The Q Word Podcast
'Special Populations: The Pregnant Trauma Patient"
Lisa: Hello, Nyssa, how are you on this fine, still COVID quarantined day?
Nyssa: I'm doing great. How about you?
Lisa: Eh... I'm hanging in, you know. It's getting hotter up here in Boston, and there's not much air conditioning in my place of residence. So I'm rather trapped in one small room, but hey, I'm healthy, and you're healthy, and our families are doing well. Um, and, um, yeah.
Nyssa: We're all doing the best we can.
Lisa: We're doing the best we can. Exactly. So: we have a series of episodes, and -
Nyssa: Yeah, they actually were born out of COVID because classes were not able to be held in person. So this is the platform that we're using to get trauma education out in the COVID era.
Lisa: In the quaran-times!
Nyssa: Did you make that up?!
Lisa: I didn't, I can't take credit. I saw it from somebody else and I asked them the exact same question and they said that they probably read it someplace as well. But I'm gonna go ahead take it. So we are excited to be doing this series of short but quick and hopefully very informative episodes on four different types of trauma situations or special trauma populations.
Nyssa: Yeah, so our special population series focuses on these vulnerable groups that require modifications to the standard trauma assessment and interventions. So that's what we'll be focusing on is what modifications you need to make when you have these patients roll into your resus room.
Lisa: So these are the four most common types of special patients?
Nyssa: Special populations of patients, that's right.
Lisa: Special populations of patients, okay. But we're going to focus on these because the nurses are most likely - in the ER - less likely to encounter one or all of these situations at some point in time in their career, so it's nice to be armed with information about what to do when that happens.
Nyssa: But very unlikely at the same time.
Lisa: Ah, I see. Okay. All right. Let us begin. So, we've decided to start with the beginning of life in a manner of speaking and our first episode is on... Nyssa?
Nyssa: The pregnant trauma patient.
Lisa: Mmm, okay, the pregnant trauma patient. So wait, before we even get started: How pregnant? What qualifies as pregnant? I would assume somebody who just found out five minutes ago is vastly different from somebody who's about to drop that puppy.
Nyssa: Yes, you would assume correctly. And as we go through the different assessment qualities, I'll let you know when during a pregnancy you would need to consider this or the other.
Lisa: Okay. All right.
Nyssa: But you're exactly right. It can be anywhere from just now pregnant to just now about to be a mama.
Lisa: Okay, cool. And then another one? Which in a pregnant situation is most important, the mother or the baby?
Nyssa: Yeah, so that's a great question. And pregnant, a pregnant trauma patient, it's one of those distracting injuries like an amputation or a big burn, where it will get you focused on that little baby because we all love babies. And it's all, it's - you know, it's such a special time and can be very distracting. But what, what the focus should be is that in order to save that precious little baby, you have to save the mama. In order to treat that precious little baby, you have to treat the mama. So it's - it is two patients, but it's a package deal.
Lisa: Okay. And television shows will always show you the moment of truth with a doctor or the nurse has to decide that it's time to switch the attention to saving the baby. Is that in any way shape or form realistic or are we going off-topic here? I'm just curious.
Nyssa: And there is one scenario where that is true. And we will cover it.
Lisa: Oh, exciting! Well then, let's get going. Okay, so, so, so let's - so get me started. Tell me more.
Nyssa: So the first thing to know is the way that these pregnant women injure themselves. So kind of the epidemiology behind the pregnant trauma patient.
Lisa : Okay. And you told me a little bit about it. You said that there are three most - three common or the top three common reasons for why a pregnant woman would find herself in a trauma is number one: motor vehicle collision. That makes sense.
Nyssa: That's the number one cause of trauma across any population.
Lisa: Okay, cool. And now, do you wonder if it's, it's that last moment drive where the mother's giving birth in the car and then they get into a car accident on the way or this is just even your regular fender bender?
Nyssa: That's right.
Lisa: Okay, cool. All right. I've been watching too much TV during the COVID times. The second reason is a fall, which -
Nyssa: Right, so the second - the second most common is the fall. And it's this is the number one cause of minor injuries. So moms don't tend to be extremely injured. But there are multiple reasons why mamas fall, and that includes this big belly, the loosening of the joints, this altered center of gravity because of that gravid uterus, sometimes their shortness of breath, dizziness, and fatigue that comes along with pregnancy, even edema. All of these things can contribute to this minor, minor trauma, which is a fall.
Lisa: Okay, got it. All right. And then number three is an unfortunate reality that I wish I did not now know. And that is intimate partner violence as a main reason for why pregnant women are. . .
Nyssa: Right. And what the numbers tell us is up to 20% of all pregnancies, that's one in five women will experience intimate partner violence during their pregnancy.
Lisa: Wow, that's a very sad commentary on a lot of things. Okay, so now that we've established that, so I'm assuming that once you figured out how they were damaged, or hurt or injured, probably the better word. Then you went try to figure out what to do next.
Nyssa: Yeah, so let's talk about that for just a second. So with the motor vehicle collisions, what you want to know and this is information that you want to know before the patient even gets to you, if possible, is whether or not Mama was wearing a seatbelt. If she was not wearing a seatbelt, there's an increased risk of fetal death or premature birth. And then the other thing to remember is the very pregnant women like that third trimester, were they wearing the seatbelt correctly, and if you can get that information that's really important. So if they were wearing the lap belt only, or if they were wearing the lap belt too high, they're at higher increased risk for uterine rupture, and then the research tells us that really there's no difference with airbags, no difference of risk in a pregnant patient versus a non-pregnant patient, so -
Lisa: Can we go back to the seatbelt for a minute? What is the proper way to wear - as a woman who has never been and never will be pregnant - what is the right way to wear a seatbelt? What is the right way to wear a seatbelt when you're very pregnant?
Nyssa: Good. So you're gonna wear the lap belt under your gravid uterus, across your pelvis. And then you should still wear the shoulder harness. It's probably gonna slide a little bit higher, but don't use lap belt only.
Lisa: Okay, got it. All right.
Nyssa: So, when you have a penetrating injury to the abdomen, to that belly, because the uterus and the baby are there, Mama's internal organs are kind of displaced and protected. And so moms with penetrating injuries to the abdomen actually do quite well. Unfortunately, the fetus does not. If your patient has an isolated injury to the abdomen, they don't require immobilization on a long spine board or with a C collar. So that's important to know.
Nyssa: And that's pretty much all I have for epidemiology, so.
Lisa: Okay. So nothing specific about falls, or -
Nyssa: Just that all those different - the loosened joints, the shortness of breath, the dizziness, that's what, what causes the falls.
Lisa: And then intimate partner violence.
Nyssa: We'll do a blurb about that at the end.
Lisa: Okay, cool. All right. So now that we know what the - what to look out for or what to ask, or to find out about your patient when they arrive at the ER, you need to assess the situation.
Nyssa: Yeah, there's one more piece that I would say if you get in report that you're about to receive a pregnant trauma patient, then you immediately need to start making moves to get OB on board. So if you have OB in your facility, get them down into the trauma bay as quickly as possible. Nurses, have them call the on-call physician. If there is a physician in-house, bring them down. If you don't have it in your facility, then minimally, you want to get them on the phone. So you want to get OB involved, even before the patient arrives, if possible, if you know that's what's coming.
Lisa: Gotcha. Okay.
Nyssa: Third time's the charm.
Lisa: Sorry, ah, maybe we better keep this in here. Now that you have assessed, oh, yeah. Now that you know what your patients - what caused your patients to be injured in the first place, and you have contacted or at least reached out to get OB down there so that they can meet you in the ER, what's the next thing that you do?
Nyssa: Okay, so we're going to now assess our patient and we're going to go through the ABCs as you would with a regular non-pregnant trauma patient with some deviation, some exceptions.
Lisa: Okay, well remind me of what the ABCs is again.
Nyssa: So airway, breathing, circulation. Those are the top things that you always are going to assess on every patient trauma, not, pregnant, not. So for the airway. For the mom, you know, we've talked about on these episodes multiple times that oxygen is not benign. And that we should titrate the patient's oxygen to between 94 and 99, 98 or 99. This would be one exception. So we want to put a non-rebreather on mom provide her supplemental O2, and it's okay in this case, if she's at 100%.
Lisa: Got it. And we've talked about this in an episode yet to come about the 10 commandments of nursing.
Nyssa: Yes. So the reason why we leave mom on supplemental oxygen and it's okay for her to have a 100% is because we cannot measure the oxygen level of the baby and so we want to be able to provide as much oxygen as we can. The other reason is this is going to be for a very small period of time while we are resuscitating her in the trauma bay. So, so that in this case, the benefits outweigh the risks. When you are if you are, if you're pregnant patient is requiring intubation and we're going to do rapid sequence induction on her. There are no contraindications to any of the medications that we use for RSI in the pregnant patient. But just remember if you do have to perform an emergency C-section after mom has been induced with a paralytic, especially if you use a long-acting paralytic, like rocuronium that baby will be impacted. So as you or as OB or whoever delivers the baby, be aware that they may have effects of the paralytic on board and you will need to support especially their breathing.
Lisa: The baby's?
Lisa: Okay, so because -
Nyssa: As long as the baby is in, in Mama, they are fine, but if you're doing a C section right after an RSI then know that baby could be impacted by the paralytics.
Lisa: Okay, interesting.
Nyssa: So on to breathing, if mom requires a chest tube - so that would be for a pneumothorax or hemothorax - the normal place that we put a chest tube would be at the fifth intercostal space, but there's a little nugget there. So in the case of a mom with a gravid uterus, you would need to move up two rib spaces. So you would be in the third intercostal space.
Lisa: Okay. That's a great little rule of thumb.
Nyssa: Yeah, so that's going to be your provider who's inserting that but you'll just want to remind them and... So for circulation, there's quite a bit about circulation to know. The main thing is when you put a trauma patient on a long spine board and they have a gravid uterus and they're lying flat on their back, that uterus is putting pressure on the inferior vena cava and mom can develop something called inferior vena cava syndrome. And that's going to mimic hypovolemia. So she may get hypotensive she may get cold and clammy she may say that she's dizzy or queasy because that baby is laying right there on her large vessel. And so in order to accommodate for that, what we'll do, she still needs to be immobilized until her C-spine is cleared. So but she'll put a towel or a pillow up under the long spine board so that she is laying left lateral. So that, that tips that baby off of that large vessel. So we were talking about tipping her over we're talking four to six inches of, of a towel or a blanket 10 to 15 centimeters. If she has an injury that precludes her from being propped up, propped on her left side, you can do the right side. You can also manually displace that baby, just kind of move it over to the side. That's I think the least, probably the third option, the first would be the left side and then if not possible, the right side and that will help her with her venous return.
Lisa: And why the left side? It's just that most women's physiology.
Nyssa: Yeah, that's where the vena cava is.
Lisa: Okay, got it.
Nyssa: Yeah. So, vena cava is on the right side. So if you move the baby to the left side, then they're off of that. Okay, so when you are in that later trimesters of pregnancy, mom develops increased volume, blood volume, because she's providing for the baby as well. And so her heart rate's a little bit higher and her blood volume has increased, which means that it can mask hypovolemia so you want to be really diligent in watching for bleeding and watching for signs of hypovolemia.
Lisa: Is this still breathing or are we in circulation at this point?
Nyssa: In circulation.
Lisa: Okay, cool.
Nyssa: Circulation. We try to avoid vasopressors in all trauma patients, but particularly in moms, because if you're squeezing those vessels, it's going to decrease uterine blood flow, blood flow and can be detrimental to the fetus.
Lisa: So I'm going to assume that when we talk about the other three special populations, what are they? Special patients?
Nyssa: Special populations.
Lisa: Special populations that they're going to be that - that we're going to see deviations of all of these steps, these assessment tools for differently for each of them? Is that about right?
Lisa: Okay, cool. That'll be interesting to see.
Nyssa: Yeah. So when you - if your pregnant trauma patients requiring blood you want to ensure that you have O negative if at all possible. And this avoids just kind of what your guy was talking about, this avoids the Alloimmunization in RH negative moms if you haven't had a chance to have her type in crossed yet. She needs the blood now. You give O negative.
Lisa: My guy, the guy I was telling you about before we started recording the scientists that I work with that has studied something like for 50 years with all of these grants in the NIH, why the pregnant mothers body doesn't reject the fetus, which is apparently a modern miracle or not a modern miracle, but a physical miracle. That's super interesting.
Nyssa: It is. Yeah, right.
Lisa: Yes, that's what we were talking about earlier. That's my guys nice to put it together.
Nyssa: So as early as 10 weeks, so that's very early in a pregnancy, mom may not even know she's pregnant yet. But as early as 10 weeks, you should be able to take a Doppler and find fetal heart tones. So that's something you would definitely want to do in the trauma bay. A normal heart rate for the fetus would be 120 to 160. So anything less than that would be bradycardia. Anything greater than that would be tachycardia. Both of those would indicate fetal distress. So if you find that you need to make sure mom has repositioned you need to bolus her with some fluids and make sure she's got that non-rebreather on and refer yourself - to refer your patient to OB.
Lisa: I'm suddenly thinking very differently about the fact that every time I would go to my doctor at college or anyplace else, the first thing they would ask you is if you're pregnant; it makes sense I suppose at least in terms of the ER whether or not they need to plan for that particular - maybe not obvious - complication.
Nyssa: And in the beginning of the trauma before we have lab results back we have to assume that anyone of childbearing - any female of childbearing age - is in fact pregnant. So what that means is that they need x rays. We have to weigh the benefits with the risks and we're going to shield with lead apron any woman but particularly if they are obviously pregnant.
Lisa: So when we get to the bariatric episode, are we going to discuss pregnant bariatric patients?
Nyssa: Yeah, remind me and we can.
Lisa: Okay. What could we say - coming soon to a podcast near you, audience. Stay tuned, stay tuned. Thanks.
Nyssa: So, you've resuscitated your patient's airway, their breathing and their circulation. And now there are some other considerations to do further on in your secondary assessment. So you want to evaluate for contractions, you want to ask the mom, is your belly feeling tight? Is it coming and going? I had one mom because oftentimes the trauma will can induce labor. Not oftentimes, but a trauma can induce labor. And so you want to look for vague symptoms like the belly pain, but also things like back pain, you know, you don't assume that it's that uncomfortable spine board or that it's because she's laying flat hopefully you've gotten her off the board by the time you're doing your secondary assessment, but you know, ask her is it coming and going. If your patient is unresponsive, and you've had to intubate them, put your hands on their belly and see, or see if you can get the fetal monitor from OB as quickly as possible, so you want to be evaluating for contractions. You also want to have someone who is trained in it do a pelvic exam. That would be your OB, hopefully they're looking for blood and ruptured amniotic sac and maybe a little nugget like "Hey, how ya doin, here I am!" Hopefully not.
So in in cases of pregnant trauma patients, even a minor maternal injury can cause great damage to the fetus. So we talked about just a little stumble down the stairs because her center of gravity is off, could cause fetal distress or rupture. So this is where you want to assess your patient really well and reassess frequently. The Eastern, let's say, hopefully, the evidence shows that they should be admitted for six hours of observation if you haven't found any other reason to admit them, but the fact that they're pregnant trauma patient, admit them for six hours for observation and that can happen in the emergency department. Okay. For the trauma surgeons and other things that you want to know in your secondary assessment is how many pregnancies all total has this mom had? Is this her first? Is this is her fifth? How many children does she have at home, live children? And then what -
Lisa: Why does that change things?
Nyssa: So you could have a woman who's on her fifth pregnancy but has no living children, because she's had four miscarriages, that's a different mom, then there's somebody who's had four healthy children at home. So you want to know, is there a combination of those kinds of things? Did all the pregnancies end up in a healthy live birth? If not, then that's a little bit higher risk.
Lisa: Are there physiological differences between a woman that's had five children and a woman that's only had one -
Lisa: -that you also would need to consider?
Lisa: Like for C section wounds - things like that.
Nyssa: Right, that's right. You also want to know, of course, how far along she is, what is her estimated date of conception? That's important. And then has she received any prenatal care and that will help determine is this baby healthy at baseline or has something changed was something wrong with them all along?
Alright, so let's talk about a couple of ethical issues. One would be with your pediatric trauma patients that may also be a pregnant trauma patient. So oftentimes pregnancy is discovered in the emergency room as an incidental finding. A woman comes in for some other reason, it could be a trauma, it could be medical, and we do lab work and find out she's pregnant. This also happens with young girls. And this could be an incidental finding in the trauma bay on a young patient who knew it but is hiding it from her family or who may not have realized that they were pregnant. So that's going to be something to handle with care when you're discussing it with your patient. And when young people are pregnant, they have the right to determine what their parents know and what their parents don't know. So -
Lisa: That was gonna be my very next question.
Nyssa: Yes, good question.
Lisa: Well, except you didn't give me the chance to ask it, but it would have been a good question.
Nyssa: Sorry! As far as intimate partner abuse and domestic violence, I have a screening tool that is in my book, which is sitting on my kitchen table that I didn't realize I was going to refer to here. But it's a good idea to refer to - to do domestic violence screenings really on any woman. Oftentimes, we know that women come to the emergency room for things that are related to their abuse, like - but not an obvious injury. So they'll come in for migraines or GI symptoms or - that are because of the stress of being abused and if you don't ask the questions, you won't get the answers and you will miss them in a screening. So we know that the majority of domestic violence patients have been to the ER multiple times before, before it was discovered, or before they asked for help. So because we know that 20% of pregnancies experienced domestic violence, this is a high index of suspicion if the story doesn't match, or if it's a little bit strange. She may just come out and tell you. So let me go do - let me go get that screening?
Lisa: Yeah, yeah, knock yourself out.
Nyssa: All right. Okay. So your institution may have an intimate partner screening, I hope that it does. But oftentimes, those screenings are done in triage, or in the triage assessment so they could get lost or forgotten in the trauma bay, but really, in your pregnant patients, make sure that you are doing them. An example of one would be 'Have you been kicked, hit, punched, or otherwise hurt by someone within the past year? And if so, who was that person? Do you feel safe in your current relationship? Or do you feel safe in your home?' is another way to put it. And 'Is there a partner from a previous relationship who's making you feel unsafe now?' So it doesn't have to be lengthy. Definitely, if there's a partner who has come to the trauma bay, you don't want to ask in front of them. So you nurses are often very clever and crafty in thinking up an excuse for getting that partner out of the trauma bay just for a minute to run through those quick questions, and then they can come back in. So that's an important piece of your secondary assessment on your pregnant trauma patient.
Lisa: All right, so let me ask you what - I'm going to imagine like a really bad situation and tell me what you would do. So you have a young mother, she's unresponsive. She's in arrest. She has an injury both to her womb. And, and two or three, it looks like maybe she was strangled. You're unable to ask her any questions, but you get the sense that this was a domestic violence situation. What do you do now that she's unresponsive and she's already going into arrest?
Nyssa: Okay, so you have a mother arresting, a pregnant trauma patient who is arresting. So there is something called a peri-mortem C-section. So this is when, you know, initially we said that we're going to treat mom to save the baby, but it has gotten to the point where mom is arresting, and there's any chance that that baby is viable. And so here would be the criteria for viability. You are 24, 25, 26 weeks gestation or greater. So you said our mama has a big belly, right? Okay, so we may not be able to ask her exactly how far along she is, but we're guessing that she's further than 24 weeks. And also, she has an isolated injury. So if this mom has been suffering from maternal hypovolemia, she's had a lot of bleeding that baby he's been suffering from a lot of hypovolemia to and this is not going to be a good outcome. But if mom has isolated injury, for instance of brain injury and arrests, if we can perform a peri-mortem c section within four to five minutes of arrest - and obviously this would need to be someone who is skilled in C-sections who can do it quickly and adeptly, and get that baby out - there is a slim chance that we could save the baby. So this is the worst-case scenario. It's very rare. But it is, it is a possibility. And this is where, you know, we've lost mom, but we're going to try to, try to save the baby. It's a hail mary.
Lisa: It's a hail mary. Got it. But if any of those criteria were not there, you could try to save the mother, then that's the goal is to save all the life.
Nyssa: That's right, all the life.
Nyssa: So around 20 weeks gestation is where the uterus reaches the umbilicus. So if you don't have a patient who's able to tell you, that's a good, a good measurement about halfway through the pregnancy baby's not viable yet, but you should be able to get fetal heart tones easily. The uterus has reached the umbilicus.
Lisa: Okay, so this is what when you have an unresponsive Mama, you can you can make some assessment to try to gauge how -
Nyssa: Or if someone knows they're pregnant, but they're not exactly sure how far because they haven't had prenatal care. That's very common. The other thing that I will say is that in a trauma bay, often the setup has the nurse who is scribing, kind of off to the side where he or she can see the whole activity of the trauma bay. And oftentimes that patient is, they are at the patient's profile. I've been in one trauma bay in Greenville, South Carolina, where the scribe was actually up on almost like a stage or -
Yeah, where they're looking over from a bird's eye view of the trauma bay, which I think is a really cool way to do it. But this the scribe may be the one who notices in profile, 'Hey, we may need to consider this, you know, gravid uterus." And then the providers can do a quick, fast exam which is the, quick ultrasound and look and see "Do we in fact have a fetus there?"
Lisa: All right. All right. So this is the first step of our journey through special populations.
Lisa: We have started with birth, we will move on next to pediatrics.
Lisa: And we'd like to thank the - why don't you say this thing? Now listen, whatever bla bla bla bla bla bla bla just like try to name it.
Nyssa: Yeah, so it's a it's a Georgia region five trauma.
Okay, we can check it out later. Okay, cool.
Nyssa: So at least if you had three top takeaways as a non-nurse, what would be your three top takeaways that are different for a pregnant trauma patient. So Lisa, having been through this this session on pregnancy special populations, what would you as a non-nurse takeaway, as the top three tidbits for treating the pregnant trauma patient?
Lisa: Figure out how they got hurt. Tip them up on their side to protect baby and get get OB - get OB on site as quickly as possible.
Nyssa: Very good high index is sufficient with mechanism. Get ob in there early and flip her up off her side left lateral if you can.
Nyssa: Very good!
Lisa: All right. Well, I was paying attention.
Nyssa: You're promoted?
Lisa: Right? Yay. Excellent. So right.
Nyssa: So you guys, stay tuned for our series on special populations. Next, we'll have Pediatrics then Bariatrics and then Geriatrics.
Lisa: We're going to work our way through the -atrics!
Nyssa: That's right. I like it.
Lisa: Okay. We'll talk to you next time.
Nyssa: All right. Bye.