General Principles in the Care of the Obese Trauma Patient Objectives At the conclusion of this presentation the participant will be able to: Describe how the obesity epidemic impacts the delivery of trauma care. Discuss considerations needed in the initial assessment of the obese trauma patient
Describe the management of blunt, penetrating, and burn injures in the obese patient US Most Obese Country in World 1. United States 2. Kuwait 3. Croatia 4. Qatar 5. Egypt
6. United Arab Emirates 7. Trinidad and Tobago 8. Argentina 9. Greece 10. Bahrain Epidemiology (BMI>30) 33.8% of the population Comorbidities
Hypertension DM Stroke Cancer Asthma Sleep apnea
Definition of Obesity Overweight with BMI over 25 to 29.9 Obese with a BMI of 30 to 39 Morbid Obesity with a BMI of 40 or more BMI= ratio of weight (kilograms) to height (in meters) Cost of Hospital Care Higher
Infection rate Ventilator days CVP days ICU LOS Hospital LOS Mortality rate
Long term disabilities http://www.nydailynews.com/polopoly_fs/1.1097737!/img/httpImage/image.jpg_gen/derivatives/landscape_370/image.jpg Epidemiology Trauma is leading killer: 1-44 years old Mortality 8x higher in the obese population MVC
$200.3 billion Costs $478.3 billion Challenges/Considerations Pre-hospital care
Personnel Equipment Transport Ground/air POV Intrafacility
Patterns of injury Assessment Adjuncts Mortality/morbidity Pharmacology Heavy Lifting For Ambulance Crews, Obesity Epidemic Is
Changing Emergency Medical Transport Headline in Hartford Courant Oct. 20, 2012 Principles Primary Survey
Focused Adjuncts Secondary Survey Tertiary Survey Coordination of care Airway (C-Spine Protection) Airway (C-Spine Protection) Challenges
Short thick necks Poor extension Loss of landmarks Adipose tissue Fat deposits in pharyngeal tissue Gastro-esophageal reflux Backboard weight limits Increased airway resistance
Airway (C-Spine Protection) Considerations Position with head of bed slightly elevated Use of sandbags and tape for immobilization Gastric tube insertion Dedicated member to maintain c-spine
control Early surgical cricothyrotomy Optical equipment (i.e.: video laryngoscope) History of gastric banding Breathing Breathing Challenges Fat deposits in diaphragm and intercostal muscles Elevated diaphragm
Rapid desaturation Chest weight Skin folds Increased work of breathing Sleep apnea Impaired lung compliance Tension pneumothorax Breathing Considerations
CPAP Reverse trendelenburg Move all skin folds 2-person bag-mask ventilation Needle decompression/ chest tube placement Awake intubation vs.. RSI
Wikimedia.com Intubation Indications Positioning Pre-oxygenation Rapid Sequence Intubation Ventilator Settings Alternatives Mallampati Scale
Wikimedia.org Circulation Circulation Challenges Adipose tissue Lacking carotid and femoral pulse landmarks Non-hypertension state Hypertension CHF Normotension may be
hypotension Pericardial tamponade Circulation Considerations IV Access Cardiovascular Assessment Monitoring
Disability Disability Challenges Sleep apnea somnolence Difficult to determine GCS Lack of mobility Airway problems with less neurological impairment
Disability Considerations Close monitoring of GCS Early discharge planning Establish baseline marilyn barbone / Shutterstock.com Exposure/Environment Exposure/Environment
Challenges Skin shearing Hypothermia Longer entrapment times Inspect for skin rashes, fungal infections, decubitus, wounds Large pannus Exposure/Environment Considerations
Larger patient gowns Moving boards Assistance Stretchers/beds Primary Survey Adjuncts Considerations
Penetration Weight limits Transport Secondary Survey Challenges Large arms ECG variations
Low QRS voltage leftward shift of P wave, QRS wave, T wave axes Left ventricular hypertrophy Left atrial abnormalities Thick fingers Abdominal weight Secondary Survey
Considerations Normotension may be hypotension
Mark cardiac probes Pulse ox probe to earlobe Need for gastric tube Need for urinary catheter Large BP cuff or CVP Nosocomial infections Use of doppler Give Comfort Challenges
Patient size Bias Stigma Psychosocial issues Give Comfort Considerations Addressing bias may be first step to
improving outcomes Medication doses Specialized beds and equipment Inspect Posterior Surfaces Challenges Number of people needed to log roll Patient safety Bed width
Skin folds Considerations Additional staff Interlock beds Caveats
Disposition Post-Operative Care Missed Injuries Fractures Morbidity Mortality Pharmacology
Consultations Disposition Decide early Interfacilit y transfers Intrafacilit y transfers Post Op Care Wound
LOS Infection Metabolic Skin Nutrition Missed Injuries
Sternal fractures Flail chest Pelvic fractures Rib fractures Pulmonary contusions
Fractures Strength of rods Compartment Syndrome Casting more difficult TLSO Morbidity and Mortality Morbidity
Lack of primary care Isolation Non-compliance Mortality Multisystem organ failure Traumatic brain injury Cardiac failure
Respiratory arrest Pulmonary embolism Pharmacology Drug effect considerations: Distribution Renal clearance Hepatic metabolism Protein binding
Dose weight (DV) Ideal body weight (IBW) ;Total body weight (TBW) DW = IBW + 0.3 (TBW IBW) Common drugs Antibiotics Anti-thrombotics Pain control Consultations
Consultations Nutrition Pharm D Primary care providers Case management Social work Sleep apnea Management: Blunt Trauma TBI
More Complications Higher Mortality Fewer Head Injuries Cushion Effect
Management: Blunt Trauma Chest Higher incidence of chest injuries Incidence of thoracotomy similar to lean counterparts Obesity-related injuries: [not found in lean]
Management: Blunt Trauma Abdomen Ultrasonography Damage Control Laparotomy (DCL) Laparoscopic Abdominal Repair Cushion Effect DPL
Management: Blunt Trauma Management: Blunt Trauma Musculoskeletal High-speed side impact MVC Obese less likely to sustain severe pelvic fractures vs.. lean counterparts Pelvic Fracture Operative Repair Complications 19% Lean patients
39% Obese patients Return to OR following initial operative repair 16% Lean groups 31% Obese groups Management: Blunt Trauma Spinal Cord/ Vertebral Column Literature suggest obese less likely to sustain column or
cord injuries Wikimedia.org Management: Blunt Trauma Complications Overall obese patient 42% higher complication rate vs.. 32% lean population Require slightly higher total hospital LOS (24 vs.. 19 days) Higher ICU LOS (13 vs.. 10 days) Slightly higher ventilator days > 2 days vs..
lean No difference in incidence of pulmonary complications Management: Blunt Trauma Complications NIH / WHO: Obese vs.. Lean Severe Trauma Increased ICU LOS Increased propensity of: Cardiac arrest Acute Renal Failure Multisystem Organ Failure
No difference in initial leukocyte inflammatory response However, resolution of initial inflammatory response appears to be lengthened in the obese population Management: Penetrating Trauma Current Clinical issues Similar to blunt trauma management Challenges related to body habitus similarly associated in blunt trauma Prohibitory radiological imaging due to body habitus
Airway control in obese patient Prohibitive diagnostic ability (i.e. ultrasound, radiological imaging, laparoscopic intervention) all due to body habitus Management: Burns Increased surface area Increased LOS Increased complications
Summary Obesity is an increasing epidemic There are special physiological, social and emotional considerations in caring for critically injured patients that healthcare providers must understand Intervention measures specific to the management of critically injured patients is paramount to optimal outcomes
