Maternal Trauma and Cardiac Arrest 18.05.2023 v3.pdf

Maternal trauma and cardiac arrest Roles and responsibilities Maternal anatomy and physiology Assessment and management Objectives Understand the anatomy, physiology and assessment of maternity patients Understand the assessment and management considerations of pregnant trauma patient...

Maternal trauma and cardiac arrest Roles and responsibilities Maternal anatomy and physiology Assessment and management Objectives Understand the anatomy, physiology and assessment of maternity patients Understand the assessment and management considerations of pregnant trauma patients Outline the key modifications when managing a pregnant patient who has experienced trauma and/or is in cardiac arrest London Ambulance Service NHS Trust 2 Background In the UK: - Cardiac disease is the leading indirect cause of maternal death (however pregnancy is likely to exacerbate pre-existing conditions) - 5% of maternal deaths are caused by trauma - Most deaths occur in the early post-natal period (within 42 days of birth) Maternal mortality in London is double national rates London Ambulance Service NHS Trust 3 Maternal considerations in trauma Risk of compression of inferior vena cava >20 weeks gestation (requires manual uterine displacement) Signs of shock may be slow to appear (Hypovolaemia may not be clinically evident until >35% blood volume lost) High risk of placental abruption – may occur up to 3-4 days after an incident (falls, RTCs and assaults are most common causes of maternal trauma) Safeguarding must be considered if domestic/sexual abuse are suspected London Ambulance Service NHS Trust 4 Maternal physiology Blood volume and cardiac output increases by 50% Blood pressure decreases by 10mmHg Growing uterus compresses the aorta and the inferior vena cava Vessels retain fluid, oedema of the larynx can result in a difficult airway London Ambulance Service NHS Trust 5 What does this mean? NEWS2 is not validated for use in pregnancy Maternity patients compensate well- abnormal observations are a late sign of deterioration We have a lower threshold for conveyance in maternity than with the general population London Ambulance Service NHS Trust 6 Red flags Primary survey problems Increased RR >21 (first vital sign change to occur) Increased HR >110 Abdominal pain Vaginal blood loss Reduced fetal movements Hypotension (last vital sign change to occur) London Ambulance Service NHS Trust 8 Management DR CAcBCDE – Correct any problems and don relevant PPE. Request police if required Consider paramedic/HEMS assistance/Advanced Paramedic and Second Crew Look for: Major primary survey problems If present = TIME CRITICAL Haemodynamic compromise Undertake blue light transfer with pre-alert. Decreased LOC Ascertain MOI Assess the capacity of the patient and gain consent London Ambulance Service NHS Trust 9  Examine the abdomen for external injuries Administer oxygen as per JRCALC Monitor vital signs and ECG Apply relevant dressing at a time that is appropriate Analgesia as required – Entonox Consider other injuries Transport to an appropriate hospital - Use major trauma tree – Step 4 special consideration - Use maternal assessment card Bring patient’s notes if available London Ambulance Service NHS Trust 10 Optimisation In a pregnancy >20 weeks gestation there is a risk of the uterus compressing the vena cava and aorta, therefore reducing blood supply to the fetus. Any conscious woman >20 weeks pregnant should be transported in a lateral position, if compromised When fully immobilised the stable woman should be tilted to the patients left or right on the long board London Ambulance Service NHS Trust 11 Manual Uterine Displacement If the woman has a significant decreased level of consciousness then her uterus can be manually displaced to the maternal left hand side. This will need to be maintained so call for second crew early This must be recorded on the ePCR London Ambulance Service NHS Trust 12 Additional history required Any abdominal pain? Where? Is it constant? Any vaginal blood loss? Revealed/Concealed? How many weeks pregnant? Fundal height? Any complications/problems so far during the pregnancy? When did they last feel fetal movements? Pregnancy notes? London Ambulance Service NHS Trust 13 Advanced Clinical Interventions If a pregnant woman is exhibiting any signs of shock then advanced clinical assistance will be required – early call for help (paramedic/APP) or immediate transfer to an obstetric unit/ED/MTC as appropriate DO NOT DELAY ON SCENE WAITING FOR ASSISTANCE London Ambulance Service NHS Trust 14 Maternal Cardiac Arrest Causes? Heart failure Hypovolaemia Anaphylaxis Embolism Sepsis London Ambulance Service NHS Trust 15 Management Over 20 weeks (in absence of known gestation, visibly pregnant or fundus palpable at umbilicus)→ Manual displacement ALS Early call to critical care and HEMS Aim is to increase probability of ROSC by reducing aortocaval compression. To save mother. London Ambulance Service NHS Trust 16 Communication Pre-alert Hand-over Situation – Identify yourself and your role, describe your concern including the red flag. Background – State the reason for admission, summarise relevant history, state the risk status if known Assessment – A-G Assessment and clinical impression Why SBAR? Recommendation – Explain what you need and be specific London Ambulance Service NHS Trust 17  Maternal traumas and cardiac arrest require an URGENT datix to allow the maternity team to complete a rapid review alongside the receiving maternity unit. Want to know more? Further information and CPD opportunities: JRCALC PLUS Maternity Lead CTMs- one for each group station Monthly maternity webinars- advertised on LiA and on The Pulse The Pulse- Maternity page Maternity Care Policy- The Pulse MBRRACE reports: www.npeu.ox.ac.uk/mbrrace-uk London Ambulance Service NHS Trust 19 Summary Maternity patients have altered physiology- signs and symptoms are often a late sign of decompensation Remember additional systematic pressures of a pregnancy (large uterus, higher cardiac output) Make a safeguarding referral whenever abuse is suspected Call for help early, but do not wait on scene if additional resources are delayed (balance of risk) London Ambulance Service NHS Trust 20