2. ED nursing the Obese Patient
• Some Facts & Stats
• Pathophysiology & complications of obesity
• Critical care management
• Trauma management
• Pharmacology in the obese
• Being prepared
3.
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!
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
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
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