Emergency Nursing of the Obese Patient
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Emergency Nursing of the Obese Patient
Kane Guthrie FCENA
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ED nursing the Obese Patient
• Some Facts & Stats• Pathophysiology & complications of obesity• Critical care management• Trauma management• Pharmacology in the obese• Being prepared
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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!
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The BMI
BMI = weight (kg) divided by (height (m))2.
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BMI Ranges
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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.
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The Stats
• National Heart foundation 2012
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The Stats
• National Heart Foundation 2012
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Obesity in ED
• Becoming common• Confronting issue• Challenges lie:– Managing– Treating
• But also providing:– Dignity– Respect
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Its about RESPECT
R- RapportE- Environment/EquipmentS- SafetyP- PrivacyE- EncouragementC- Caring/CompassionT- Tact
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Pathophysiology & Complications of
Obesity
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“Obesity has multiple pathophysiological effects & leads
to numerous multi-system complications.”
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The CVS System
• ^ Increased venous pressure• ^ Blood volume• Polycythemia (^ Red blood cells)• ^ cardiac output & ventricular work
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Respiratory System
• Restrictive pulmonary physiology • Decreased lung capacity• ^ Pleural pressure – chest wall compression
• Obstructive sleep apnea• Obesity hypoventilation syndrome
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The Neuro System
• ^ICP: – associated with raised intra-abdominal & pleural
pressures.
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The GI System
• ^ Intra-abdominal pressureLeads to:• Renal & hepatic failure• Visceral necrosis
• Can result abdominal compartment syndrome
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Haematology/Immunology
• Hypercoagulable, platelet hyperactivity=Increased risk of VTE!
• Obesity is a proinflamatory state.
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Pathophysiology Effects of Obesity
• Restrictive pulmonary physiology• ^ intra-abdominal pressure• Hyperkinetic circulatory system• Myocardial hypertrophy• Diastolic dysfunction• ^ Circulating blood volume• Prothrombotic state
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Critical Care Management
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The Airway
Securing the airway:– Lack of landmarks– ^adipose tissue– Difficult BVM- preoxygentaion – ^ difficulty – intubation/surgical airway
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Worth a Read!
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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!
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Easily Obstructed
“Airway obstruction is easy in the supine patient”
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The Airway
• High risk of aspiration:– GORD– Hiatus hernia– Increased abdominal pressure
• Regular O2 mask difficult fit• Complicated by sleep apnoea
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Intubating Obese Patient
Equipment:• Laryngoscope – long blade• Video laryngoscope• LMA• Bougie
Surgical Airway Kit:• Have 6mm ETT handy!
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Pre-Oxygenation
• Prepare for difficult BVM– Two handed technique
Preoxygenation:– Sitting up position– Nasal canula 15l (Apneic oxygenation)– BiPAP 100% > 5min
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Ramping
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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!
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Ventilation & Perfusion
• Lower lung lobes predominately perfused• Upper lung zones predominately ventilated
=VQ mismatch & hypoxemia
Respiratory muscle inefficiency:• 5 fold ^ o2 consumption
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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
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Positioning
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Obesity Hypoventilation Syndrome
• Well-known cause of hypoventilation
Caused by abnormal central ventilatory drive & obesity.
• Expect chronic hypercapnia (PaCo2 >45mmHg)
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NIV
• Limited data in acute setting
• Most on CPAP @ home for OSA
• BiPAP good for 0HS
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Circulation
• Hypertension is the norm• Normotensive = be worried• Fluid loading often poorly tolerated
• Measuring BP:– Thigh/forearm– Doppler– Consider early art line
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The ECG
• Low voltage complexes related adiposity over heart.
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Disability
• Assessment difficult– Motor function– Reflex– Sensory perception
• Pain perception deceptive– Often higher pain threshold – missed injuries!
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Exposure
• Exposure is difficult• Look between the adipose tissue • Log roll:– Signs of injury– Infection – cellulitis
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Getting Vascular Access
• PIVC often difficult• Ultrasound can help
Consider going early for:• IO• CVC
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Diagnostics
• LP – consider US or CT guided
• Liaise well for – MRI– CT– Cath lab
• Generally have weight restrictions
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Obese Trauma Patient
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Obesity in Trauma
Implications for:• Assessment• Management• Outcomes
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Injury Patterns
More likely:• Pulmonary contusions, rib fractures • Pelvic injuries• Extremity injury
Less likely:• Head injuries• Liver & other significant abdo injuries
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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
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Trauma Management
• Transport – positioning• Difficult procedures• Difficult airway maintenance• Haemodynamic instability• Aspiration risk• C-spine immobilisation• Chronic inflammatory state
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Cardiac Arrest
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Cardiac Arrest
• Is common• Principles largely the same• Hopefully ILCOR statement in 2015• Effective ECC is challenging
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Cardiac Arrest
• Space around bed/room• Patients position in bed• Maintaining the airway • Using 2 defibs?
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Pharmacology
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Pharmacology
• Obesity affects all aspects of pharmacology• Patients generally under dosed• Require careful drug monitoring
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Absorption
• ^ absorption for oral meds– Increased gastric emptying
• Decreased SC absorption• IMI administration may fail
• Drugs vary based on TBW vs IBW
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Being Prepared
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Being Prepared
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Transport
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Looking After Your Staff
• Safety focused approached:– Staff– Patient
• Policy manual handling• Environment
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Questions
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Take Home Points
• Assessment in challenging• Bariatric equipment should be available• Limited CVS & Resp reserves• Remember RESPECT
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Thank-you