Attack One responds to a report of an auto accident, with one of the patients being pregnant. On scene, the crew finds an unusual accident with one vehicle submarined under the other. There is significant damage to the lower vehicle, with the upper auto penetrating its windshield. A quick assessment notes five victims: two in the lower vehicle, two in the upper vehicle and one who's been ejected from the upper vehicle. The victims in the lower vehicle will require some minor extrication.
Personnel from the first-arriving engine stabilize both vehicles and provide a charged hose line for any potential fire, as well as perimeter control and an entrance pathway for heavy-rescue assets. The triage operation is carried out quickly, as there is relatively less injury to all patients than was anticipated from the mechanism of the accident. The ejected victim is alert and talking and complains of leg and arm pain without obvious deformity. The driver in the upper car has neck pain and lacerations. The upper car's front-seat passenger is a 25-year-old female who is approximately 38 weeks pregnant. She is still in her seat and shoulder harness and says she's not injured, just too scared to move. The victims in the lower vehicle complain of neck pain and have extensive lacerations. The Attack One crew controls bleeding in both.
The crew calls for a total of three medic units for transport. Based on her request, the pregnant female will be transported separately to the hospital that had provided her prenatal care.
The victim on the ground was ejected through a side window and landed in a grassy area, with injuries to her left arm and leg. No other injuries are noted. She can be quickly packaged and placed in the transport medic unit.
The pregnant upper-vehicle passenger, still denying any pain, is immobilized and lowered from the vehicle to the medic unit. The driver of the upper car is immobilized on a short board and brought down a ladder. Those three patients are then removed from the scene as patients in the lower automobile are extricated.
The pregnant woman smiles and converses with the crew as she's placed in the medic unit that will transport her. She is packaged quickly on a backboard and rolled onto her left side, where she says she's comfortable. This is her first pregnancy, and her obstetrician has estimated she has one more week until delivery. She's been through an unremarkable pregnancy to date, and was out with her friends to shop for some baby items. She'd felt the baby moving quite a bit over the last week. The woman says she always wears her seat belt low over her pelvis, as her doctor told her.
Her vital signs are taken and found to be normal, except for a pulse oximetry reading of 94%. The facility to which she requested transport-where her obstetrician practices and her prenatal files are located-is a community hospital that does not provide trauma services.
As the paramedic prepares to place an oxygen cannula on her, the patient's expression suddenly changes, and she says she's having severe abdominal cramping. Her pulse rate increases rapidly, and her pulse oximetry value drops into the 80s. "I think I'm going to die!" she gasps.
The medic requests an immediate change in destination to the regional trauma center, which is at least 10 minutes closer than the originally requested hospital and, fortunately, has an outstanding labor unit and a high-level neonatal intensive care service. The change in destination is explained to the patient. Her clinical condition is changing dramatically, her abdomen now rigid, and she is pale and quiet. She maintains the left-side position, receiving oxygen by mask and a liter bolus of fluid by large-bore intravenous line. The paramedic makes a crisis call to the trauma center, requests the emergency physician and relays the patient information. He asks a key question: "Where do we take her, to the ED or the Labor and Delivery area?"
In this situation, with the clinical situation of the patient explained, he is told to take her to Labor and Delivery, and the trauma team will meet them there. It will be more timely to do an immediate surgical delivery and resuscitation of the baby in that unit, rather than the ED. (It is important to note that this is a decision best made on a case-by-case basis. The decision will depend on the mother's injuries, the placement of key equipment in the hospital, the immediate availability of an obstetrician who can perform an emergency c-section, and the best site for neonatal resuscitation.)
The patient is minimally responsive as the medic pulls into the Labor and Delivery Unit. The trauma and obstetrical teams are waiting on the ramp and receive the medic's report. The patient is examined on the ramp, and an ultrasound probe placed on her abdomen. Her uterus has ruptured, and the baby is floating in the abdomen-in distress, with a heart rate over 180 beats per minute. A crisis c-section occurs as soon as she is wheeled into the delivery room.
The remainder of the accident scene is managed in a timely manner, and the two victims in the lower automobile extricated rapidly. The other four patients remain clinically stable.
The four patients with moderate injuries receive emergency department evaluation and treatment. No unexpected injuries are found, and all are released from the ED.
The pregnant woman requires extensive resuscitation from a ruptured uterus and severe hemorrhage. The lower section of her uterus had ruptured, prompting her complaints of pain. The baby was then carried out into the abdominal cavity. The woman's uterine blood vessels were hemorrhaging into the abdominal cavity also. The obstetrical team opens her abdomen to deliver the baby, hands it off for resuscitation by the neonatal crisis team and then locates the uterus. The team is able to repair the uterus and control the bleeding. The trauma team then evaluates her for other injuries and assumes responsibility for managing her shock state. She ultimately recovers completely. The child is resuscitated by the neonatal crisis team and has a relatively rapid recovery.
Three teams of hospital providers collaborated here for a good outcome with both the mother and the baby. Members of the trauma, obstetrical and neonatal teams all credited the outcome to the medic crew, which managed the patient(s) through a six-minute scene time, a seven-minute transport and a clear report to the ED physician that allowed the decision to be made to transport the patient to Labor and Delivery, where the resources were in place for an immediate c-section that saved both her and her baby.
Organization and Scene Management
Command was established, and the crews made great decisions in prioritizing care. The pregnant patient was recognized as a priority even though she had no obvious injuries and offered no complaints on assessment. Resources were allocated in a timely manner to stabilize vehicles, triage and prioritize a transport unit for the victim with the most potential for bad outcome.
The second victim with concerning mechanism of injury was the ejected young woman, and assessment placed her second on the transport priority list. The other victims could then be managed as they were removed from the vehicles.
The Right Decision
A third-term pregnant woman in a traumatic event is a potential crisis even if no immediate threats to life are identified. This can pose a very difficult decision in a multiple-casualty incident. As demonstrated by this encounter, the thin uterus of the third-trimester pregnant woman can rupture, and within seconds the lives of both the mother and the baby will be in jeopardy. The only procedure that will save either patient is an immediate c-section.
This special clinical condition deserves the utmost attention by the EMS provider. Trauma to the abdomen in a third-trimester pregnant female requires immediate transport to a hospital capable of immediate surgery. (This is community-specific!) This may or may not be the hospital where the mother has received her prenatal care. It is a situation every EMS organization should address in its protocols. In any individual case, this is a patient interaction that should be discussed with the emergency physician serving as medical control.
Another critical decision is which door to take the patient to: ED or Labor and Delivery. This must be discussed directly with medical direction, and will require precise communication about the mechanism of injury, patient condition and ETA. If the Labor and Delivery Unit is not immediately capable of a crisis surgical delivery, the patient will be directed to the ED, where the appropriate resuscitation teams and equipment will need to be brought.
Some EMS systems prepare for the care of pregnant patients beyond 20 weeks by conceptualizing two patients, mother and baby. Those two victims are often best managed by providing optimal care for the mother. Any severe pain or bleeding in the mother, or subtle signs of shock, should indicate a crisis that requires management in minutes.
What other clues from the scene or patient presentation could have helped diagnosis? From the history, a woman pregnant at 38 weeks with potential trauma to the lower abdomen from a motor vehicle accident.
Was this the only treatment path? The best management path is rapid assessment, appropriate packaging and immediate movement of the pregnant woman to a hospital prepared to do an immediate surgical delivery, should her injuries require it. This should be done without alarming the mother or her family, and with rapid communication to the emergency physician.
What communications are critical for the patient? Communication with medical control about the mechanism of injury, clinical condition of the patient and ETA will drive the decision about which hospital unit will be best for patient care. In some cases it will be the Labor and Delivery Unit. In most cases it will be the Emergency Department.
How would this case study be different with a longer travel time to the hospital? This encounter may have resulted in the death of both mother and baby if transport were longer or to a hospital not prepared to do crisis surgical delivery. Three teams are often utilized to stabilize mother and baby in these cases.
Would different equipment or medication have helped? Fluid resuscitation was the most critical prehospital intervention for both mother and baby. A pregnant woman requiring immobilization must be packaged on a long backboard, and the board then rolled to the left side to prevent the large uterus from compressing the inferior vena cava and compromising blood return to the heart.
Learning Point: Pregnant trauma-a crisis intervention requiring rapid removal to the right hospital.