Shotgun - Pregnant female scenario

[rhan101277]

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?

 

[Two-Speed]

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?

Abdo pad on the shotgun wound, 02, 12-Lead, quickclot (R), Load & Go, I wouldn't want to keep her on scene any longer than necessary. Transport Code 4 CTAS 1 to the nearest hospital, MediVac if possible.

(Primary Care Paramedics, cannot intubate or do IV's)

 

[DrParasite]

panic???

load and go, make sure the trauma team knows what is going on, have an OB team waiting with the trauma team, drive really really fast to the hospital (medivac might be a good idea) make sure the trauma attending and the OB attending know what is going on, control all bleeding with trauma dressings, drive really really really fast to a trauma center.

 

[Onceamedic]

Make sure you get a couple of large bore IVs. Your big problem is going to be hypovolemic shock. Might be a good idea to review your drip rates for dopamine.

 

[Akulahawk]

This is a situation where the EMT-B instinct of "Load & Go" should kick in. Attempt to control whatever bleeding you can, load in the ambulance, try to get a couple large bore IV's in place before the peripheral veins collapse due to lack of volume, apply much diesel to a Trauma Center, advise them to have an OB team ready, and why. If you can delegate some of these tasks to another provider, do it.

You want the bare minimum scene time you can. This patient and her fetus need a surgeon. Now. This patient is already well into shock, probably starting to decompensate. Another round of vitals or two would likely confirm that. BP will be one of the last things to go. Kaisu makes a good point... hypovolemic shock is going to be the problem we see in the field. Dopamine? Well, that might work if the vasculature still has volume in it... don't pop clots. That would be bad...

Beyond that... hope the patient and her fetus survive.

 

[Seaglass]

As a basic with no medic... yeah, panic sounds pretty good...

More seriously, this would be a flyout, in my area. Our local hospitals aren't bad, but this would be going to the trauma center two counties away. I'd call ALS as well in case anyone's close enough to show up before the helicopter arrives. In the meantime, try to control bleeding (if at all possible), pad over the abdominal area, administer O2, keep patient warm and calm, and elevate legs.

If the weather sucks too bad for a helicopter, then load and go, call for ALS intercept, confirm which hospital can and should take her, and drive really fast.

 

[Smash]

Scary job

Nasty job. Is it a real one or hypothetical? Not that it matters for the discussion, so don't worry about answering that if yo don't want to .

I agree, load and go to appropriate facility. O2 cos I can, dressing, large bore IV x however many you can. Permissive hypotension is good, but we need to consider the foetus as well. Of course the foetus will suffer first, so we may not be able to do much for it anyway. Fly them out if distance/time/weather dictates. Notify early. As akulahawk has mentioned, this patient is shocked, which means the foetus is more shocked already, and they need surgery soon.

A couple of questions:

Kaisu: do you regularly use inotropes in hypovolemic shock? As far as I am aware (which may indeed not be very far at all, it must be said) inotropes are not indicated for hypovolemic/hemorrhagic shock and may in fact cause worse outcomes from increased HR, decreased filling time, increased MvO2.

Two-speed: I'm curious as to the usefulness of a 12 lead in this patient. I suspect that having a 12 lead will not provide any useful information in this setting and may take time away from more important tasks (like changing underwear)

 

[Onceamedic]

Kaisu: do you regularly use inotropes in hypovolemic shock? As far as I am aware (which may indeed not be very far at all, it must be said) inotropes are not indicated for hypovolemic/hemorrhagic shock and may in fact cause worse outcomes from increased HR, decreased filling time, increased MvO2.

I wouldn't say regularly but it is done. Usually, fluid and rapid diesel bolus preclude the need for dopamine - the only drug I carry that could possibly be of use. I mention for this case primarily to stress the extreme bleeding a compromised uterus causes.

Not that replacing a patient's blood volume with Kool-aid is all that good either. In this situation, I would be happy if the systolic stays above 80. Below that, and I would have to do something.

 

[DV_EMT]

I'd start by controlling bleeding... probably throw her in shock position (just in case). Then High flow O2 and transport code 3 (l&s).

As a medic... bolus fluids and a 12 lead if available...

 

[reaper]

I ask the same question that Smash asked. What is with the 12 leads?

 

[DV_EMT]

I ask the same question that Smash asked. What is with the 12 leads?

Its just good to get V4-6.... helps with more interpretation. Its little bit limited with only a 3 and 5 lead. some medics im sure can extrapalate a little bit on the benefits.

 

[boingo]

I'd start by controlling bleeding... probably throw her in shock position (just in case). Then High flow O2 and transport code 3 (l&s).

As a medic... bolus fluids and a 12 lead if available...

Shock position? Not sure what that is exactly. What do you think about the L side, seeing she's 37wks? Hand sticking through the hole means pretty damn big hole, can you elaborate??

 

[Smash]

Its just good to get V4-6.... helps with more interpretation. Its little bit limited with only a 3 and 5 lead. some medics im sure can extrapalate a little bit on the benefits.

I understand what a 12 lead is for, I'm just not clear how useful it is to obtain one in this kind if scenario. It is possible that this patient is having some myocardial ischaemia. It is definite however that she and the fetus are bleeding to death. Even in the unlikely event that a 25 year old female is somehow having a STEMI (whilst at the same time having been shot with a shotgun in the stomach; how unlucky can you get?!) what are you going to do about it? Aspirin? Nitrates?

In the event that there were changes, one would have to be suspicious that they would be related to global hypoperfusion secondary to loss of circulating volume as opposed to the rupture of a plaque.

I just don't think that a 12 lead has any real use in such a scenario, and at worst may detract or take time away from more important tasks.

 

[Lifeguards For Life]

I understand what a 12 lead is for, I'm just not clear how useful it is to obtain one in this kind if scenario. It is possible that this patient is having some myocardial ischaemia. It is definite however that she and the fetus are bleeding to death. Even in the unlikely event that a 25 year old female is somehow having a STEMI (whilst at the same time having been shot with a shotgun in the stomach; how unlucky can you get?!) what are you going to do about it? Aspirin? Nitrates?

In the event that there were changes, one would have to be suspicious that they would be related to global hypoperfusion secondary to loss of circulating volume as opposed to the rupture of a plaque.

I just don't think that a 12 lead has any real use in such a scenario, and at worst may detract or take time away from more important tasks.

i agree and think that your time would be much better spent doing a host of other services to this patient than getting a EKG

 

[Seaglass]

Shock position? Not sure what that is exactly.

It's also known as Trendelenburg. Supine on back with legs elevated.

Left side is usually recommended for pregnant women, but come to think of it, I don't know what to do with someone who's both heavily pregnant and in shock. Left side with legs elevated?

 

[Lifeguards For Life]

It's also known as Trendelenburg. Supine on back with legs elevated.

Left side is usually recommended for pregnant women, but come to think of it, I don't know what to do with someone who's both heavily pregnant and in shock. Left side with legs elevated?

The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicin

 

[Melclin]

The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicin

The amount of times I've been in a prac tute at uni or doing a scenario with St Johns with a haemorrhaging/hypovolaemic pt, and at the end had them say something like, "Yep, I'm happy, except you should have raised their legs". 50% of their blood volume is on the ground, and you want me to raise their legs like its a life or death intervention? Eugh.


Rhan, I might be wrong, but I feel like you're trying to suggest that their is some sort of dilemma between mother and baby (the hand sticking out through the hole...37 weeks...you're not hoping for one of us to say emergency caesar right?).

Other than the obvious and substantial emotional component to a case like this, I don't really see how the prehospital management is going to be any different than a normal abdominal GSW with the same vitals, with the obvious exception of the post handover consumption of a case a beer.

+3 on the "whats with the 12 leads". What can you possibly hope to gain from using 2/4 hands for a few minutes to do a 12 lead. Whats ganna happen? "Hey Joe, our lady has 2mil of ST^ in V3-5, better activate the cath lab, her GSW/dying baby is just ganna have to wait". While we're at it ordering up wacky and useless tests, we should call Derick Sheppard for a neuro consult

 

[Smash]

Also agree with the stuff about trendlenburg position. It was used originally in abdominal surgery to allow better access to the pelvic region by having everything shifted up. For some reason this then became a standard for shocked patients. One can understand the idea behind doing it, however all it does for us is impair respirations and raise ICP whilst having no effect on hemodynamics at all. It's one of those deeply ingrained habits that is really hard to get rid of but has no data to support it's use.
I'll post a study or two when I get a chance.

I trust we weren't heading for an emergency in-field c-section. These two are sick enough without ambos with scalpels fossicking around in there.

 

[DV_EMT]

for the trandeleberg.... I was taught that by elevating the legs... your using gravity to help move the blood that is stored in your thighs towards the organs in the abdominal cavity. since theres about 2-4 Liters of blood in the legs, and Basics can't start IV's to restore the bodily fluid, its meant to be used in the field while transporting on a BLS rig.

As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.

 

[Lifeguards For Life]

for the trandeleberg.... I was taught that by elevating the legs... your using gravity to help move the blood that is stored in your thighs towards the organs in the abdominal cavity. since theres about 2-4 Liters of blood in the legs, and Basics can't start IV's to restore the bodily fluid, its meant to be used in the field while transporting on a BLS rig.

As for the 12 lead... I know that most rigs (if not all) use the 5 lead... so I'd go a 5 lead.

here is a decent link
http://ajcc.aacnjournals.org/cgi/content/full/14/5/364