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A 35-year-old pregnant woman, approximately 36 weeks gestation, is admitted to the emergency department (ED) following a motor vehicle crash. She has a closed head injury, bilateral femoral fractures, and possible abdominal trauma. Her Glasgow Coma Scale (GCS) score is 5: she does not open her eyes (1); there is no audible vocalization (1); and she is showing decorticate rigidity (3). Her heart rate is 135 beats per minute, blood pressure is 85/40 mmHg, and respiratory rate is 40 breaths per minute and shallow. Fetal heart rate (FHR) is 110 beats per minute. Her oxygen saturation (SaO2) is 90% on a non-rebreathing oxygen mask. A cervical collar is in place and Thomas splints are being applied to both legs.
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INITIAL ASSESSMENT OF THE PATIENT
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What Are the Immediate Evaluation and Management Priorities in This Patient?
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Initial evaluation and management priorities for the near-term parturient are no different than any other trauma victim—assessment of airway, breathing, and circulation (ABCs), followed by a secondary survey, including assessment of the abdomen and fetus.
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Unique considerations related to the pregnancy, such as supine hypotensive syndrome and the significant capillary engorgement of the nasal and oropharyngeal mucosa, may impact positioning, hemodynamics, and airway management.1
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Immediate attention is directed to the airway. Her GCS and oxygen saturations mandate endotracheal intubation and ventilation. She is not a crash airway, and therefore, there is time for an airway evaluation utilizing the MOANS, LEMON, CRANE, RODS, and SHORT mnemonics (see Chapter 1). In this particular patient, difficulty should be anticipated and an approach as suggested in the Difficult Airway Algorithm (see Chapter 2) adopted; recognizing that parturients at term have a substantially elevated risk of aspiration, particularly in this circumstance where protective airway reflexes are compromised and the patient is not responding to commands.
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Following airway management, attention is directed to an assessment of breathing. Her lung fields must be evaluated for presence, equality, and quality of breath sounds. This evaluation, coupled with a stat portable chest X-ray, may uncover a pneumothorax and/or hemothorax that may require treatment.
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In pregnancy, minute ventilation is normally increased by approximately 45%, largely through an increase in tidal volume. This increased minute ventilation results in a fall in PaCO2 to approximately 30 mmHg. Therefore, one should initially (moderately and empirically) hyperventilate this patient. Ventilation may be guided by arterial blood gases, once resuscitation has been established.
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Pregnant women should be considered to have a full stomach after 18 weeks gestation. There is an increase in gastric acid production, which results in both an increase in gastric fluid volume and a decrease in pH. Coupled with a decrease in the competency of the lower esophageal sphincter, the risk of reflux is greatly enhanced. The most effective protection against aspiration in ...