E15: Trauma in pregnancy: Perspectives and practices for clinicians

In this episode of EMERGE, I sit down with Dr. Ricky Tripp to dive deep into the challenges and best practices of managing trauma in pregnancy. As your host, I guide the conversation through the latest evidence and NAEMSP guidance, real-life stories, and practical pearls that every clinician should know when faced with these high-risk, low-frequency events.

We discuss the unique physiology of pregnancy, how to spot and manage shock, and the critical nuances of trauma assessment in pregnant patients. Dr. Tripp shares her expertise from the field, her work with AKOMA United, and her perspective as an emergency physician and EMS medical director.

I also highlight the importance of community, communication, and understanding the psychosocial factors that impact patient care. Whether you work in the field or in the hospital, this episode will help you feel more prepared and confident when caring for pregnant trauma patients. Join me for expert insights, actionable tips, and a reminder of the power of teamwork and compassion in emergency medicine.

Transcript

Mohamed: 0:00

What's up everyone? Welcome back to Emerge, where we address the intersection of emergency medicine, education, resuscitation, and global health empowerment. Today I have a special guest, but even before I introduce my guest, I want to just address some statistics that are significant for both you and I. About one in 12 pregnant women experience some sort of trauma, whether from a fall or a fender bender. Yet truly a major trauma is relatively rare, impacting just a fraction of this group or about 0.1% with a high injury severity score of more than 15. This is a very high risk, low frequency event, and this is where really your training gets tested like never before. Today's episode, spotlight the intersection of trauma, care and obstetrics, will translate the current evidence and the latest NAEMSP guidance into practical pearls, share stories from the field and discuss some cases and reveal why understanding pregnancy physiology can make all the difference in the trauma bay and the pre-hospital setting. Guiding us through this crucial topic is my friend, Dr. Tripp. So please, Ricky Tripp introduced us to you and tell us about any fun projects you're doing lately.

Dr. Tripp: 1:20

Oh, wonderful. Again Mohamed, it is a honor to be onto your show and thank you so much for the opportunity especially to talk about, trauma and dealing with pregnant women specifically in traumatic situations. And, and so I just wanted to highlight, one of the things that I do is, I am part of a nonprofit that's called AKOMA United, which is really dedicated to teaching skills to communities about lifesaving therapies such as, CPR,AED, stop the bleed training. So, we believe every life is worth saving. So that's one of the things that I do, in addition to the multiple different jobs of the emergency medicine doctor and an EMS medical director.

Mohamed: 2:08

I wanna say congratulations for your recent leadership award, Ricky. This is, as you know, only a fraction of the many things you do leading communities and systems and hospitals. and I just have a question for you. How do you find the time?

Dr. Tripp: 2:25

I was say, that's a great, question. do I don't, the interesting thing is I've learned to become a bit more efficient with my time. So I may try to do things simultaneously, or, you may see like when I have a meeting, literally I'm trying to write down everything that I think that needs to happen in the meeting. So then literally we can quickly progress through. Trying to build more efficiency, I would say with finding the time and then recognizing how can we merge different things together, because we'll find that sometimes we can be in these different silos and we can have same great ideas. And it's interesting'cause when the silos and everybody thinks that, hey, this is the new idea, but however, when we start doing more merging or really coming together, that our ideas align, that's one of the things that I do to try to interconnect, people. And that's one of the things that I try to build that efficiency with connecting people, building on programs where now we can do a combined program compared to doing multiple small programs to really. Emphasize a greater impact and, emerging different community organizations for, event. So recognizing that, I would say that, community mindset of, networking, mentorship and for us to have more engagement with each other and be more inclusive so that we're not so isolated. So that's one of the things that I try to do to maximize and optimize my time, is making sure I'm connecting folks together, aligning them and being more efficient, impactful with, a lot of different initiatives.

Mohamed: 4:14

Community building is empowering. Ricky, as you know, and this is one of the many goals that I have for this podcast, is global health empowerment because, different countries have different resources and sharing ideas of how we can improve care. It can be empowering to that nation, to that person, to that system, to that group, So this is a nice segue to the paper because this is a paper that you co-authored with, a lot of my colleagues and friends that I, recognize. And the paper is titled pre-Hospital Trauma Compendium, management of Injured Pregnant Patients, A position Statement and Resource Document of NAEMSP. This is not a trial. This is basically a review of studies. and most of these papers are either case reports or observation papers. This paper specifically addresses a very important and very high risk and low frequency event. And I'll be honest with you, Ricky, when I was reading it, I was, I started thinking about my own experience and cases that I was exposed to caring for pregnant trauma patients. It's been a while for me. I mean, I was a paramedic. Um, I was working at a, a major level one trauma center in San Antonio, Texas. Obviously residency here, university of Pittsburgh with, our big trauma centers here. And I haven't seen that much. I mean, I cared maybe for more for minor traumatic injuries, in pregnant patients, at the community and academic settings. But really true major trauma is not something that I was exposed to. I just want to hear your experience. What, when was the last time you took care of a sick pregnant trauma patient?

Dr. Tripp: 5:53

I would say for most of the injuries, about 91% of them are, blunt trauma So really a major one is vehicle accidents. And, and it's interesting because it's during different stages of pregnancy where we start having different complications that we're become worried about. Now I work at Magee Women's Hospital. And I will admit that, technically at a, at Presbyterian Hospital, that's where the, traumas for pregnant patients, are coming to. And I think for Pittsburgh, we established that, I think about four years ago, I believe. And before that,'cause I worked, I've been working at Magee for about eight years. When we did have, women that, were coming to us that were, pregnant, that had a trauma, we would really focus on, we're going to observe them. And so typically, because recognizing that. The early signs of any type of, impact, I would say, with the life of the mother, life of the baby, is really monitoring the fetus because the fetus gonna be that first initial indicator with looking at the fetal heart rate if anything is going wrong. And so when we talk about having that monitoring system for four to six hours, it's because we're really trying to make sure we're giving enough time to make sure that we're not missing something. Because when we miss something, it is so detrimental that we have two lives in our hands and if we miss something, we now could possibly end the life of the mother and the child. And we typically, and of course that's not what we wanna do. so I would say my experience. When I was, residency in Chicago and then when I came to Pittsburgh, it was, a lot of it was, really making sure that, am I doing a proper assessment? Am I doing a great evaluation? Because I would say that I did not get a most of, similar to the statistics that I said that most are blunt, traumatic injuries most. Were people who were in a motor vehicle accident or they had fallen downstairs. Blunt trauma, I would say I did not receive anyone that had any, like penetrating trauma, any type of, someone that was stabbed or had gunshot wounds as a pregnant woman. but for the most part, mine were blunt traumas. And with the blunt traumas, really, that's where you can have things that can be inconspicuous or very hidden compared to penetrating trauma traumas where you are like, yeah, bam, this is where that stab wound is. Or, woo, here are these gunshot wounds. Blunt trauma. You're like, hold up. How did this person fall? What is really the indication for us to do any further imaging that is needed? Because we have to balance, radiation risk with the benefit of recognizing do we need to explore more, especially with a head injury. So these are the different things that we have to really balance and have a really great assessment and evaluation with our physical exam findings and our history.

Mohamed: 9:12

So more nuances with blunt trauma pregnant patients as, you rightfully discussed, because this is also very important because it's sometimes it's very easy to miss an occult injury in an otherwise well looking stable pregnant women and, and I think this is also a nice segue to first understand what is normal. What is normal in pregnancy, might not be normal for me and you right now. so why is that important? And I know Ricky, you take care of a lot of pregnant patients at Magee Women's Hospital. What are some of the, uh, normal physiologic changes in pregnancy when it comes to vital signs that our audience need to know?

Dr. Tripp: 9:56

Sure, no problem. So I will say that, for a woman in pregnancy, there's gonna be different physiological changes that are happening. not only are they having a 25, 35 pound weight gain. Other things that are increasing are their blood volumes or their plasma, where now they're having more blood volume that is circulating within the system. Their heart rate cardiac output goes up, minute ventilation. So especially if you have a woman that's in her like, late second trimester, third trimester, where now she's very grave, you know that diaphragm's gonna come up and you know they're gonna start being out of breath. So their minute ventilation's gonna be a bit faster. if you ever, follow a pregnant woman, especially up the stairs, you'll see that she probably is stopping in the middle.'cause she's woo, I gotta catch my breath boy, because literally she's having a reduced capacity with her functional residual capacity. So recognizing that, gonna be more time for. this, pregnant woman to, sure that she's, you know, having oxygen because that oxygen consumption is increased now. Um, the other things that happen too, which are really, you know, pertinent when we're talking about airways and if we have to intubate a pregnant woman, is that she has delayed gastric emptying. So she's gonna have food sitting there for a longer period of time than a person who is non-pregnant. So just recognizing that there can be an aspiration risk when it comes to that. these are different things that I would say that are the normal physiological. And then, one of the things that people always ask too is, how do I know if a person is pregnant? And I will have to say, depending upon the body shape of the person, it can be difficult. It can be very challenging. However, though, there's a certain different characteristic of, how a pregnant woman's body will be. And when we're really in the first trimester, again, the baby's all included into the pelvis, so you may not see much, you may not show a little bit, a little itty bitty bump. which we basically say is maybe the size of a, like a baseball type of deal. But then when we're now going above those 12 weeks now, especially when we're going to 20 weeks, you'll see that the really, the precipice of, really the outpouching or the bump as people say, being at its height and being at the umbilicus. So that's where you typically will start seeing fully a person showing. And then of course, when we're now in like the third trimester. Late stages where, we're really in like the 38 weeks to, know, 40 weeks, you know, this person is fully gravid where, they could just eat off of their belly type of deal because they're so gr that I was in that, it is very hard ever to miss when,'cause it's interesting'cause sometimes at MAgee will have people who are checking in and so we have a separate emergency department and then a separate, triage for labor and delivery. And when people are coming in, they're like, oh, I'm in some abdominal pain. And so we have to decipher of, when they're more than 20 weeks, then they should go to labor and delivery and not stay in the emergency department if they're really coming with just abdominal pain. But it's interesting that you have some women. Who have not received any prenatal care and they'll, you know, they'll say, yeah, you I'm not really sure. So we have to really look at that physical assessment and look at how gravid this person is. And so again, if I'm seeing that height, especially at the umbilicus or anything above or now, like the breasts are sitting on that, I'm abdomen, I know they are far. Above 20 weeks. So they will go straight to labor and delivery, but just these different things when it comes to the physiological changes and the physical changes of a woman who is pregnant that we can help to decipher along with. Again, first question is, are you pregnant? And typically women will state Yes, I am. I've had a couple situations where a woman did not think that she was pregnant, and I will admit having been pregnant, I did have, a bit, lack of understanding of when I did not have a pregnancy myself, of being like, huh, I'm so curious about how you can't, you don't know that you're pregnant. And this is like women who are late, second trimester, third trimester, talking about that they didn't know that they were pregnant. and having the experience, the beauty of pregnancy along with the reflux and the kicks that get you in the nights, it's very hard for me to really, to think about someone not knowing that they're pregnant because GERD does not kick you and it does not kick your bladder. Where now you gotta go pee. So, I think what I have learned is that we have people who are more in denial that they are pregnant, where they're like, no, it just can't happen. That, that one time that we had sex that was unprotected, happen. I can't get pregnant. And sure enough. Yes, you can. So I would just say that's the different things that I would say for evaluation standpoint, know about, pregnant women when you're evaluating them and assessing them.

Mohamed: 15:32

You bring up a lot of important points. I just want to, you know, uh, mention one thing, and this is from experience. Definitely the mental health of that pregnant patient is also important to consider when reporting pregnancy because as you know, like people with schizophrenia, bipolar, substance use disorder, highly exposed patient population. Can be pregnant and not know it because either they're, have psychiatric conditions, or they just don't know lack of education as well. So we have to kinda also make sure that, uh, yes, we ask, but that answer might not be accurate. So I guess the safest way to proceed is pretend that all childbearing women are pregnant until proven otherwise.

Dr. Tripp: 16:24

That is exactly

Mohamed: 16:25

Yeah.

Dr. Tripp: 16:26

because I've had women who are consciously in denial. I've had women who are currently in depression or have schizophrenia who think that they're pregnant when they are not pregnant, or vice versa. So I will say that definitely I agree with you that anyone that is a childbearing age and really I would say anyone that is under the age of 53 that still has a uterus and, and with, along with ovaries, they are, considered as, for pregnancy. and it's interesting that I've had situations where some women have said that they have had either. PCOS, polycystic ovarian, syndrome. Or they've had, an ectopic pregnancy where they've had, or ovarian torsion where now there's been a removal of one ovary or fallopian tubes. And people have told them that the probability of pregnancy is very slim. Or even I've had some physicians tell patients that they can't get pregnant and then miraculously they do get pregnant. And some of them, that is a miracle and a blessing. And for some of them it's not. And we have to think about sometimes of how, we've had patients that are struggling trying to find ways to deal with a situation that they are currently in that depending upon what state they live in, politically, they are forced into doing different options. And and that's the other thing that we had to be on our radar too, if people have used any type of means, which could be even means that they do themselves to, upon themselves to harm, to really elicit an abortion or going to a certain service that may not be legit to have this performed. Or taking medications to try to have an abortion if they're not really desiring to continue with the pregnancy. But because of now when they have investigated this pregnancy, it may be out of the window from the state regulations of when they can have an elective abortion. Thank you so much for bringing those things up, that we have to think of all different situations that can happen, and really focus on how we communicate and ask those questions and make sure that we are asking these questions and not be afraid to ask these questions. Because the questions that we don't ask, that's information that we do not know that then can lead to more adverse, outcomes.

Mohamed: 19:14

I wanna summarize regarding pregnancy physiology and what the audience needs to know before we discuss the cases is that pregnancy for me, the way I think about it is high volume, low resistance kind of environment. So you have increased plasma volume by up to 50% increased cardiac output, increased minute ventilation and also secretions, edema, and all of these things can either alter or even impede our interventions in a pre-hospital and hospital settings. And this is why it's important that we need to modify our intervention specifically to this patient population. Before I discuss the cases, one last thing. What will be a clue to you that the pregnant patient who just suffered a major trauma in front of you is in shock?

Dr. Tripp: 20:06

So to me, if a patient is suffering shock, I would say that, depending upon the mechanism of injury. That is happening with, if a patient is saying, I'm having severe abdominal pain, and this is a person who may have fallen down a few stairs, or may have had an impact where they fell into their back or been in motor vehicle accident, where now there's an impact upon the abdomen, that's going to signal to me that I need to look for signs of shock. And the signs of shock. Really, when we talk about, perfusion, looking at capillary refill or looking at a person when they're talking about a. Airway respirations, are they having struggling with, breathing? are we talking about a person that, has any vaginal bleeding that can then can signal that we're going to possibly have a shock-like state? Now I will say that, when we talk about, shock with having, and oxygen delivery type of different, issues, that late type of symptoms would be if we started having a low blood pressure, symptoms, especially for tachycardia. And I will say that. For, for, anyone that has been any type of like trauma situation that, you can have some anxiety, you can be like so stressed and you can see that the, yes, your heart rate can go up, don't completely dismiss that, especially for a pregnant woman, that is just anxiety and stress. If you start seeing tachycardia, heart rate that is going up automatically start thinking, am I in a shock light state? And because when we go into hypotension, a pregnant woman can lose about 1.5 liters volume of blood. Before she becomes hypotensive. so recognizing that we don't wanna wait that late in the game because that's really gonna have an adverse effect upon and lead to bad outcomes for the fetus specifically because that's gonna be the most vulnerable compared to the mother. And you wanna make sure that, again, we're really preserving life of both mother and baby. We recognize that mother has to be the first priority because the baby cannot survive without mom. But I would say some of the, early signs, if a person having hypoxia, tachycardia their tachypnic, those would be early signs for different shock compared to hypotension, which would be like a later sign that we need to make sure that we are doing more early intervention when we're seeing those initial signs and those indicators, along with continuing with our monitoring.

Mohamed: 22:56

Ricky, how dare you tell me that Shock is not hypotension. The number is always accurate, Ricky. It's in front of me. it's telling me 120/80. This patient was involved in the major MVC. They're fine. Okay. So you're telling me that actually I should do some physical examination. I should examine the patient, talk to them if they're awake and responding to you. Check for those findings of tissue hypoperfusion. Because shock is not equal to hypotension, is it really? No, it is not. So this is not the test Answer. Shock is tissue hypoperfusion. Okay. So with that in mind, and thank you for putting up with my sarcasm. let's go to case one.

Dr. Tripp: 23:46

Okay.

Mohamed: 23:46

EMS responds to an MVC. So motor vehicle collisions. The patient is a 28 week pregnant. Alert talking to you, having abdominal cramping and pain with mild dizziness post the MVC when, uh, the paramedic examines them, they noticed the fundal heights up to the umbilicus and, uh, they did the initial assessment. But I just wanna want you to walk us through your seen approach with this patient.

Dr. Tripp: 24:17

Sure. So of course we all have to say scene safety first. So, making sure that the scene is safe before i, I approach on, to the scene, especially for, EMS, making sure that it's continuing being safe. the second part is gonna be your assessment. So again, we always want to do your ABCs, your airway, your breathing, your circulation, which, when we're talking about advanced trauma life support, even though I will say that if there was, and, really distinctly with this one, it's a blunt trauma. So that's why we do the ABCs compared to penetrating trauma where the ATLS may be switch to circulation or any life-threatening emergencies than airway and breathing. just wanted to make sure to put that little caveat, but for this blunt injury with a, with a motor vehicle accident. I would make sure that, was that again, I'm assessing how this airway is, how the person is breathing, what their circulation is. Recognizing, am I getting a good papillary refill? is the skin color, looking like it's, perfused very well. what is gonna be, with my heart rate and, am I getting pulses that are bilaterally, with the radial pulses? And, and then also, recognizing what stage of pregnancy I'm in. So you said that the fundal height is at the umbilicus. And so I would say that that at least tells me we're above 20 weeks, so my concern definitely is gonna be injury to the fetus along with the mother, compared to if it was less than that, like less than that 12 weeks, baby's in the pelvis. So I'm not as concerned so much about the baby. And now that we've established that we're above 20 weeks, we got our airway, breathing, circulation, then we have to, recognize, do we need to give any fluids? Do we need to, place an iv, an io? are they tachycardic? Where now we need to, give some fluids, again, recognizing that, that women, especially mothers, can really have a loss of volume that is substantial before you actually are seeing hypotension. So if they are tachycardic, making sure that we are giving IV fluids, if they are hypoxic, recognizing we need to give some, oxygen. Such with that increased ventilation that a pregnant woman's going to have. And then, and then really I would say, recognizing early, transport. And so we need to go to where the, location for, pregnant patients who have traumatic injuries, where's gonna be the best location for them to go. So what is gonna be that OB trauma center that has those capabilities, especially with OB GYN Care.

Mohamed: 27:12

So a few nuances. Obviously you mentioned ABCs. So what would be your initial target for SpO2.

Dr. Tripp: 27:21

So for the SpO2, my initial target would be above, 94, 95%. Now, for your PCO2 just because the minute ventilation a woman's gonna be blowing off of lot of carbon dioxide. Normally we'd say like 35 to 45 for a pregnant woman, you may be 30 to 35 for the PC O2 or for that end tidal CO2 that you are gonna be monitoring. so that's why I would say for the airway for breathing that, that's where I would be trying to shoot for to make sure that I am above that 94, 95% looking at some different, research. and then the, other thing I wanted to mention too, when we're talking about circulation is recognizing that again, this woman is gravid so she has a lot of pressure that is upon her IVC. And so one of the things that we wanna make sure that we've changed now modified, everyone used to say we're gonna put this pregnant woman onto her left side. So now we can, the compression of the IVC. But now we're actually doing more of a lateral displacement. So we're just basically just pushing the uterus over to the side, not really putting the woman onto her side to release that compression against that IVC. So now we're increasing that venous return coming to the heart that will help the cardiac output and with circulation.

Mohamed: 28:55

I have to bring this up because everybody loves their backboard. Okay. Every pregnant trauma patient, Ricky should be on backboard and tilted to the left side. Is that correct?

Dr. Tripp: 29:08

I was like, that used to be, but that is not. yes. So no, we do not have to have any, every pregnant patient onto a long board. Now, I will say if there is neurological type of injuries, I would say that, we can definitely do different spinal precautions for that, but however, not every pregnant woman needs to be on a spinal board. And I will say I always want to, I, tell people, and I do this for some of my EMS clinicians, I'm like, you know what? should all just get strapped into a long board see how long that we last, because I wanna see, especially some of, our, like our older EMS clinicians, already have, a little bit of some back problems unfortunately due to the length of career and, lifting and different ways that can be, inappropriate And, um, I just wanna put them on a long board and say, lemme see how you long you last. Can you last for 45 minutes. And for the most part I've been on longboard. I don't know if you've been on longboard Mohamed, but I'm telling you that sucker, I already, after 10 minutes, I was like, ee was like, Hey, can somebody ahead and me out of these straps?'cause this is uncomfortable.

Mohamed: 30:28

Yeah

Dr. Tripp: 30:28

so just recognizing, again, having that full understanding, empathy with our patients of, are there things that we need to put a person on long board. Now I will say that sometimes when it comes to, our, air medical service, for transport, there may be different situations for that. But however, to just have a blind protocol that every pregnant woman needs to be on a long board, that's completely incorrect.

Mohamed: 30:53

Yeah, I agree with you completely. A hundred percent. Okay, so summarized for this case would be establish IV access, thorough physical examination, lateral displacement of the, gravid uterus, ETCO2, to allow for that respiratory alkalosis and destination, uh, transfer as soon as possible. obviously we need to be mindful this is gonna be a trauma with OB capabilities, which not a lot of people have that access, but whatever closest to you in someone who is hemodynamically unstable. now we'll move to the dire situation or dire case scenario here. So the EMS crew responds to now to a pregnant woman in active cardiac arrest after a fall, and they do all the things we just discussed. What is a specific consideration in a arrest or in a trauma pregnant woman who is now in cardiac arrest?

Dr. Tripp: 31:55

Whew. Yeah, that's a bad situation. so I would say the, besides looking at, are there any reversible causes for this cardiac arresting, depending upon different rhythm that you're having, what needs to be treated? The big thing, especially a recognizing if this person is above those 20 weeks. If you are having that fundal height at the umbilicus, you're in a cardiac arrest, you still wanna do that lateral displacement of the, gravid uterus. having someone to help with that, while we're doing CPR and ACLS resuscitation, but we also have to prepare for, do we need to do resuscitative hysterectomy, which is basically where we're going to take the baby out of the mother. When you remove the baby, remember we talked about that compression against the IVC. So now you're having in the venous return coming to the heart and circulating volume to the heart. And when you do resuscitative hysterectomy, you are literally now removing that compression. Now we improve the cardiac output by at least 30%. So now that increases the chances of saving the life of the baby and the mother when we do that resuscitative hysterectomy. Now again, this needs to be done within four minutes of the cardiac arrest. So it's really quick thinking that needs to happen and prepare for if that's what the decision is gonna be made.

Mohamed: 33:24

The initial, uh, perception is that we're just gonna try to save the baby. The mom is already dead. That's the initial assumption, because we're not gonna say mom anymore. But this is like that to me, like exactly what you're saying. We're taking the baby out to allow mom a chance to recover from this while we fix the cause of this cardiac arrest. Whether it stop the bleed or give more blood, or, you know, do another surgery or something like that. But again, the mom has a chance to live in addition to the baby, especially nowadays that we have really good care in the sick, uh, neonatal, period too. This has to be done or performed by an EMS physician, correct?

Dr. Tripp: 34:08

I would say for the most part, yes. Now I will say the different regions, possibly in Texas per se, where, there can be different protocols that are given, for different scope of practice for, EMS clinicians. But I would say for the most part, this would be done by a physician on scene. And typically, when you know it is being taught, because I will say that there's not a lot of simulation exercises when you're doing a RH. It literally is grab the scalpel. You're gonna do a midline and incision really from like the xiphoid. And you're literally going to dissect all the way down to the uterus. You're gonna pop that uterus on out and we're gonna perform. A and typically we try to do a low transverse incision when it comes to the uterus itself, just, and we are going to then pop that baby out. And so that's one of the things that, we're taught to do and doing this with that whole process. And again, we're doing it within four minutes of an arrest, but we're doing the full RH about one minute to do just recognizing how quickly the process is. And, and again, we can always, suture up the mother, things of that nature, do any packing that needs to happen once the baby is out. We're trying to save the life of both the mother and the baby.

Mohamed: 35:34

And for those systems that don't have an EMS position like you and I having in Pennsylvania, it's very important that the crew expedites transport with advanced notification to a center that can perform the procedure. And it's important also for the system to have already planned kind of preparation, uh, algorithm or system in place to allow for rapid transport and notification of these sick trauma, pregnant patients, especially the ones that, that are suffering cardiac arrest. Now, I love TXA. You love TXA. We give it for multiple reasons. Is TXA contraindicated in pregnant patients and can we give TXA in the field?

Dr. Tripp: 36:16

we can give TXA. I will say that, TXA, definitely has been shown and proven time and time again to really help with, stopping significant hemorrhage. especially if you're giving it within three hours and improves, you know, patient outcomes. And that's for non-pregnant and for pregnant patients. Now, I will say that there hasn't been, when talked to pregnant patients, the studies have been focused on, C-section. So having bleeding from, cesarean sections, not so many, cases related to, traumatic pregnant patients. But however, just looking at the current evidence, there really has not been shown to be any, mortality, to the mother and to the baby from at least some of the instances that. We are, really reviewing. so I would say at least for overall right now, we are saying that it is a benefit and, not harmful, at least currently to the mother and the baby if we do administer, TXA. So I would say that TXA is okay with me.

Mohamed: 37:29

So TXA is okay with Ricky is okay with me as well. I tell you give it early. Um, and the dose is usually a gram over 10 minutes.

Dr. Tripp: 37:43

Yes, exactly. yes. So at least over 10 minutes that you're gonna give that one gram, was, and you wanna make sure that you're giving it within three hours, if you can, to optimize the effect. Now, I would say if it's beyond three hours and the person is still having significant bleeding, please give the TXA. but we just give you guidelines, what are the optimal treatment. But again, TXA is gonna be beneficial if you're having, profuse bleeding that's coming from a traumatic injury.

Mohamed: 38:14

A lot of EMS agencies now are starting to carry blood in the field. just give us a little bit of why we need to pay attention to the type of blood we give, to these patients.

Dr. Tripp: 38:27

So for pregnant women, because some pregnant women can be RH negative, so this would be your a negative O negative B negative, pregnant mothers that, for the most part when we're looking at, blood types, that typically, because again, when you're looking at has chromosome for not only mom, but also from the father. And so there's a high probability that even though the mother may be RH negative, that the baby may be RH positive. And when we talk about. RH isoimmunization. And so that's basically when there could be an intermix of the maternal blood and the fetal blood mixing together. And those antibodies unfortunately each other and that can lead to, really bad outcomes So we try to prevent that by giving RH negative mothers Rhogam, and that's where Rhogam comes into play. And so you wanna give RhoGAM as soon as possible if you do recognize that there has been some bleeding that is happening where there could be the chance of intermixing of the blood. And along with that, we wanna give blood. so giving blood, if we give o negative blood, that's universally gonna be okay for every pregnant patient. Now, I will say that there are some situations where you don't have O negative blood, you have o positive blood. You can still give the O positive blood, but just recognizing that we need to give that Rhogam as soon as possible when we're arriving in the ED and making sure that we're giving that report to the emergency department. if we don't know the blood type, or if we don't know the blood type of the mother, if we do know the blood type of being mom, being a positive, if we give o positive blood, we know that's gonna be okay. But if we don't know that blood type, we always have to have the precaution. So giving Rhogam is gonna be safe even if we're giving it to a person that, an A positive or O positive, or B positive, A, B positive. blood as the, mother. the other thing I wanted to say too is, know, making sure that we do place tourniquets when there, you know, is any type of bleeding that we can see visibly, that our tourniquet can help. So making sure that we are placing tourniquets, we're giving TXA, we're giving blood, those are gonna be the big things that we want to really optimize circulation for both the mother and the baby.

Mohamed: 41:00

The main message to our field clinicians. Give blood, whatever you have, give it. And then we will take care of the isoimmunization possibility in the hospital, but they need blood. So give it, don't delay it, just consider the specific blood type. If the mom knows it, that'd be awesome. Some others do know the blood type, and this is a good information to relate to the hospital. Now, uh, let's stick with the same sick trauma patients like we just discussing, needing blood, needing TXA and, uh, one of the physical exam findings is unstable pelvis, maybe some hematoma there, maybe blood coming from the meatus, or the vagina even. So what are some consideration in caring for this subset of patients?

Dr. Tripp: 41:48

I will say that you can definitely, unfortunately lose, like I think one to two liters of blood into the pelvis. And and one of the things we always talk about is that open book pelvic fracture, where now literally you have some, unfortunately lacerations or slicing of the vasculature and the pelvis that is now leading to this perfuse bleeding. I would say that, we typically do for non-pregnant patients is putting a pelvic binder on, and you still will do the same thing for a pregnant patient. So putting a pelvic binder on is gonna be as essential and helpful really again for, helping to build that compression so that we at least can help to stop that profuse bleeding that's happening within the pelvis. So it has been shown that definitely you can use a pelvic binder to help when it comes to, any suspicion of a pelvic fracture that could be leading to, some, bleeding that is happening within the pelvis.

Mohamed: 42:50

Place a pelvic binder at the level of the greter trochanters. And then a also in the paper mentioned that the toes or the feet needs to be placed together. Kind of like rotated a little bit medially. So the same sick trauma patient got a pelvic binder, uh, got TXA, got blood, and now they also have burn and burn injuries up to 25%. This is a sick trauma patient and they're definitely coming to you, Dr. Tripp, because they know you're the best doctor that would take care of them. What are they gonna do about the burn now? The burn is involving upper extremities, uh, the, some of the anterior abdomen as well in it's like 25%, total burn surface area.

Dr. Tripp: 43:38

I have to say, first of all, this patient is not having a good day, and that's, preface that. for this particular patient that not only has active, bleeding hemorrhaging, now having a burn inhalation injury, and burns upon, across the body, would say that, as we've already gone through our ABCs. And we're given the blood. I gave the TXA put tourniquet on as need be, put a pelvic binder on to really help to stabilize. And now thinking now we're going into our whole exposure and looking at, and given oxygen and also looking at the body for any burn wounds, you still want to do your calculations and of, the percentage of service area that has been burned and really recognizing, this a superficial, this a partial thickness burn. Is this a full thickness burn that is happening because our partial thickness is where we're really and full thickness are gonna be the burns that we're really concerned about, especially those that are circumferential. where we may had to do an escharotomy but I would say that at least for on the pre-hospital setting, when we're analyzing the presented surface area that is burned, recognizing that, when we have a gravid uterus that we need to increase, really our percentage, really recognizing for when we're giving IV fluids by about 30%. people typically use the Parkland formula, but we need to actually add additional fluid onto that just because of the gravid, abdomen having a greater surface area that people may not understand or, Because if we do the regular Parkland formula without adding in that 30%, we're typically under, our fluid resuscitation goals. So that's why this helps to really improve that. The other things, especially for any burn inhalation injuries, we're worried about carbon monoxide poisoning, recognizing that, this, pregnant woman having any altered mental status, is she having any type of confusion?'cause typically in the prehospital setting, we can't really measure carbon monoxide levels. But however, if now this person's having any neurological kind of deficits along with having confusion, we can tell that, along with having some hypoxia, that this could be a carbon monoxide, poisoning that. We need to now have a hyperbaric oxygen chamber. And so now we need to go to, not only, this burn center that hopefully also has a hyperbaric oxygen, which tank, so the HBO. and then for cyanide, for the, hydroxocobalamin gonna be safe in pregnancy. So you can already, that if there is any suspicion that there may be, cyanide posoining in addition.

Mohamed: 46:39

If you have that ability to transfer a patient to a hyperbaric center, know exactly where that center is. Uh, sometimes can also be important, especially in CO poisoning exposure. And you mentioned, uh, cyanide exposure and poisoning. So if you have access to hydroxocobalamin, they also need to be administered that too in order to prevent, uh, severe hypoxia, death. All the other complications. Briefly, Ricky pain medication and pain management. So pregnant female, of course, we are not allowed to give them acetaminophen. Is that right?

Dr. Tripp: 47:19

Oh, no. So to say, at least from the current studies, and again, these are studies like hundreds and thousands of pregnant women with getting Tylenol, that it has not led to any adverse reaction. what has really led to adverse reactions when we don't treat the pain for pregnant women where now we're having preterm labor, where, literally can lead to, a worsening of, outcomes for the fetus when it comes to delivery. So giving Tylenol for pain relief has actually led to improved health outcomes. I would say that Tylenol is always gonna be your first, treatment medication to give. And, and we give IV Tylenol, all the time we at Magee Women's Hospital. Now, I will say that again, we don't wanna do any NSAIDs now when we do any NSAIDs now that is actually has research showing that is led to having adverse effects upon the fetus. And so that's why we did not give any NSAIDs, all. So no Motrin, no Advil, no Toradol. And that's why, when people are like, oh, can I get the toradol? I'm like, wait a minute. Is this person pregnant because that is truly contraindicated in pregnancy. the other thing, so if we give Tylenol and that's not working and people are saying, now what else can I give? And we can give opioids, but just recognizing that opioids similar to what they would do for, a non-pregnant person, is that it can lead to some respiratory depression. And that can also be for the fetus, along with having bradycardia for the fetus. And so that's why we are very cautious when we are giving narcotic medications to pregnant women because that effect is gonna be onto the fetus also.

Mohamed: 49:13

In a setting of severe trauma, so we need to treat the pain. Don't be hesitant about giving Acetaminophen iv, if you have access to that medication or an IV analgesic such as, uh, fentanyl IV morphine. But it's a good habit to always tell the receiving center that you gave IV analgesia in case that baby needs to be delivered, imminently. And they can be prepared for, uh, decreased respiratory drive. for the sake of time, just last but not least, uh, high risk refusals. I know I can have another podcast episode on refusals on Refusals period, but let's say in this setting, you know, maybe minor to moderate trauma, the pregnant women obviously has the capacity to refuse, and she doesn't wanna be, she doesn't wanna be evaluated in the hospital. What are some of the things that prehospital clinicians need to make sure they covered? And in terms of from a liability standpoint, what are the things that you care about as a clinician as well?

Dr. Tripp: 50:17

The first thing that I wanna make sure that a, patient is understanding all the risks involved recognizing that even with minor trauma, 5% of that can lead to placenta abruption when we looked at the different studies. So even minor trauma where a person is having a fall from standing, that can still lead to adverse outcomes for the mother and for the baby. So first, having the person having an understanding of the risks of not being evaluated in the hospital, but then also what are the reasons why they're not coming to the hospital or afraid to come to the hospital? Is it because they've had maltreatment in the past at that particular hospital are with providers where they did not feel respected or they felt that they were being judged. Is it because they're worried about financial reasons, the cost of going into that hospital, they're trying to just even afford for food on the table, keeping the lights on. Is it because they don't feel that it's really important? They feel as though that it's not necessary. So trying to understand the reasons why a person does not wanna come to the hospital, be transported. That's one of the number one things I teach my EMS Clinicians, along with let's talk about the full information and making sure a person has the understanding of the risks involved, that they don't have that evaluation. then, and the other thing from the EMS clinician side is to recognize, is this person also afraid to go because of intimate partner violence, and that's one of the things that sometimes gets overlooked when we're really thinking or coming onto the scene for traumas. Is there a situation that this person was pushed down the stairs or this person was kicked? Punched in the abdomen, by that, partner who literally is hovering over them and they are responding in a certain way because they're afraid that they're going to have an additional assault if they don't answer questions correctly. So we have to be very cognizant and aware by the actions of the patients with their partner and, recognizing are they really timid? Are they looking as confirmation to this partner every time that they're answering a question, are they looking down so they can avoid contact with anyone because they don't want to lie per se, but however they know that whatever they say, because they're an unsafe situation, don't want it to become worse. So that's the other things that we have to be cognizant of when we are evaluating patients that have any trauma.

Mohamed: 53:13

So many important points. I'm gonna try to do my best, Ricky to summarize. Cause ultimately, Ricky is not really about caring for just the injury. it's also recognizing the whole system and the environment and the other important factors, the psychosocial factors, the, like I said, the resources and. Also crew support. So today's discussion illuminated the complexity and importance of pre-hospital care for pregnant trauma patients. So the lessons that I learned today be systemic. Always check for pregnancy and estimate gestational age. Prioritize the left lateral uterine displacement from 20 weeks onward. Anticipate atypical presentations of shock. Don't just trust the blood pressure, tailor your interventions, everything from area maneuvers, suctioning to hemorrhage control, and safe analgesia. Don't make these patients suffer on the way to the hospital. Remember, resuscitative hysterectomy within four minutes. If you have the resources from an EMS physician. This can save lives or have a system. That can allow for prompt hospital notification to allow for availability of resources. Lastly, counsel, patients on risk, advocate for injury prevention and remain vigilant for intimate partner violence. Let's not forget finally, about EMS team's wellbeing and, specifically their psychological support caring for these high acuity patients. Anything else I missed? Ricky, anything else you want to add?

Dr. Tripp: 55:04

No, I was gonna say, I think you highlighted everything, and I think big thing too is don't be afraid. Of when you're taking care of a pregnant patient. I think a lot of times people are very timid and they're like, oh no, I really don't know what to do'cause they're pregnant. But I would say, recognizing your, your airway, your breathing, your circulation, your ABCs are gonna be the same for a pregnant patient and not pregnant patient for your evaluation. Now, your interventions, you have to just be understanding the physiological changes where some adaptations or your interventions will be. But again, you still wanna make sure that, as you said, Mohamed, the optimizing the care for the mother, which will then lead to optimizing the care for the baby. And so I think. we're looking at, pregnant patients that we don't look at them as fearful or that we don't know what to do, but that we really practice, confidence and encourage, Exercises simulation to really get past that fear so that when you do, have a call that is a traumatic pregnant patient, that you are completely vigilant to look for those early signs of shock, to look for those different, things that physiologically can be changed during a pregnancy that you need to make sure that you're having early interventions for. And, and really also, reasons why, a person may not wanna go to the hospital because there can be a multitude of different complications that can happen, from the person having, previous experiences that may have been negative compared to, having intimate partner violence compared to having different socioeconomic When we talk about those social drivers of health, we have to think about and consider that where people don't feel that they have the finances to really support having that evaluation, but really encouraging them of what is their goal. Their goal, for the most part, is a person who is desiring their pregnancy, is to help a healthy baby and for them to be a healthy mother to live after that delivery so they can take care of that baby. So really emphasize that, especially to the patient of, we have a common goal, which is to help you have a healthy baby and for you to be a healthy mom.

Mohamed: 57:32

Thank you Ricky, for discussing this paper with me.

Dr. Tripp: 57:35

Thank you. Thank you so much, Mohamed. It was a pleasure and honor and I truly, am so thankful to have you as a friend and and definitely appreciate everything that you do and your leadership.