Presentation on the emergency nursing of the obese patient.

1. Emergency Nursing of the Obese
Patient
Kane Guthrie FCENA

2. ED nursing the Obese Patient
• Some Facts & Stats
• Pathophysiology & complications of obesity
• Critical care management
• Trauma management
• Pharmacology in the obese
• Being prepared

4. 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!

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

6. BMI Ranges

7. 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.

8. The Stats
• National Heart foundation 2012

9. The Stats
• National Heart Foundation 2012

10. Obesity in ED
• Becoming common
• Confronting issue
• Challenges lie:
– Managing
– Treating
• But also providing:
– Dignity
– Respect

11. Its about RESPECT
R- Rapport
E- Environment/Equipment
S- Safety
P- Privacy
E- Encouragement
C- Caring/Compassion
T- Tact

12. Pathophysiology &
Complications of
Obesity

13. “Obesity has multiple
pathophysiological effects & leads
to numerous multi-system
complications.”

14. The CVS System
• ^ Increased venous pressure
• ^ Blood volume
• Polycythemia (^ Red blood cells)
• ^ cardiac output & ventricular work

15. Respiratory System
• Restrictive pulmonary physiology
• Decreased lung capacity
• ^ Pleural pressure – chest wall compression
• Obstructive sleep apnea
• Obesity hypoventilation syndrome

16. The Neuro System
• ^ICP:
– associated with raised intra-abdominal & pleural
pressures.

17. The GI System
• ^ Intra-abdominal pressure
Leads to:
• Renal & hepatic failure
• Visceral necrosis
• Can result abdominal compartment syndrome

18. Haematology/Immunology
• Hypercoagulable, platelet hyperactivity
=Increased risk of VTE!
• Obesity is a proinflamatory state.

19. Pathophysiology Effects of Obesity
• Restrictive pulmonary physiology
• ^ intra-abdominal pressure
• Hyperkinetic circulatory system
• Myocardial hypertrophy
• Diastolic dysfunction
• ^ Circulating blood volume
• Prothrombotic state

20. Critical Care
Management

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

22. Worth a Read!

23. 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!

24. Easily Obstructed
“Airway obstruction is easy in the supine
patient”

25. The Airway
• High risk of aspiration:
– GORD
– Hiatus hernia
– Increased abdominal pressure
• Regular O2 mask difficult fit
• Complicated by sleep apnoea

26. Intubating Obese Patient
Equipment:
• Laryngoscope – long blade
• Video laryngoscope
• LMA
• Bougie
Surgical Airway Kit:
• Have 6mm ETT handy!

27. Pre-Oxygenation
• Prepare for difficult BVM
– Two handed technique
Preoxygenation:
– Sitting up position
– Nasal canula 15l (Apneic oxygenation)
– BiPAP 100% >5min

28. Ramping

29. 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!

30. Ventilation & Perfusion
• Lower lung lobes predominately perfused
• Upper lung zones predominately ventilated
=VQ mismatch & hypoxemia
Respiratory muscle inefficiency:
• 5 fold ^ o2 consumption

32. 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

34. Positioning

35. Obesity Hypoventilation Syndrome
• Well-known cause of hypoventilation
Caused by abnormal central ventilatory drive &
obesity.
• Expect chronic hypercapnia (PaCo2 >45mmHg)

36. NIV
• Limited data in acute setting
• Most on CPAP @ home for OSA
• BiPAP good for 0HS

37. Circulation
• Hypertension is the norm
• Normotensive = be worried
• Fluid loading often poorly tolerated
• Measuring BP:
– Thigh/forearm
– Doppler
– Consider early art line

38. The ECG
• Low voltage complexes related adiposity over
heart.

39. Disability
• Assessment difficult
– Motor function
– Reflex
– Sensory perception
• Pain perception deceptive
– Often higher pain threshold – missed injuries!

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

41. Getting Vascular Access
• PIVC often difficult
• Ultrasound can help
Consider going early for:
• IO
• CVC

42. Diagnostics
• LP – consider US or CT guided
• Liaise well for
– MRI
– CT
– Cath lab
• Generally have weight restrictions

43. Obese Trauma
Patient

44. Obesity in Trauma
Implications for:
• Assessment
• Management
• Outcomes

45. Injury Patterns
More likely:
• Pulmonary contusions, rib fractures
• Pelvic injuries
• Extremity injury
Less likely:
• Head injuries
• Liver & other significant abdo injuries

46. 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

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

48. Cardiac Arrest

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

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

51. Pharmacology

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

53. Absorption
• ^ absorption for oral meds
– Increased gastric emptying
• Decreased SC absorption
• IMI administration may fail
• Drugs vary based on TBW vs IBW

55. Being Prepared

56. Being Prepared

57. Transport

58. Looking After Your Staff
• Safety focused approached:
– Staff
– Patient
• Policy manual handling
• Environment

59. Questions

60. Take Home Points
• Assessment in challenging
• Bariatric equipment should be available
• Limited CVS & Resp reserves
• Remember RESPECT

61. Thank-you