Published on March 15, 2014
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.
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- Rapport E- Environment/Equipment S- Safety P- Privacy E- Encouragement C- Caring/Compassion T- 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 pressure Leads 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
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
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 • 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 • 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
Looking After Your Staff • Safety focused approached: – Staff – Patient • Policy manual handling • Environment
Take Home Points • Assessment in challenging • Bariatric equipment should be available • Limited CVS & Resp reserves • Remember RESPECT
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