alternatively, an OGT can be placed under careful direct visualisation. Care should be taken with inserting an NGT in pregnant patients due to mucosal congestion and the added risk of epistaxis.
Antibiotic prophylaxis should occur in all open and penetrating injuries as well as when there is suspicion of any base of skull fractures. The risk of local wound infections are particularly high in patients with a penetrating injury due to the presence of contaminated foreign objects such as skin, hair or bone fragments.
The routine prophylactic use of antibiotics remains controversial.
Cephalosporins, penicillins and metronidazole are category A or B medications and are usually considered safe for use where indicated in pregnancy. Tetracyclines and aminoglycosides are category D medications and their use should generally be avoided. Consultation with the ARV clinicians and obstetric specialists is indicated regarding the choice of antibiotics.
The importance of frequent reassessment cannot be overemphasised. Deterioration in a pregnant patient can be rapid, leading to catastrophic haemorrhage, shock and other complications if not identified early. Patients should be re-evaluated at regular intervals as guided by the patient’s condition.
If in doubt about any aspect of a patient’s condition, repeat the primary survey and assessment.