Author: AlHanouv AlQahtani, KSA

I recently finished Emergency Medicine residency in KSA and continuing my training on Master of Healthcare Administration. From my little experience in working and studying Emergency Medicine, I have to admit that having such projects made things more easier and enjoyable. By using different ways of sharing knowledge, this has made a big difference in Physicians practices also in their confidence in being updated and discussing topics anywhere at anytime with everyone you can imagine. We can all benefit from each other by trying our best to find new ways in sharing/explaining knowledge in a more smoother way.

Trauma in Pregnancy

October 25, 2019October 25, 2019 ~ AlHanouv AlQahtani, KSA ~ Leave a comment

Trauma remains the leading cause of morbidity and mortality in pregnant women. It increases the risk of preterm delivery, placenta abruption, fetomaternal hemorrhage, and pregnancy loss. Motor Vehicle Accidents (MVAs) account for 70% of blunt abdominal trauma, then comes falls and direct assaults.

Evaluating and managing pregnant trauma patients requires knowing some physiological changes in pregnancy.

Physiological changes in pregnancy

Maternal blood volume increases at 10 weeks and reaches a peak level at 28 weeks (45%)
Mild anemia because of increased plasma volume (plasma > red blood cells)
Cardiac output increases by 1-1.5L/min at 10 weeks until the end of pregnancy
Heart rate increases by 10-20 beats/min at the 2nd trimester + decrease in the blood pressure (BP) by 10-15 mmHg. This explains the late deterioration in dropping BP; they may lose 30-40% of blood before signs of hypotension
Uterine blood flow = maternal mean arterial pressure
At 12 weeks, the uterus becomes an intra-abdominal organ, which is susceptible to direct injuries
The bladder becomes anterior
Gravid uterus causes stretching to the abdominal wall
At 18-20 weeks, an expanding mass of gravid uterus causes hypotension in the supine position by compressing the IVC. Avoid placing IV lines in the femoral/lower extremities.
Diaphragm elevated 4 cm, which makes the tidal volume increase by 40%, residual volume decreases by 25%, which causes the short apnea time in pregnant patients
Splenic injury is a common cause of hemorrhage

Important actions in pregnant trauma patients

Apply supplemental oxygen early because of compensation of hypoxia is limited
Consider early intubation
50% more fluids are needed for volume replacement
At 20 weeks, place wedge under the right hip, tilting to 30 degrees during the transfer on trauma board
Early nasogastric tube placement to avoid aspiration
Avoid pressors, which causes uteroplacental hypoperfusion

Rhogam (Rh immunoglobulin) and Tetanus Prophylaxis

Administer RhoD (Human Rho(D) immune globulin) to Rh-negative women; 50 mcg for <12 weeks, 300 mcg for >12 weeks. Tetanus prophylaxis is safe but considered as category C.

Images and Radiation Exposure

Do not withhold needed images. The greatest risk to fetal viability from ionizing radiation is within the first 2 weeks after conception and the highest malformation during the embryogenic organogenesis at 2-8 weeks. The risk of central nervous system teratogenesis is highest at 8-16 weeks. A dose of 5 rad is the threshold for human teratogenesis. Plain radiographs is <1 rad. Abdominal CT + Pelvic angio has the highest dose of rad (2.5-3.5). One of the critical problems is the abruption of the placenta, and CT is sensitive for abruption placenta, 86%, and has 98% specificity. The iodine contrast could cross the placenta and causing neonatal hypothyroidism.

Pelvic exam can be done only after performing an ultrasound to determine the placenta location and exclude placenta previa.

Special Tests

Vaginal fluid pH. If the pH is 7, it is amniotic fluid. If the pH is 5, it is vaginal secretions. Ferning on microscope slide = amniotic fluid.

APT ( alkali denaturation) test is qualitative evaluation to determine the presence of fetal Hg in maternal blood.

Kleihauer-Betke test measures fetal hemoglobin transfer to mothers’ blood.

Specific Issues

Direct fetal injuries

It is rare. It can be seen some injuries such as maternal pelvic fractures, direct trauma to the fetal skull.
Uterine rupture

It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.
Uterine rupture

It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.
Uterine irritability

The sign of the onset of preterm labor. Avoid using tocolytics; it causes tachycardia for both mother and fetus.
Placental abruption

1-5% from minor injuries, 40-50% of major injuries. Even simple falls can cause sudden fetal demise. Most sensitive clinical findings; uterine irritability, which can be explained by having more than 3 contractions per hour at the ED.

Fetal viability

The fetus will likely be viable at 24 weeks and above.
The normal fetal heart rate is 120-160 bpm. Heart rate below and above these limits is critical. Because ultrasound may not detect placenta abruption, nor rupture or fetal-placental injuries, high-suspicion and close monitorization are necessary.

Cardiotocography (CTG)

4-6 hours will be enough for most of the cases. Persistent contractions or uterine irritability needs an external CTG for 24 hrs. Fewer than 3 contractions per hour could indicate a safe discharge.

Indication for Emergency C-Section

Fetal tachycardia.
Lack of beat to beat on long term viability.
Late deceleration = fetal distress.

C-section has a 75% survival rate in 26 weeks or above. If the fetal heartbeats are present and the procedure was performed early, the success rate is higher.

References and Further Reading

Tintinalli, J., Stapczynski, J., Ma, O. J., Cline, D., Cydulka, R., & Meckler, G. (2010). Tintinalli’s emergency medicine: a comprehensive study guide: a comprehensive study guide. McGraw Hill Professional.

Cite this article as: AlHanouv AlQahtani, KSA, "Trauma in Pregnancy," in International Emergency Medicine Education Project, October 25, 2019, https://iem-student.org/2019/10/25/trauma-in-pregnancy/, date accessed: June 1, 2023

Some Hints About Airway!

July 17, 2019September 4, 2019 ~ AlHanouv AlQahtani, KSA ~ Leave a comment

Introduction

The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.

Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.

Here are some tips in airway management at the Emergency Department (ED)

I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal.

Preparations

Attach the patient to monitor
Check the vitals,
Check saturation continuously,
Open IV lines (2x) and attach a bag of normal saline,
If the blood pressure is low use pressure cuff on the fluid’s bag,
If the patient maintains oxygenation don’t bag, just leave the mask on. Moreover, do not forget; bagging is not a safe procedure.
Your equipment’s; choose your tube size depending on the patient’s size, size of the laryngoscope
Make capnography ready
Call the respiratory therapist, if you don’t have one, you check the ventilation machine by yourself
Keep bougie on the side, and SUCTION! Doesn’t matter Yankuer or not anymore, as long as it takes away whatever is on your way. Don’t go too deep to avoid vomiting.
Raise the bed highest, keep the level of the patient up to your chest or even higher, the higher the better.
Have someone on your side in case you needed tracheal manipulation or pressure to facilitate the view.

Pay attention to hemodynamic parameters

Never intubate before knowing the blood pressure readings.
Never intubate with low blood pressure below 90 systolic.
Resuscitate then intubate.
Neutral hemodynamic resuscitation (some studies tried the use of paralytic agent alone, with local anesthetic on the glottis, the same idea as awake intubation, in case of hemodynamic instability to avoid the use of induction agents that might decrease hemodynamics). The risk of using multiple doses of an induction agent can cause hemodynamic instability.
However, if there is no contraindication, you can think of using ketamine to help boost the blood pressure.
Double the dose of your medication if the patient has low cardiac output. As with low cardiac output, the medication won’t reach fast; it might take longer than 4 min. There is no harm in increasing paralytic agents ONLY IF THE AIRWAY IS NOT DIFFICULT. Induction agents can be used as boluses also, but again be careful if the patient is unstable as it might worsen the condition.

Here is a great video summarizing hemodynamic issues in airway management

Intubation and beyond

Use direct laryngoscopy first, use the old school equipment to keep your skills fresh, but keep the video laryngoscope ready on the side. Some experts recommends using video laryngoscope blade for direct laryngoscope and if you need, just look to the screen.
Still failed multiple trials with the laryngoscope? Consider difficult airway. One of the recommendations is to “leave the tube in the esophagus and insert another tube; the other opening is definitely the trachea.” By the way, there are tools to understand the difficulty of the airway, so know and use it.

Rapid Sequence Intubation (RSI) and Delayed RSI: Delayed RSI used mainly in the ICU, and many authors hate this term. However, there is no harm if the patient is maintaining oxygenation, you can give a sedative and look before proceeding to RSI. Just don’t call this approach “RSI.”
Rocuronium or Succinylcholine; both will paralyze the patient; it is not about which one is better; it depends on the type of airway you are dealing with. If it is a difficult airway, you do not want to use rocuronium and end up bagging the patient for one hour. Using a short-acting agent is a smart move.
However, if it is easy, use it as it would help in paralyzing the patient for an hour, but doesn’t mean the patient is fine, do not forget analgesia/sedation!
The tube is in, yay! Good for you, but your work is not done yet. All of us been through the situation where we jump into the airway, insert the tube and leave. This is not a skill lab; it is a real patient. The patient is not moving does not mean he is fine, you paralyzed him but he can still feel. Insert the tube, attach capnography, bag, auscultate, make sure of the level of the tube’s depth, order x-ray STAT then start analgesia/sedation infusion! No matter how naive you are or had a blackout, use midazolam and fentanyl! However, please learn other options too, because different patients may require different agents.
Propofol infusion, the bright side of Propofol is its analgesic and sedative effect, although it has a high risk of causing hypotension.
The dilemma of which medication to use, as for induction or paralyzing. No one can tell you that one medication is better than the other. Read everything about each medication, understand it, then you make your own mixture.

As long as you keep reading, and updating your knowledge, with of course practice and exposure to different type of situations, you will always know how to deal with every situation.