¶ Intro / Opening
Welcome to the East Stroma Cast.
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Before we get started, we'd like to say thank you to Humanetics for their generous and unrestricted grant for the Educational Resources Committee and Trump.
¶ Welcome and Physiologic Overview
Thanks for joining us today on the East Trauma Cast as we discuss pregnancy and trauma. My name's Anthony DeSantis and I'm an acute care surgery fellow at the R. Adams Cali Shock Trauma Center at the University of Maryland.
My co host today is doctor Lauren Crawl, who's an assistant professor of surgery at Indiana University. Joining us will be doctor Sigrid Burris, an associate professor in the Division of Trauma, Burns, Critical Care, and Acute Care Surgery at the University of California Irvine. doctor Burris, the first author of a recent review article on pregnancy and trauma, published in the February edition of the Journal of Trauma and Acute Care Surgery, part of their What You Need to Know series.
Also joining us is Dr. Allison Lankford, an assistant professor of maternal fetal medicine in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Maryland. doctor Langford is additionally a board certified critical care physician, and in addition to her obstetric practice, she serves as an intensivist at the R Adams Cali Shock Trauma Center. This episode is intended to be an overview of the management of the traumatically injured pregnant patient.
We'll discuss the initial evaluation and resuscitation of these patients, pregnancy-specific causes of shock, management of traumatic injuries, and appropriate monitoring following the initial presentation.
So let's jump in. Discussion of the of the pregnant patient usually starts with an overview of the physiologic differences seen in this population. So, Dr. Langford, could we start by asking you to describe how these patients are unique?
Unique.
when compared to other traumatically injured patients?
Absolutely. Thanks for having me today. It's nice to be on the podcast and talk about the traumatically injured obstetric patients, uh, something that often we encounter, but always get a little bit uncomfortable with when we do. So just to touch on the physiologic changes of pregnancy that sometimes make it very challenging in the assessment of the obstetric patient, uh number one is the increase in the cardiac output.
So these patients from a cardiovascular standpoint have an increase in their cardiac output that's primarily driven by an increase in their stroke volume. They also have a modest increase in their heart rate. and they have an expansion of their plasma volume. And these changes in the cardiovascular system generally are at their peak or their max at around the twenty-six to twenty eight weeks of gestation.
And the reason why this is so relevant is because these patients can often compensate for hemorrhage and can sort of mask some of the early signs of hemorrhagic shock that we would otherwise see in the non-obstetric patients.
¶ ABCs and Pelvic Trauma Care
Thank you so much. So Dr. Burris, with these differences in mind, how do the physiologic changes of pregnancy impact the trauma surgeon's initial evaluation and resuscitation of this patient?
Yes, thank you for having me on the episode and happy to talk about all this as we see a fair amount of pregnant trauma patients. And for those who come in after a severe injury with unknown injuries that we still need to identify, it can become a lot more challenging when there's pregnancy involved. Especially when we think about going through our ABCs with the airway starting with that.
There's a lot of edema that develops and so intubation becomes quite more challenging if that's required. Patients who are pregnant also have increased risk of aspirations because of the hormonal relaxation. of the lower esophageal sphincter. And so as we're monitoring patients uh and for the ones who potentially need to be intubated, really having the most qualified and experienced individual at the head of the bed is necessary.
I was amazed by your paper, the eight to ten times risk of failed intubation. I think we all get nervous with a pregnant patient, but I don't think I realized just how high it was until reading that and really why it matters to have that experience provider intubating that patient.
Yeah. And the challenge with the intubations is that because of the pregnancy And the decrease in our functional residual capacity, the increase in minute ventilation, and just the less time that you have to actually intubate someone because there's less respiratory reserve. uh it it just becomes more difficult to intubate and you have less time to do it. So having everything ready prior to arrival of the patient is really key.
having all of your equipment, whether that's your video laryngoscope, your bougie, again your most experienced provider and other equipment available in case the initial attempts aren't successful because with every additional attempt, there's more edema, there's fribal mucosa that then bleeds more easily. And so it becomes more and more challenging with each attempt to intubate.
I'm gonna keep going through the rest of the ABCs here.
Yeah. And so uh the other things to think about as we move on to breathing. is that the oxygen requirements of the mother are increased because of the overall increased metabolic demands. And with that, that's why we have that decreased respiratory reserve and less time to intubate our patients. So really ensuring that uh we get that supplemental oxygen on, have a rapid assessment of our ABCs.
And intubate early if needed. Especially keeping in mind, too, that our uh arterial CO2 is gonna be much lower in pregnancy. So if we're getting ABGs that show a normal
Oh no.
CO2 level, then we're really at risk for respiratory failure. And we probably need to start thinking about intubating this patient. Another consideration is uh h depending on how far along we are in a pregnancy, uh that diaphragm is gonna get displaced upwards. And so for those patients who do need thoroughcosmic tubes, going up a couple of rib spaces higher so we don't inadvertently go below the diaphragm.
And then lastly, as we get to our circulation, as was already mentioned, there's a lot of higher circulating plasma volume. And so with that higher amount of plasma volume that's circulating, it takes a longer time to recognize shock. And so being uh really mindful of uh the potential injuries that are present, uh monitoring what those blood pressures are.
And continuing to cycle them, not just looking at one blood pressure and thinking it's okay, and again, getting through our assessment rapidly as well.
So you already mentioned chest tubes. What about maybe another procedure we might be doing in the trauma bay, like placing a pelvic binder? Do you think about that differently in the pregnant patient?
Absolutely. Uh in the setting of maternal pelvic trauma, uh the whole the fetus is really in the way. Uh if we were to try to put a pelvic binder on. And so for those open book fractures, it can be quite challenging to get pelvic binders on, uh in addition not just placing it in the right spot, uh, but being able to uh compress everything appropriately because that compression With the pelvic binder is also going to compress the uterus.
which puts added pressure on the inferior vena cava and thus decreasing the preload and potentially worsening any hypotension that's present. And so if we are having to place a pelvic binder in the setting of a confirmed or presumed open book fracture, I think having that patient in left lateral decubitus or having an assistant just place that gravid uterus over as the pelvic binder is positioned is really essential.
¶ Essential Labs and Imaging Strategies
Great. And what about when we're gonna move to the next step? We're ordering labs, we're getting imaging. What should we be thinking about?
As we think about labs that we need to order, a lot of them are going to be similar to what we order in our other trauma patients with our CBC, our BMPs. But in addition to those, we also really want to get our coagulation panel and fibrinogen. Because especially if the fibrinogen is low, we're going to be much more concerned about bleeding and risk to mother and fetus. In addition, we also want to get a Kleinhauer Beckke test as well, especially if uh we're concerned that there may be
disruption of the uh fetomaternal membrane and thus uh mixing and if there's an Rh positive fetus and an Rh negative mother, then that's gonna cause problems down the road in the future. And so being able to assess that appropriately and provide rogue Am if necessary. One other consideration for labs is also getting liver function tests, especially if we're thinking about possible preoclampsia with severe features.
Doctor Langford, did you want to speak to any of the labs specifically?
I think one thing just to touch on is the assessment of the fibrinogen in pregnancy. specifically if we're looking at a patient that may have a placental abruption or disseminated intravascular coagulation, I rely a lot on the fibrinogen, which is normally elevated in pregnancy. Again
usually in a value less than two hundred to be suggestive of DIC in pregnancy as opposed to a value of less than one hundred in our non obstetric patients. So certainly when we're getting our coagulation profile including the fibrinogen.
And then anything specific, you know, on tags, since we're getting those more and more in the trauma bay that we should be looking at.
Yeah, absolutely. So a tag in the obstetric patient is often hypercoagulable. So if you're actually seeing normalization of those quality factors, that is could be concerning for a patient that is either, you know, developing DIC. So always think in pregnancy you should see more hypercoagulable uh with like a decreased R time than in your non-obstetric patients. Okay.
And then Dr. Burris, what about imaging? Where where should we head after we've ordered these labs, we've done our surveys? What's next?
Something that imaging's really gonna depend on the mechanism or the severity of injury that occurs But uh keeping in mind that if someone is in shock, you know, hypertensive, requiring blood transfusions, we're gonna image whatever we need to, regardless of pregnancy or not, right? And that might be x-rays of the pelvis, chest x-ray, or CT scan imaging as well. knowing that the first thing we need to do is support the mother so that the fetus uh remains as healthy as possible.
With that in mind, the radiation exposure obviously can have potential for field harm as well. So we do want to be careful and mindful of what we radiate and how much we radiate with shielding of the fetus when possible. so that they have the lowest uh possible radiation dose exposure. Um but with that, you know, performing a fast exam in the trauma bay and also
uh ultrasound of the fetus is really crucial. Easy to do. The sensitivity is slightly lower of a fasting SAM in pregnancy, but still overall. very good and it may take a little bit more effort to find the right windows just with uh the fetus and and the way there, but uh, you know, performing that in conjunction with the fetal ultrasound.
Will give us a sense of there's free fluid or other things that we need to be concerned about that then we need to proceed forward with in getting a CT scan of.
Dr. Langford, any kind of tips when you're doing these fast fetal ultrasound or anything that we should be looking for from the trauma side?
I think one of the most helpful things from the OB side when we were coming down and meeting with our trauma colleagues in the trauma bay when we have an injured obstetric patient is When they're doing the ultrasound, one confirmation of fetal heart rate or fetal heart tones, that's important because that's usually the first look at the fetus to assess number one whether or not it's viable.
And number two, just a gestational age. So if we're uncertain of the gestational age, not only using anatomic landmarks, but if we can either just get a quick femur length, that will often be kind of um an easy thing to assess the gestational age, but also things that help me if I know that I'm thinking I we may have to go um to the operating room, but the placental location, uh position of the fetus, which is helpful.
And then just a really crude estimate of the fluid. If the fluid appears normal or if there's no fluid at all, sometimes that can be indicative of a uterine rupture or rupture of membranes, you know, that the patient has with the Trauma has had preterm rupture of membranes.
Great.
I think we just uh just to emphasize what Dr. Burris said too about CT scans, all the guidelines, everything we're all in agreement. Get the C T scans that you think the na patient needs based upon mechanism. But the radiation is relatively small and taking care of mom is the most important.
Especially when we look at the radiation dose that is obtained. When we do the standard trauma pan scan, again, only if indicated based on your physical exam findings and and mechanism, but a non-contrast CT head, a CT of the neck uh with C spine reconstruction, CT uh chest with contrast and abdomen pelvis with contrast has less than 0.1 gray of radiation. So
very safe for any gestational age. Certainly we again need to be mindful and put the lead apron on if we're only getting, let's say, a CT head because they had loss of consciousness. or a CT of the chest because of some abnormality seen on say a chest x-ray. But within that context, it's very low radiation if the patient needs it.
¶ Pregnancy-Specific Causes of Shock
Great. So in addition to all the common reasons that trauma patients can present in shock, pregnant patients might have some other potential causes kind of driving their presentation. So can we talk for a little bit just about some of these pregnancy specific causes of shock and maybe a little bit regarding their work up and management?
So we think about all the spaces where uh bleeding can occur leading to hemorrhagic shock. We have the usual pulprits, whether it's our extremities, from a femur fracture, uh bleeding into the thigh, or hemothorax. But when we think about bleeding in the abdomen
Now that we have a fetus in there, that's going to add a whole nother dimension of potential issues that are sometimes really difficult to diagnose, especially without imaging. And that's where that ultrasound comes into use when we think about placental abruption.
or uterine eruptions. And with that, even say if you have any kind of respiratory issues, low oxygen saturations, they're decompensating from that uh standpoint, keeping in mind that an amniotic fluid embolism is also on your differential.
Dr. Lankford, any other thoughts on maybe some of the pregnancy specific pathologies that we wouldn't normally be thinking about with our non-pregnant trauma patients?
You know, I think a lot of these conditions overlap and which makes the obstetric patient so challenging in that Um, you not only with a placental abruption, in order to actually see the blood behind the placenta or, you know, greater than fifty percent of the placenta has to be abrupted essentially. So sometimes it's really difficult to detect on ultrasound. But you can still have a hemodynamically unstable patient with a placental abruption.
I think as we talked about the amniotic fluid embolism, although an extremely rare entity, but if someone were to have rupture of membranes, that's often the time around that period that it can occur. Um and that can be associated with, you know, significant cardiovascular collapse, respiratory compromise.
So always keeping that in mind and and I do think, you know, with our fast and our point of care ultrasound really assessment of the biventricular function can be really helpful in that scenario to look to see if they have any right ventricular dysfunction. And certainly there's lots of other potential causes that may have led to the accident. You know, just the patient
have some degree of hypotension related to septic shock and and that caused them to have some type of cardiac arrest or syncopol episode that led to the traumatic event. Or as we talked about before, did they have you know, severe range blood pressures in the setting of preeclampsia that led to eclampty an eclamptic seizure and that led to the traumatic event, such as a fall or a motor vehicle collision.
Anything specific we should be looking for to kind of clue us into the uterine rupture aspect? Because I feel like that's a really scary one from the trauma side of things.
Yeah, that's probably the most challenging diagnoses. I think, you know, in the very few times that I have seen that it was associated with On fast, we were unable one to even identify normal anatomy. There was no fluid around the fetus and there was free fluid in the abdomen consistent with, you know,
certainly having hemorrhage and and in that scenario the patient had a posterior uterine rupture in a um in someone that had never had a prior scar on their uterus. So I think Even if we don't know the obstetric history, a patient doesn't have to have any history of a previous uterine scar to have a uterine rupture.
Yeah. And the ones that I've seen with the uterine rupture, uh, same where the ultrasound is just does not appear normal, where again, there's no free fluid around fetus. And in that case, the fetus was actually free-floating in the abdomen. It was a unfortunate delay in presentation after a motor vehicle collision. But again, those abnormalities on ultrasound.
uh and the trauma bay as well as abnormalities on fetal monitoring are the things that'll us into do we need to go immediately to the operating room or do we need to get additional imaging such as a CT or an MRI to further evaluate for a potential placental abruption or uterine rupture.
¶ Transfusion Guidelines and Fetal Monitoring
So obviously, you know, if we're talking about a patient in shock, the next thing we're thinking about is blood transfusions. And there's been a lot of recent discussion about Whole blood versus component therapy. So, how do you approach transfusing the pregnant trauma patient? Do we need to keep anything specific in mind?
I think the first important step is recognizing that they're in hemorrhagic shock. Right. And so Just like pediatric patients, uh, pregnant trauma patients are fine until they fall off the cliff. And and so that's where we we need to prevent that from happening. So early identification and early transfusions, whether that is component therapy.
Whether it's whole blood, with or without TXA, which is off-label in pregnancy, something has to be done quickly at what the moment that we recognize that they're in shock. The whole blood is certainly up for discussion with um, you know, many studies showing the benefits of it in our general trauma population.
The challenge with it being that if it's whole blood, then it's uh usually gonna be Rh positive, which can lead to aluminization of the mother and then potential problems down the road for a second pregnancy.
I guess just a question for Dr. Lankford is, you know, hemorrhage is not unique to trauma. So in your obstetric practice, what kind of thoughts, guidelines do you have about transfusing pregnant patients that are bleeding?
Yeah, I just to echo everything Dr. Boris said in terms of the early recognition and early transfusion, as soon as I see a patient that I suspect of bleeding if they have tachycardia. In my mind, that's almost one of the later findings. You know, in general, these patients can lose up to two and a half to three liters.
before they're truly gonna have significant hypotension or decreased urine output. So really trying to um assess for the subtle signs like that tachycardia, which we know can be secondary to pain as well. So it's very challenging. But Early transfusion. The other thing that sometimes is really helpful is the fetal heart rate monitor. If you're have the ability to have continuous fetal monitoring, we always say that acts as an additional vital sign.
So if you have loss of variability in the fetal heart rate tracing, you're starting to see decelerations. Um sometimes that can be suggestive that there may be some degree of hemorrhage that's not otherwise easily seen.
And I think as we think about whether whole blood um can should be given to our pregnant trauma population, even though there is a risk of uh alleto immunization, um, the risk is quite low. And so if we have to balance the risk of persistent shock and uh poor perfusion to our end organs with uh worsened outcomes for fetus as well, versus let's say whole blood that's immediately available.
Um, I think that's where the hospital that you're working in needs to have a guideline in place and a discussion amongst the trauma surgeons, the obstetricians, and uh uh the blood bank as well to really know what we're gonna do so that that question doesn't come up in the trauma bay when the patient's already there.
And I think the other thing to add to that too is, you know, that risk of alloimmunization, we're certainly talking about subsequent pregnancies. And, you know, in this scenario right now, we're focusing on everything that we can do to stabilize the pregnant individual. So again, just having policies in place and of a discussion with the patient should whole blood be utilized, what that could mean in the future and what sort of monitoring they may need to seek in subsequent pregnancies.
¶ Adjunctive Therapies: TXA and REBOA
A little bit of Pandora's box maybe, but TXA was mentioned. So do we want to tackle that a little bit or?
Sure. The the TXA is certainly something that we give for our trauma patients that come in and hemorrhagic shock. And there's some data for its use as well in postpartum hemorrhage. TXA for hemorrhagic shock in our pregnant trauma patient is off label. And so that's I think again where we have to have those guidelines in place. Do we for someone who is obviously bleeding and we're providing them with massive blood transfusions?
Do we give them those two grams of TXA or do we use viscoelastic monitoring to guide the use of TXA?
And the only thing I add to that is, you know, if you have a patient that you suspect may have had an eclamptic seizure as the etiology of their initial injury, perhaps That's the patient that we don't use TXA in just because we know it can lower the seizure threshold. But otherwise we do use it off label in our patients that are bleeding antenatally.
great point. Thank you.
So just to follow one Pandora's box with a second Pandora's box, Reboa. Any thoughts on the use of zone three or or I guess zone one reboa in the pregnant patient?
Yeah, with the reboa, uh it's challenging question the setting of trauma, but with our goal being to take care of mother first and to address that bleeding. it may require the use of reboa, especially in zone three. We do use Reboa, especially for bleeding from placenta acrita, but that's once the baby's already been delivered that the balloon goes up in order to finish the hysterectomy and decrease the amount of blood loss.
So again, if we're having to think about severe pelvic bleeding, uh getting the patient to IR or to the operating room. coordinating everything with OB, especially if the fetus is viable and potentially requires delivery because of some issues there, then the reboa, especially in zone three, might be necessary.
Yeah, I think if we're considering the use of reboa, we are coordinating our approach for delivery. uh recognizing that as soon as we place that balloon then we have certainly, you know, minimized flow to the uterus um and the uterine arteries. So we would certainly need to move forward with delivery.
¶ Hypertensive Emergencies and Management
So everything so far we've hit was hypotension and shock. But what about the opposite of the really unique situation of the pregnant trauma patient who's hypertensive? You know, what do we need to look for? What do we need to know the bare basics from the trauma side to at least start addressing the hypertensive pregnant patient?
That's such a unique scenario that your patient comes in and it's hypertensive and if you're suspecting uh preeclampsia or really any hypertensive disorder of pregnancy things that you're looking out for is is a systolic blood pressure greater than one sixty or a diastolic blood pressure greater than one ten. Because we know not only does severe hypertension, as kind of we define it in the obstetric world, greater than one sixty,
increase the risk of placental abruption, but also can increase a patient's risk of stroke. So even at systolic blood pressures in the 150s and 160s, obstetric patients are at much greater risk.
for stroke compared to our non obstetric patients where we see much higher systolic blood pressures before they have any type of neurologic insult. So I think utilizing IV antihypertensives, I guess in our trauma patient, perhaps we would err on the side of caution and use things like low doses of IV hydrolysine.
compared to an a beta blocker that they may actually need to compensate if they let it deteriorate. So I would probably avoid the beta blockers and use more of the IV hydralizine, such as five or ten milligrams, to reduce their blood pressure or Even potentially an infusion that is easily titratable and is rapid on and off like um cardine or clavidopine.
What about magnesium? When should we reach for it? What dose? Just a quick trauma provider guide.
Sure. Yeah. So if we're suspecting pereclampsia or eclampsia, absolutely low threshold to start magnesium sulfate, it can be given IV or IM. So if you have IV access, we usually give a six gram bolus up front. followed by two grams an hour. Again, that's usually in our patients with normal renal function, which we may not have the benefit of knowing their renal function, but even in a patient that has some sort of
renal disease um and impaired creatinine, giving the bolus up front, generally we'll get them to a therapeutic level, uh, which is four point eight to eight point four milligrams per deciliter. That's the target range for patients that have preoclampsia. And then continuing a maintenance dose of two grams an hour. And if you don't have IV access, they're seizing, and you're really suspicious of preoclampsia, then you can give a total of 10 grams IM, so we give five grams in each buttocks.
I think the other thing to add with the preeclampsia is you know when a patient comes in and they're hypertensive, it's usually a somewhat nice thing. But again in our pregnant trauma patient, if they have preeclampsia, uh come in with a blood pressure of one twenty, again, that is potential relative hypotension for them, depending on if their blood pressures were running at home.
So being really mindful that that um blood pressure, although it looks good for that moment, is is potentially relative hypotension. So making sure we get through our primary and secondary uh thoroughly and rapidly. So again, if there is bleeding, that we identify it in a timely manner.
¶ Fetal Monitoring and Patient Placement
So I'd like to circle back to uh fetal monitoring. So I feel like, you know, every time we're taking care of a pregnant patient, there's always a lot of questions about this. So Can we spend a moment and just talk about who needs it, when we should be performing it, uh and just any kind of additional thoughts or points you have on fetal monitoring?
So I think one of the most important things is the assessment of viability. And again, that's gonna be somewhat institutional specific. Uh there's a period of what we call periviability that is between 22 weeks and zero days. and twenty-four weeks and six days. A lot of institutions will resuscitate as early as twenty-two weeks and zero days, and that's usually the gestational age at which we would recommend fetal monitoring. So after the
primary and secondary survey are complete, our recommendation would be for some assessment of c and continuous fetal monitoring. So you're assessing the fetal heart rate, but you're also assessing for contractions. There's kind of data to um suggest that there should be a minimum of four to six hours.
of fetal monitoring um and in the absence of contractions and a negative trauma workup, then potentially that is the patient that may be discharged home. But At our institution, if there's any signs of contractions in a any trauma patient in general were observed for twenty four hours.
And I guess I'm not sure. That's another question I have, it's maybe a little bit related, but let's say we get the pregnant patient who comes in and they have a an isolated extremity fracture. Do they go to the L and D floor? Do they go to the trauma floor with an obstetrics consult? Obviously a lot of this is going to be you know, depended upon the clinical scenario. But any kind of thoughts over ownership for lack of a better word?
I think that truly just requires a coordinated approach between the trauma team and the labor and delivery team and what each unit is comfortable with. Some institutions have the capacity to have a labor and delivery nurse monitor the patient off the floor.
Which I know always makes our trauma colleagues feel a little bit more comfortable to have a L and D nurse at the bedside doing the continuous fetal monitoring. I think if it's an isolated extremity fracture you know, that patient still does warrant prolonged fetal monitoring because they've had a mechanism that is severe enough to cause that type of injury.
The other thing that I think I I hadn't mentioned before, but if when you have a trauma patient that may require prolonged observation, there should be consideration for um what we call antenatal corticosteroids. which is two doses of steroids to facilitate fetal lung maturity should there be any type of maternal or neon or fetal decompensation warranty and delivery.
Other thing, you know, in terms of whose service does the patient go to, who does that primary monitoring? It really, as was mentioned, depends on the viability or or non viability of the fetus. And so uh you know, if s if there's a viable fetus, you know, at twenty-three weeks or so, then that in general at our institution will go to the OB4 because that requires the continuous monitoring.
especially if we're looking for uterine contractions, feel heart rate and and we want them to be in the right place that if delivery needs to occur, that they have access to all of the individuals that need to be there.
And if they're not viable, uh, but require serial abdominal exams, you know, maybe they have a uh you know abdominal wall contusion or something like that, or some mild abdominal pain, but uh we didn't scan them because the uh risks and benefits were ex explained, but they didn't want a CT scan. Then we would keep them and monitor them on the trauma service since they're non-viable to our labs and zero abdominal exams.
And I think those patients that need intensive care monitoring, certainly those are the patients that, you know, often require continuous fetal monitoring off of the labor and delivery unit. that benefit with either remote fetal monitoring or having a labor and delivery nurse in the ICU with the patient.
¶ Perimortem Cesarean Section Protocol
So one of the last things we want to talk about, it's often discussed, but fortunately rarely performed in the pregnant patient is the perimortem C section. So many trauma surgeons will never perform one, but it's obviously a topic that generates a lot of angst and discussion. So What's the who, what, one, where, and how of the Perimortem C section?
I think one of the first things that we have to recognize is that this is luckily a very rare event. And so for those rare events that will have life-altering impacts. So we want to make sure that we have guidelines in place at our institutions. to really know for whom we provide resuscitative cesarean sections and who is involved for those as well. So that everything is as coordinated as possible and with that simulations help as well.
Luckily it is rare, but for those times that we do need to perform a resuscitative hysterotomy. We want to know if this is a viable pregnancy or not. And again, in those situations, it can be challenging to get our ultrasound done, get our femur length measured, and really get an understanding of if that how far along they are in pregnancy. But again, an estimate is going to be the best
We can always do. And so if there is a maternal cardiac arrest, knowing that we want to try to do the operation within four minutes with baby being delivered at that fifth minute, but there is data. uh successful s uh outcomes with good survival rates both for mom and for the neonate, uh even as late as twenty or twenty-five minutes. So just because you're outside of that four or five minute window. doesn't mean that we can't go ahead with doing a resuscitative hysterotomy.
I'm I can talk briefly about the kind of who, what, when, uh certainly when you are faced with a maternal cardiac arrest kind of coordinating and making the decision is sometimes one of the most difficult decisions. And for those providers that may not be familiar with performing a cesarean section, certainly my recommendations are Number one, always just perform the resuscitative hysterotomy, perimortem cesarean delivery, at the location of the cardiac arrest.
one should not spend time to transfer a patient to the operating room. It should certainly be done in the location where the patient experiences the cardiac arrest. Really, there does not need to be significant sterile technique. Oftentimes we'll just if we have something that we can wash the abdomen with such as C H D or beta dyme will splash the abdomen, but even that's not necessary. And really from a instruments perspective, you really only need a scalpel.
So the technique that we teach our providers is that you want to maintain a vertical midline incision. Oftentimes this allows for improved visualization and also if there needs to be further abdominal exploration, you can always extend your incision. And then with regards to the incision on the uterus, you know, most obstetricians are the most comfortable depending on the gestational age.
if the lower uterine segment is well developed, but determining that for providers that are not familiar with assessing the lower uterine segment, again, I think it's easiest just to stay vertical on the uterus. So
Easy to remember, just stay vertical and then you you know, you're going through the more muscular layer of the uterus, which may take a little bit more time, but that's okay. That's gonna be the safest because you minimize the risk of extending your uterine incision or hysterotomy out laterally into the broad ligaments. And then delivery of the fetus immediate cut the cord and hand the neonate off to hopefully a pediatrician or a neonatal team.
And I think the one thing I forgot to mention before you even make the decision to proceed with resuscitative hysterotomy is highlighting the importance of effective chest compressions. for the patient that experienced the cardiac arrest. So number one, there's really no change in the ACLS for the maternal cardiac arrest. You same medications, same positioning of your hands.
And the one thing that you really want to remember is displacing the uterus off of the inferior vena cava. So we always describe manual left uterine displacement because we know that chest compressions with a patient that has a wedge underneath of them are not as effective. So left uterine displacement, if the patient experiences a cardiac arrest in front of you, you don't need to check the fetal heart rate per se.
That's very different if you're presented with a patient that had an out of hospital cardiac arrest that's coming into the trauma bay. Um but if a patient experiences a cardiac arrest in front of you, then Do not spend time with fetal monitoring once you've made the decision to proceed with a resuscitative hysterotomy.
Just go forward with it. And again, medications should not be altered, so epinephrine, anti uh arrhythmic should not be altered and defibrillation timing should not be altered either.
¶ Post-Resuscitation Care and Key Takeaways
Great. I think that also goes back to if we're in the position of having to deal with a maternal cardiac arrest and a resuscitative hysterotomy, you know, whether or not to proceed with a resuscitative thoracotomy, right? Um, because again, we don't know where the source of bleeding is. We do want to cross clamp aorta. So, you know, if you can do that from the abdomen, uh
that might be an option, but depending on how far along we are with pregnancy, that might be harder to do. Um so doing the resuscitative thorochotomy, uh cross clamping aorta. while a second team is uh doing the resuscitative hysterotomy and all within the context of making sure that we have good access, continuous blood transfusions as well for ongoing resuscitation.
Yeah, and you know, certainly if you achieve ROSC, which is the ultimate goal, we know that uh recessitive hysterotomy, the objective is Uh number one to restore preload and improve cardiac output, minimizing the aortocable compression and shunting blood away from the uterus. But if you do achieve ROS, You're certainly going to have pretty significant uterine atne and postpartum hemorrhage. So not only will you potentially have hemorrhage from other sources.
um such as when you're doing the resuscitative thoracotomy, but just know that you'll likely have s marked uterine atne and be prepared for that whether that's with uterine compression with, you know, other type of tamponade devices that we have, or even as Dr. DeSantis described, do we need a potential reboa to help kind of buy us some additional time to resuscitate that patient?
Great. Uh thank you. This has been great discussion. Uh Dr. Burris and Dr. Lankford, thanks so much for joining us today on the Trauma Cast. I hope our listeners feel better prepared to take care of pregnant patients when they come into the trauma bay now. Any parting thoughts before we go?
I think there's a few things. Um thank you for having us. This is really fun. And as we think about our pregnant trauma patient, for starters, I think every institution needs to have a discussion ahead of time with all of the involved providers, your trauma surgeons, our ED, our obstetricians, our neonatologists, blood bank, and so forth as to what those guidelines look like so that
when our really sick trauma patient comes in that requires all of these interventions, whether it's blood transfusions, going to the operating room, that is already outlined and defined. But with that in mind, as you go through your ABCs knowing that the airway is much more difficult, um, that they are dip more difficult to intubate. Um, when we see our CO2s on the ABGs as normal, that might signify impending respiratory failure.
And that as we think about C, um, that we may have again hypotension that is somewhat mass just because of that increased blood volume. And that takes quite a bit of blood loss, you know, the 2.5 to 3 liters before we see that represented in our vital sites. So going through our uh primary and secondary survey thoroughly and quickly so that we can identify hemorrhage and and treat it.
Yeah, and just to piggyback on that, you know, having a really uh high index of suspicion that these patients can be in hemorrhagic shock without overt evidence in um significantly altered vital signs. resuscitating the patient, whether it's with whole blood or individual components.
utilizing your coagulation profile and your functional assays for resuscitation. And if you're, you know, always thinking if if there may be a risk of delivery, whether it's immediate or in the next seven to fourteen days if you have any concerns that considering a course of antenatal corticosteroids, continuous fetal monitoring when the patient arrives.
uh and left uterine displacement in order to fa to um improve aortocable compression. And if you're ever faced with a maternal cardiac arrest, you know, uh Following ACLS but then with a consideration for resuscitative hysterotomy within four minutes of the cardiac arrest. at the location of the maternal cardiac arrest.
Thank you so much. This has been great. So this has been another edition of our East Trauma Cast, which is brought to you by the Educational Resources Committee of the Eastern Association for the Surgery of Trauma.
That wraps up another episode of the U.S.
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