Emergency Nursing of the Obese
Patient
Kane Guthrie FCENA
ED nursing the Obese Patient
• Some Facts & Stats
• Pathophysiology & complications of obesity
• Critical care management
...
Obesity
Obesity is the chronic abnormal or excessive
accumulation of fat in adipose tissue to the
extent that health may b...
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...
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:
– Dignit...
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 & vent...
Respiratory System
• Restrictive pulmonary physiology
• Decreased lung capacity
• ^ Pleural pressure – chest wall compress...
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 ...
Haematology/Immunology
• Hypercoagulable, platelet hyperactivity
=Increased risk of VTE!
• Obesity is a proinflamatory sta...
Pathophysiology Effects of Obesity
• Restrictive pulmonary physiology
• ^ intra-abdominal pressure
• Hyperkinetic circulat...
Critical Care
Management
The Airway
Securing the airway:
– Lack of landmarks
– ^adipose tissue
– Difficult BVM- preoxygentaion
– ^ difficulty – int...
Worth a Read!
Anatomic Alterations
• Large neck circumference
• Excess cervical fat
• Large tongue
• Constricted glottic opening
• Exces...
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 fi...
Intubating Obese Patient
Equipment:
• Laryngoscope – long blade
• Video laryngoscope
• LMA
• Bougie
Surgical Airway Kit:
•...
Pre-Oxygenation
• Prepare for difficult BVM
– Two handed technique
Preoxygenation:
– Sitting up position
– Nasal canula 15...
Ramping
Breathing
Physiological alterations
• Decreased pulmonary reserve
• Increased intra-abdominal pressure
• Rapid onset hypox...
Ventilation & Perfusion
• Lower lung lobes predominately perfused
• Upper lung zones predominately ventilated
=VQ mismatch...
Mechanical Ventilation
• Tidal volume – 6-8ml/kg IBW
• PEEP
– Obese lower FRC
– Leads to collapsed alveoli
– Need higher P...
Positioning
Obesity Hypoventilation Syndrome
• Well-known cause of hypoventilation
Caused by abnormal central ventilatory drive &
obes...
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:
...
The ECG
• Low voltage complexes related adiposity over
heart.
Disability
• Assessment difficult
– Motor function
– Reflex
– Sensory perception
• Pain perception deceptive
– Often highe...
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:
• Hea...
Difficulties with Assessment
• Confounded by pathophysiology
• Clinical exam less reliable
• Mediastinum appears wide on X...
Trauma Management
• Transport – positioning
• Difficult procedures
• Difficult airway maintenance
• Haemodynamic instabili...
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 monitor...
Absorption
• ^ absorption for oral meds
– Increased gastric emptying
• Decreased SC absorption
• IMI administration may fa...
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
• Rem...
Thank-you
Emergency Nursing of the Obese Patient
Emergency Nursing of the Obese Patient
Emergency Nursing of the Obese Patient
Emergency Nursing of the Obese Patient
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Emergency Nursing of the Obese Patient

  1. 1. Emergency Nursing of the Obese Patient Kane Guthrie FCENA
  2. 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. 3. 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!
  4. 4. The BMI BMI = weight (kg) divided by (height (m))2.
  5. 5. BMI Ranges
  6. 6. 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.
  7. 7. The Stats • National Heart foundation 2012
  8. 8. The Stats • National Heart Foundation 2012
  9. 9. Obesity in ED • Becoming common • Confronting issue • Challenges lie: – Managing – Treating • But also providing: – Dignity – Respect
  10. 10. Its about RESPECT R- Rapport E- Environment/Equipment S- Safety P- Privacy E- Encouragement C- Caring/Compassion T- Tact
  11. 11. Pathophysiology & Complications of Obesity
  12. 12. “Obesity has multiple pathophysiological effects & leads to numerous multi-system complications.”
  13. 13. The CVS System • ^ Increased venous pressure • ^ Blood volume • Polycythemia (^ Red blood cells) • ^ cardiac output & ventricular work
  14. 14. Respiratory System • Restrictive pulmonary physiology • Decreased lung capacity • ^ Pleural pressure – chest wall compression • Obstructive sleep apnea • Obesity hypoventilation syndrome
  15. 15. The Neuro System • ^ICP: – associated with raised intra-abdominal & pleural pressures.
  16. 16. The GI System • ^ Intra-abdominal pressure Leads to: • Renal & hepatic failure • Visceral necrosis • Can result abdominal compartment syndrome
  17. 17. Haematology/Immunology • Hypercoagulable, platelet hyperactivity =Increased risk of VTE! • Obesity is a proinflamatory state.
  18. 18. Pathophysiology Effects of Obesity • Restrictive pulmonary physiology • ^ intra-abdominal pressure • Hyperkinetic circulatory system • Myocardial hypertrophy • Diastolic dysfunction • ^ Circulating blood volume • Prothrombotic state
  19. 19. Critical Care Management
  20. 20. The Airway Securing the airway: – Lack of landmarks – ^adipose tissue – Difficult BVM- preoxygentaion – ^ difficulty – intubation/surgical airway
  21. 21. Worth a Read!
  22. 22. 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!
  23. 23. Easily Obstructed “Airway obstruction is easy in the supine patient”
  24. 24. The Airway • High risk of aspiration: – GORD – Hiatus hernia – Increased abdominal pressure • Regular O2 mask difficult fit • Complicated by sleep apnoea
  25. 25. Intubating Obese Patient Equipment: • Laryngoscope – long blade • Video laryngoscope • LMA • Bougie Surgical Airway Kit: • Have 6mm ETT handy!
  26. 26. Pre-Oxygenation • Prepare for difficult BVM – Two handed technique Preoxygenation: – Sitting up position – Nasal canula 15l (Apneic oxygenation) – BiPAP 100% >5min
  27. 27. Ramping
  28. 28. 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!
  29. 29. Ventilation & Perfusion • Lower lung lobes predominately perfused • Upper lung zones predominately ventilated =VQ mismatch & hypoxemia Respiratory muscle inefficiency: • 5 fold ^ o2 consumption
  30. 30. 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
  31. 31. Positioning
  32. 32. Obesity Hypoventilation Syndrome • Well-known cause of hypoventilation Caused by abnormal central ventilatory drive & obesity. • Expect chronic hypercapnia (PaCo2 >45mmHg)
  33. 33. NIV • Limited data in acute setting • Most on CPAP @ home for OSA • BiPAP good for 0HS
  34. 34. Circulation • Hypertension is the norm • Normotensive = be worried • Fluid loading often poorly tolerated • Measuring BP: – Thigh/forearm – Doppler – Consider early art line
  35. 35. The ECG • Low voltage complexes related adiposity over heart.
  36. 36. Disability • Assessment difficult – Motor function – Reflex – Sensory perception • Pain perception deceptive – Often higher pain threshold – missed injuries!
  37. 37. Exposure • Exposure is difficult • Look between the adipose tissue • Log roll: – Signs of injury – Infection – cellulitis
  38. 38. Getting Vascular Access • PIVC often difficult • Ultrasound can help Consider going early for: • IO • CVC
  39. 39. Diagnostics • LP – consider US or CT guided • Liaise well for – MRI – CT – Cath lab • Generally have weight restrictions
  40. 40. Obese Trauma Patient
  41. 41. Obesity in Trauma Implications for: • Assessment • Management • Outcomes
  42. 42. Injury Patterns More likely: • Pulmonary contusions, rib fractures • Pelvic injuries • Extremity injury Less likely: • Head injuries • Liver & other significant abdo injuries
  43. 43. 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
  44. 44. Trauma Management • Transport – positioning • Difficult procedures • Difficult airway maintenance • Haemodynamic instability • Aspiration risk • C-spine immobilisation • Chronic inflammatory state
  45. 45. Cardiac Arrest
  46. 46. Cardiac Arrest • Is common • Principles largely the same • Hopefully ILCOR statement in 2015 • Effective ECC is challenging
  47. 47. Cardiac Arrest • Space around bed/room • Patients position in bed • Maintaining the airway • Using 2 defibs?
  48. 48. Pharmacology
  49. 49. Pharmacology • Obesity affects all aspects of pharmacology • Patients generally under dosed • Require careful drug monitoring
  50. 50. Absorption • ^ absorption for oral meds – Increased gastric emptying • Decreased SC absorption • IMI administration may fail • Drugs vary based on TBW vs IBW
  51. 51. Being Prepared
  52. 52. Being Prepared
  53. 53. Transport
  54. 54. Looking After Your Staff • Safety focused approached: – Staff – Patient • Policy manual handling • Environment
  55. 55. Questions
  56. 56. Take Home Points • Assessment in challenging • Bariatric equipment should be available • Limited CVS & Resp reserves • Remember RESPECT
  57. 57. Thank-you
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