Shotgun - Pregnant female scenario

[Lifeguards For Life]

Are you sure you'd want to administer opioids to this pt? Couldn't that result in a decreased respiratory drive and some vasodilation, yielding possible lower o2 sat and bp?

I would not do any of those to this patient, but someone had asked about ways to stop contractions

 

[Smash]

80 would still give you palpaple radius pulses, yes, and if the fetus is at the core of the mother the fetus would be getting as much blood volume as the mothers vital organs. however it still comes down to blood volume not fluid volume, you can keep pressure up for some time but not actual blood amounts i dont believe civilian medics have anything that works like hextend

Actually the fetus would be compromised at this level. One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive. So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.

However if we bleed the mother out from using lots of fluids, it is a moot point as to whether the fetus will survive anyway.

Hetastarch is not used on any civilian rigs that I am aware of, and the problem is still that there is a lack of oxygen carrying ability.

 

[spinnakr]

First sentence:

Whoops. There I go again, not reading carefully.

Seems like you'd be screwed either way--for not listening to medical control if you don't, and for operating outside your scope if you do.

Anything happen to the surgeon?

In court, you'll be much better off it you refuse to do something outside your scope of practice. At least that's what I've been told.

Don't know what (if anything) happened to the surgeon.

What it comes down to though is this: if someone wants to sue, he/she will find something to sue over. You have to make sure you're operating under your legal scope in order to be able to defend yourself.

 

[blindsideflank]

Actually the fetus would be compromised at this level. One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive. So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.
.

this is what i figured. Man, i feel outclassed here on these boards, its refreshing. so if this fetus wanted to come out (birth canal not through the wound) would you encourage this or want to avoid it. anyone consider knee to chest positioning? i dont really see any indication for it unless you want to delay a birth but there is too much going on i suppose to justify this.

i think i common mistake with people is worrying about the fetus
ultimately the mother (in my opinion) is priority, not that you can do much for either.
after reading smoeones reply, do you have protocol to bolus for a delivery if you had a limb presentation etc.?

 

[Lifeguards For Life]

80 would still give you palpaple radius pulses, yes, and if the fetus is at the core of the mother the fetus would be getting as much blood volume as the mothers vital organs. however it still comes down to blood volume not fluid volume, you can keep pressure up for some time but not actual blood amounts i dont believe civilian medics have anything that works like hextend

Blood flow to the uterine arteries is normally maxillary vasodilated, so blood delivery to the uterus is maximal in the normal physiologic state. Maternal hypovolemia may result in vasoconstriction of the uterine vasculature. The third trimester fetus(as in this scenario) can adapt to a decrease in uterine blood flow and oxygen delivery by diverting blood distribution to the heart, brain, and adrenal glands. Because fetal hemoglobin has a greater affinity for oxygen than does adult hemoglobin, fetal oxygen consumption does not decrease until the delivery of oxygen is reduced by 50%. Thus, maternal shock may have a significant impact on the developing embryo/fetus.

 

[truetiger]

I'm not so sure about a 12 lead either, but I would hook her up to a 3 lead with the combo pads just incase she de-compensates.

 

[Akulahawk]

Actually the fetus would be compromised at this level. One of the first things that happens in the injured pregnant woman is that blood is shunted away from the fetus to keep the mother alive. So pregnant women will actually maintain a better BP from having greater blood volume, but still be in a dangerously compromised state.

However if we bleed the mother out from using lots of fluids, it is a moot point as to whether the fetus will survive anyway.

Hetastarch is not used on any civilian rigs that I am aware of, and the problem is still that there is a lack of oxygen carrying ability.

The other problem is that admin of hetastarch will increase blood volume, primarily by drawing fluid from other compartments, thus increasing the BP, and the volume expansion is harder to control in the field than it is with a crystalloid.

Either way, if you "pop the clot", the patient begins hemorrhaging uncontrollably again... and all the stuff used in making the first clots haven't been replaced yet, so... you could potentially have a patient who is bleeding uncontrollably who also has a limited ability to create the clots needed.

If anything can be considered "good news", it's that thanks to our overseas military operations, we're learning LOTS about trauma resuscitation and damage control surgery. While the "Golden Hour" itself is a myth, the idea behind it is good. That is... get thee to a trauma Doc fast, for time wasted is time taken from getting definitive damage control. Once the trauma victim has taken the damage, their golden hour might be 20 min or 4 hours long...

Now as to the scope of practice thing... you really would be far better off sticking to refusing to perform a procedure that's outside your scope of practice than doing (in the other case mentioned here) an emergency C-section. I do not believe the surgeon in that case received much in the way of disciplinary actions... Now if I were to exceed the normal scope of practice, and do something that is accepted elsewhere AND I've been trained to do that... I'd have a better chance of retaining my license. However, once you go outside your authorized scope of practice, you start crawling out further and further on that limb where your cert/license becomes more and more in jeopardy and there will be fewer and fewer people able to defend/back your decision to do so. Eventually... it'll be just YOU hanging in the breeze...

 

[Smash]

The other problem is that admin of hetastarch will increase blood volume, primarily by drawing fluid from other compartments, thus increasing the BP, and the volume expansion is harder to control in the field than it is with a crystalloid.

Either way, if you "pop the clot", the patient begins hemorrhaging uncontrollably again... and all the stuff used in making the first clots haven't been replaced yet, so... you could potentially have a patient who is bleeding uncontrollably who also has a limited ability to create the clots needed.

If anything can be considered "good news", it's that thanks to our overseas military operations, we're learning LOTS about trauma resuscitation and damage control surgery. While the "Golden Hour" itself is a myth, the idea behind it is good. That is... get thee to a trauma Doc fast, for time wasted is time taken from getting definitive damage control. Once the trauma victim has taken the damage, their golden hour might be 20 min or 4 hours long...

We don't even teach the "Golden Hour" anymore except as part of the discussion on the history of trauma care and trauma systems.

We do teach our students to be conscious of time to definitive care and to consider all their options. In some settings, such as isolated TBI for example you will do the patient no favours by loading and going instead of taking the time to manage them appropriately. In other cases (such as this one) PUHA is absolutely appropriate.

You are right of course about hetastarchs other problems. Until a genuine blood replacement comes along it appears we will be continuing to fight a losing battle.

 

[gamma6]

You arrive on scene after police confirm scene is safe to find a 25 Y/O female with an obvious gunshot wound to the abdominal area. You find out from family on scene that she is 37 weeks pregnant with a due date of 12/25/09. Initial assessment reveals a responsive patient who is extremely concerned about here baby. Her blood pressure is 115/90, HR 120, RR 30, skin cool, clammy. Pt is responsive but is somewhat confused you get a GCS score of 14, (E4, V4, M6). She is bleeding profusely from the gunshot wound. You notice a baby hand moving from the hole created by the shotgun blast.

What do you do?

damn!!!! now that would be a notch up on my weird shatometer.

 

[Akulahawk]

We don't even teach the "Golden Hour" anymore except as part of the discussion on the history of trauma care and trauma systems.

We do teach our students to be conscious of time to definitive care and to consider all their options. In some settings, such as isolated TBI for example you will do the patient no favours by loading and going instead of taking the time to manage them appropriately. In other cases (such as this one) PUHA is absolutely appropriate.

You are right of course about hetastarchs other problems. Until a genuine blood replacement comes along it appears we will be continuing to fight a losing battle.

When I started on my path towards being a Paramedic, the Golden Hour was still being taught. We were taught to regard it as each patient has their own Golden Hour and it's unique to them and their situation. We learned to consider time to definitive care... by ground OR by air. That lesson also applies to BLS vs ALS transports as well. If your patient needs ALS care and all you have is a BLS transport unit and that BLS unit can get to the hospital faster than an ALS unit can get to the patient... it's appropriate for the BLS crew to transport. Ideally, this scenario shouldn't happen, but in places that have either tiered response systems or the system becomes so overloaded that all ALS units locally are unavailable...

 

[kittaypie]

i saw a scenario like this on "she survived that- pregnant?" on discovery health last night. the wound was leaking amniotic fluid and she started having contractions. ended up in surgery and both she and the baby were fine.

 

[Jeffrey_169]

I agree with a lot of the others; I would give lots of O's, control bleeding, and call for immediate air transport and ALS. I would be finding the long skinny pedal to the right on the floor here as well. Surgery will be the definitive care, IV fluids for the patient would be a must, and again...HIGH FLOW DEISEL!!! Reassess vitals, treat for shock, and maintaining of the airway is really all that can be done here. Unfortunately there is not much a basic can do, and outside of a few drugs and dual large bore IVs there isn't must ALS can do either (Intubation can be considered based on your protocol). As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.

Remember, by treating Mom you are treating Baby.

 

[jrm818]

Fluid res itself will be tocolytic in this patient. administration of roughly 1L of fluid, intravenously, increases the intravascular fluid volume,which inhibits ADH secretion from the neurohypophysis. since oxytocin and ADh are secreted from the same area of the pituatary gland, inhibition of ADH secretion also inhibits oxytocin release, causing uterine contractions to stop.
(a poor choice for this particular patient)
Sedation of the patient, with narcs or barbituates allows the patient to rest. Often, after a period of "rest", contractions will stop on their own.

Generally, tocolysis in the field is limited to sedation, and hydration. though a last ditch effort, magnesium sulfate, or a beta agonist such as terbutaline or ritdrine may be administered to stop labor by inhibiting uterine smooth muscle contraction

I just stumbled over this post, so I know this is both late and in general not a major consideration for the treatment of this patient, but I though anyone who though deeply enough about that effect of hydration on OT might find this interesting:

I'm very curious if what you say about the inhibition of oxytocin is correct. I'd caution you about generalizing about the combined control of Vasopressin (VP) and Oxytocin (OT). Though they are both released from the posterior pituitary, the control of the two is not necissarily intertwined. I don't think anyone knows specifically how control works in the humans.

Most of the research relating to the control of VP/OT release under conditions of hypovolemia was done in a rat model in the context of studies focusing on plasma osmolality as well. A few of these were also done in dogs.

In the setting of osmolality, it was found that in a rat an increase in plasma osmolality (pOsm) increased secretion of VP into the bloodstream accompanied by OT. However, in dogs, it was found that ONLY VP was secreted....OT was unaffected by an increase in pOsm. Thus VP and OT are are not necessarily controlled by the same mechanisms in all circumstances, and there are differences across species, even among mammals.

Unfortunately, in the realm of hypoVOLEMIA, I am not aware of any dog research that addresses the issue of differential control of VP and OT. It is true that in a rat hypovolemia leads to VP and OT secretion (just as they are in response to increased pOsm), and that removal of hypovolemia will remove the stimulus for VP and OT secretion. However, I would not be surprised to find that in a dog only VP is secreted, just as in increased pOsm. A quick search turned up no information, and I believe I have asked this question before and that there was no data on the issue. If there is no dog data, I would be shocked to find there is any human data, and I have been unable to find any.

Similarly, I am not aware of any data indicating that an increase in vascular volume would acutally inhibit VP or OT secretion. Repair of hypovolemia will indeed remove the stimulus for their secretion, but in the context of a pregnancy, I am willing to bet money that it is simply not known how an increase in vascular volume would effect baseline OT secretion, when the baseline OT level is already influenced by pregnancy. My guess is that by repairing the loss in volume from the GSW (and I doubt 1L of fluid is enough to even reach normal volume, and only transiently if at all), you would simply return to the normal baseline OT level, rather than actually inhibiting OT.



Overall, unless there is new data that I haven't seen, it's unlikely that we know for sure how the loss of blood, or subsequent infusion of NS would affect the OT levels in this patient. I'd be surprised to learn that there is any new information, as the studies relating to volume and OT are all pretty old. If there is new information, I'd love to see it (serious, not sarcastic).

Your suggestion does strike me as incredibly interesting for another reason: it raises the question of the effect of hypovolemia on OT levels in a pregnant patient, and the possibility that hypovolemia may encourage parturition. I have no idea what blood level of OT we are talking about here, or even if hypovolemia does effect OT, as discussed, but my curiosity is certianly up. Very quick search turned up nothing of interest, unfortunately. Again, I'd love to see any relevant data.

EDIT:
I did a bad quick search....just found a few relevant articles...only had time to scan, but it appears as if hydration has little effect on preventing pre-term labor....which goes along with most of what I've said. None look like they directly address the OT mechanism.

 

[Smash]

I should have been more clear.

When I said permissive hypotension, I was referring to the idea of titrating fluids in small amounts to a target blood pressure, as opposed to what we do now, which is give none at all.

I know that its an old idea (1) and the there is plenty of evidence for not giving any at all in the prehospital setting and it is plenty possible to do an RCT, its been done (2).

What I was getting at is that there's no evidence to suggest that titrating small amounts of fluids is safer than a lot of fluids, nor if it provides better outcomes than no fluids at all. A wealth of literature agrees than none is better than lots, but no one knows if some is better than none - however, the latter is fairly common practice.

1. Cannon WB, Fraser J, Cowell EM. The preventive treatment of wound shock. JAMA. 1918;70:618-621

2. Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med. 1994;331(17):1105-1109

None at all? Surely at some point one has to attempt to maintain some perfusion, even if it is with substandard fluids. Is not the alternative allowing arrest to occur?

RCTs have been done, (by others as well as Mattox and his mates too ) but I was referring to the "gold standard" of trials, the double blinded trial, which would obviously be impossible to carry out when the two arms are -giving something- and -not giving something-

 

[Smash]

Surgery will be the definitive care, IV fluids for the patient would be a must,

Fluids a must? Really?

(Intubation can be considered based on your protocol).

It certainly could be considered. Personally I would consider it to be a very bad idea. The patient has a GCS of 14: any attempt at intubation would therefore have to be made using sedation and probably paralysis, or by allowing the patient to become obtunded to the point of loss of airway reflexes through hypovolemia alone. This is not going to be conducive to the survival of this patient who is in a haemodynamically tenuous position in the first place.

As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.

Surgery: certainly. The rest... not so sure. It does however, beg the question of why a benevolent, omnipotent god would subject an unborn child and young mother the terror and suffering associated with such an event and injury, not to mention the high risk of painful death from the injury, subsequent bleeding and inevitable infection; nor the pain and humiliation of debridements, colostomy, loss of function, life long scarring both physical and mental; not to mention the psychological trauma to the family members, EMTs, medical staff and LEOs who attend the scene and patient; not to mention the enormous cost to society both in the treatment and subsequent rehabilitation of these patients and in the investigation, prosecution and imprisonment of the perpertrator; not to mention arguably the loss of a second life as someone is incarcerated for such a heinous crime instead of having had the opportunity to become a loving husband and father through the grace of said loving, all-powerful diety.

That is assuming of course, that the Lord to whom you refer is indeed the normally imagined beneficent, omipotent, omniscient (ignoring the inherent impossibility of holding those two characteristics at once) Lord that all current monotheistic religions believe in, and not, say Ba‘al Zebûb.

But that is probably a topic for a different thread.

 

[Melclin]

None at all? Surely at some point one has to attempt to maintain some perfusion, even if it is with substandard fluids. Is not the alternative allowing arrest to occur?

No, with a but. Penetrating trauma = arrest haemorrhage + transport at .5 past light speed. Unless a carotid pulse is lost, in which case a PEA algorithm begins and they get their fluids. Which is what I argued against in an essay I wrote for uni - it didn't seem to make sense that u'd sit their and watch a person circle the drain, giving no fluids knowing in a few minutes you'd be hooking a fire hose up to their IV. But I have since been told about a few qualifying factors by one of the MDs involved in the sevice's guidelines, which I think I've mentioned before.

RCTs have been done, (by others as well as Mattox and his mates too ) but I was referring to the "gold standard" of trials, the double blinded trial, which would obviously be impossible to carry out when the two arms are -giving something- and -not giving something-

Hehe yes it would be difficult to double blind a study like that. Although in that sort of acute setting where the clinicians don't necessarily have a lot of contact with the patient and in any case its not for very long (unlike say, an oncologist and a new cancer drug), you don't get so much of that confounding experimenter variable, so I'm not sure that matters too much.

10 characters

 

[Melclin]

I agree with a lot of the others; I would give lots of O's, control bleeding, and call for immediate air transport and ALS. I would be finding the long skinny pedal to the right on the floor here as well. Surgery will be the definitive care, IV fluids for the patient would be a must, and again...HIGH FLOW DEISEL!!! Reassess vitals, treat for shock, and maintaining of the airway is really all that can be done here. Unfortunately there is not much a basic can do, and outside of a few drugs and dual large bore IVs there isn't must ALS can do either (Intubation can be considered based on your protocol). As stated, surgery and the Lord above is the definitive care for the patients, and the faster the better.

Remember, by treating Mom you are treating Baby.

D**king around with RSI is quite possibly the worst intervention I could imagine in this situation.

You know, its not a new topic, and certainly not something we should be discussing here I suppose, but it continues to confuse me as to why people say things like the lord is her definitive care after having let it happen in the first place, and then after the hard work of the trauma team, place the save in the "god" column. I wonder if people would feel similarly fond of a trauma surgeon who went out and shot a pregnant lady only to save her a little while later on the operating table...probably not going have everyone coo and say things like oh Dr. John works in mysterious ways. Pfft.

 

[Jeffrey_169]

I couldn't agree more about the RSI. I am not a big fan of it; it a patient is that bad off there other considerations and other ways to secure the airway without the time consumptoin involved, but there are places where protocol does not agree with me.

As too the reference concerning my religion, I did not intend to offend you however; i have seen more then one instance where I am certain there was a divine hand, and in my opinion, there can be no other explanation.

 

[Veneficus]

I was doing my best to stay away from public posting but I just couldn’t help myself after reading this, so please indulge my opinion.

Having been part in the care of many shotgun wounds, this was done at a range close enough to make a hole you can see a fetal hand moving in. That indicated either a single projectile, a few very large ones, or for the firearm folks, something larger than #7 shot at less than 10 feet.

Without an exist this demonstrates there was considerable force transfer, and the cavitation injuries will likely affect the fetus if there wasn’t a direct penetration to it from the start.

A heavy bleed would make me strongly suspicious of disruption of the placenta at the chorion. Which means the mother basically has multiple arterial bleeds that I conclude would require considerable electrocautery to stop. That may not be a viable intervention do to volume/time constraints. Furthermore, there is likely bleeding from arteries supplying the abdomen and bladder, adding more difficulty to bleeding control.

I would bet the farm the first intervention in the trauma bay will be a crash c section. This baby is well into term. I cannot see a reasonable way to assess it for injury while trying to control uterine hemorrhage. If the baby does have an open or closed bleed, it will act like an extra body cavity the mother is bleeding into. If by some possibility you could stop the bleeding with intervention short of radical hysterectomy your skill as a surgeon would be legendary.

The logic of save the mother/save the baby, I would not apply to this case.
***At no point am I suggesting any “heroic” measures outside of your scope of practice or protocol.***

But the knowledge of what the likely course of this mysterious “surgery” that keeps being mentioned is very important. The purpose of damage control surgery is just that. To stop things from getting worse, not to make people the way they were.

If this baby starts to come out, the faster the better. Then you could treat it as a second patient. Especially since the open wound may have stimulated breathing in it and while in a bleeding uterus its airway is definitely not controlled, much less protected. It would also make controlling the mother’s bleeding easier.

If she is GCS 14, maybe some o2 and get ready to bag or tube as required. At this point there is an airway and breathing, try to slow the bleeding. I would give no fluids!!! IV starts if possible without delay. The placental circulation works on pressure, increasing the arterial pressure proximal to the placenta will make it bleed faster. Unless you are autotransfusing in the field or delivering massive blood infusion, not a good idea.

I would suggest calling the hospital and asking for permission to pack the crap out of the abd. With everything I could stuff in there and try to locate and protect the potential fetal airway if possible. If this permission was denied, I’d do my best to control bleeding putting pads over the abd.
O2, is not going to make a difference here, enzyme kinetics dictates the available heme is already saturated and giving oxygen to tissues it is reaching. Simply blood is not returning to the pulmonary circuit for gas exchange.

Try to keep calm, driving fast or careless puts more people at risk and could kill somebody else. Not everyone is savable, as though it sucks, babies die. There is no reason to kill anyone else trying to be heroic. Pregnant women are the most abused cohort worldwide. It seems unlikely it will be the only time in your career you encounter stuff like this. Staying calm, acting safely, thinking logically, not emotionally, is the best thing you can do.

PS. Don’t forget to check for signs of a pneumo because of possible shearing of the diaphragm from the bottom and/or the pressure wave of the blast shearing the pleura.

In summary: maintain the airway that you have now, assist with BVM if need be, start IVs w/o fluid if you have time, attempt to control bleeding, deliver fetus if labor occurs, in this specific case, I would consider the baby a second patient. By remaining calm, the “save” you make might be yourself.
Sorry for the length. Quit even considering things like "driving fast" "diesel bolus" and anything else that increases the risk to providers.

 

[Sasha]

Welcome back Vene! A+ post.