Emergency Nursing of the Obese Patient

Kane Guthrie FCENA

ED nursing the Obese Patient

• Some Facts & Stats• Pathophysiology & complications of obesity• Critical care management• Trauma management• Pharmacology in the obese• Being prepared

Obesity

Obesity is the chronic abnormal or excessive accumulation of fat in adipose tissue to the

extent that health may be impaired.

Degree of obesity defined by BMI!

The BMI

BMI = weight (kg) divided by (height (m))2.

BMI Ranges

Some Facts

• 3 in 5 Aussies overweight or obese• 1 in 4 children overweight or obese• Obesity sits third to smoking & HT as burden

of disease.

The Stats

• National Heart foundation 2012

The Stats

• National Heart Foundation 2012

Obesity in ED

• Becoming common• Confronting issue• Challenges lie:– Managing– Treating

• But also providing:– Dignity– Respect

Its about RESPECT

R- RapportE- Environment/EquipmentS- SafetyP- PrivacyE- EncouragementC- Caring/CompassionT- Tact

Pathophysiology & Complications of

Obesity

“Obesity has multiple pathophysiological effects & leads

to numerous multi-system complications.”

The CVS System

• ^ Increased venous pressure• ^ Blood volume• Polycythemia (^ Red blood cells)• ^ cardiac output & ventricular work

Respiratory System

• Restrictive pulmonary physiology • Decreased lung capacity• ^ Pleural pressure – chest wall compression

• Obstructive sleep apnea• Obesity hypoventilation syndrome

The Neuro System

• ^ICP: – associated with raised intra-abdominal & pleural

pressures.

The GI System

• ^ Intra-abdominal pressureLeads to:• Renal & hepatic failure• Visceral necrosis

• Can result abdominal compartment syndrome

Haematology/Immunology

• Hypercoagulable, platelet hyperactivity=Increased risk of VTE!

• Obesity is a proinflamatory state.

Pathophysiology Effects of Obesity

• Restrictive pulmonary physiology• ^ intra-abdominal pressure• Hyperkinetic circulatory system• Myocardial hypertrophy• Diastolic dysfunction• ^ Circulating blood volume• Prothrombotic state

Critical Care Management

The Airway

Securing the airway:– Lack of landmarks– ^adipose tissue– Difficult BVM- preoxygentaion – ^ difficulty – intubation/surgical airway

Worth a Read!

Anatomic Alterations

• Large neck circumference• Excess cervical fat• Large tongue• Constricted glottic opening• Excess fat in soft tissues

http://www.youtube.com/watch?v=EAGzHjyfh04 - Mike Winters 2012!

Easily Obstructed

“Airway obstruction is easy in the supine patient”

The Airway

• High risk of aspiration:– GORD– Hiatus hernia– Increased abdominal pressure

• Regular O2 mask difficult fit• Complicated by sleep apnoea

Intubating Obese Patient

Equipment:• Laryngoscope – long blade• Video laryngoscope• LMA• Bougie

Surgical Airway Kit:• Have 6mm ETT handy!

Pre-Oxygenation

• Prepare for difficult BVM– Two handed technique

Preoxygenation:– Sitting up position– Nasal canula 15l (Apneic oxygenation)– BiPAP 100% > 5min

Ramping

Breathing

Physiological alterations• Decreased pulmonary reserve• Increased intra-abdominal pressure

• Rapid onset hypoxaemia– Healthy morbidly obese = 4 min– Critically Ill obese = 1-2 min

http://www.youtube.com/watch?v=EAGzHjyfh04 - Mike Winters 2012!

Ventilation & Perfusion

• Lower lung lobes predominately perfused• Upper lung zones predominately ventilated

=VQ mismatch & hypoxemia

Respiratory muscle inefficiency:• 5 fold ^ o2 consumption

Mechanical Ventilation • Tidal volume – 6-8ml/kg IBW

• PEEP– Obese lower FRC– Leads to collapsed alveoli– Need higher PEEP to overcome– Set PEEP 10-15cm

• Need to tolerate higher plateau pressures

Positioning

Obesity Hypoventilation Syndrome

• Well-known cause of hypoventilation

Caused by abnormal central ventilatory drive & obesity.

• Expect chronic hypercapnia (PaCo2 >45mmHg)

NIV

• Limited data in acute setting

• Most on CPAP @ home for OSA

• BiPAP good for 0HS

Circulation

• Hypertension is the norm• Normotensive = be worried• Fluid loading often poorly tolerated

• Measuring BP:– Thigh/forearm– Doppler– Consider early art line

The ECG

• Low voltage complexes related adiposity over heart.

Disability

• Assessment difficult– Motor function– Reflex– Sensory perception

• Pain perception deceptive– Often higher pain threshold – missed injuries!

Exposure

• Exposure is difficult• Look between the adipose tissue • Log roll:– Signs of injury– Infection – cellulitis

Getting Vascular Access

• PIVC often difficult• Ultrasound can help

Consider going early for:• IO• CVC

Diagnostics

• LP – consider US or CT guided

• Liaise well for – MRI– CT– Cath lab

• Generally have weight restrictions

Obese Trauma Patient

Obesity in Trauma

Implications for:• Assessment• Management• Outcomes

Injury Patterns

More likely:• Pulmonary contusions, rib fractures • Pelvic injuries• Extremity injury

Less likely:• Head injuries• Liver & other significant abdo injuries

Difficulties with Assessment

• Confounded by pathophysiology• Clinical exam less reliable• Mediastinum appears wide on X-ray• FAST scan decreased sensitivity• Size may preclude CT/MRI

Trauma Management

• Transport – positioning• Difficult procedures• Difficult airway maintenance• Haemodynamic instability• Aspiration risk• C-spine immobilisation• Chronic inflammatory state

Cardiac Arrest

Cardiac Arrest

• Is common• Principles largely the same• Hopefully ILCOR statement in 2015• Effective ECC is challenging

Cardiac Arrest

• Space around bed/room• Patients position in bed• Maintaining the airway • Using 2 defibs?

Pharmacology

Pharmacology

• Obesity affects all aspects of pharmacology• Patients generally under dosed• Require careful drug monitoring

Absorption

• ^ absorption for oral meds– Increased gastric emptying

• Decreased SC absorption• IMI administration may fail

• Drugs vary based on TBW vs IBW

Being Prepared

Being Prepared

Transport

Looking After Your Staff

• Safety focused approached:– Staff– Patient

• Policy manual handling• Environment

Questions

Take Home Points

• Assessment in challenging• Bariatric equipment should be available• Limited CVS & Resp reserves• Remember RESPECT

Thank-you