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Bariatric Patients
Presence Regional EMS System
September 2015
Objectives
• Define the terms “Bariatric” and “Obese”
• Discuss the problem of obesity in the United
States
• Discuss medical conditions complicated by a
patients who are morbidly obese
• Outline the plan of care for patients who are
morbidly obese
• Describe means to protect a morbidly obese
patient and care givers during care and transport
What is Bariatrics
a branch of medicine that deals with the
control and treatment of obesity and
allied diseases.
a Bariatric patient is categorized as
morbidly obese if they are:
100 pounds over ideal weight
50-100% over ideal weight
Body Mass Index over 40kg/m2
Obesity is one of the
leading health care
problems in the United
States today.
Obesity/Bariatrics
Condition of an excessive proportion of
adipose (fat) tissue to total body weight
Prevalence has doubled over last 20
years and still increasing
40% of adults are considered overweight
(as many as 9 million adults)
Obesity related medical costs were
estimated to be $147 million annually
Body Weight is the result of
genes, metabolism, behavior,
environment, culture, and
socioeconomic status
How did this Bariatric Epidemic
happen?
In last half of 20th century advent of tasty
and readily available fast food; high in
calories and saturated fats
Developing sedentary lifestyle
200+ cable channels
Video games
How do people become obese?
Everyone requires a certain amount of fat
to create minerals and vitamins for the
body’s use.
There is an imbalance between calories
taken in and calories used to meet
energy needs.
Prevalence of obesity among adults 2009
from the CDC
Body Mass Index Chart
Caloric Balance Equation
Overweight and obesity result from an
energy imbalance, this involves eating too
many calories and not getting enough
physical exercise/activity
Behavior and environment play a large
role causing people to be overweight and
obese. These are the greatest areas for
prevention and treatment
How To Achieve Caloric Balance
Food Diary
Writing down foods and beverages you
consume
Yes, there are Apps for that
Physical Activity Diary
Document the physical activity you have
done
Pedometers measure the number of steps
taken daily
Medical Treatment for Obesity
Dietary
Reduce calorie intake
Feeling full on less
Healthy eating
Meal replacements
(energy shakes)
Increase Activity
Exercise
Increase daily activity
Behavioral Changes
Behavior modification
Support groups
Prescription weight
loss
Olistat (Xenical)
Blocks the digestion of
fat in stomach and
intestines
Unabsorbed fat is
eliminated in the stool
Don’t they have surgery
for Obesity??
Surgical Treatment
Lap Band
One Weight loss
Component
Reduces the size of
the stomach
Gastric Bypass
Two Components
Reduce the size of the
stomach
Reduce Caloric
Absorption
Complications of Gastric Surgery
First 12 weeks after surgery
Nausea and vomiting
Decreased ability to absorb fluids due to
surgery
Sepsis due to leaking at surgical sites
Fluctuations in BP due to changes in body
size and poor absorption of medications
Psychosocial Response to
Obesity
Obese patients may be embarrassed by
their condition and fearful of ridicule as a
result of past experiences.
Some of the negative interactions may
have occurred with an insensitive health
care professional.
Mobility and the person’s general quality
of life are often negatively affected by
their size.
Obese persons are often ridiculed
publicly and are sometimes are victims of
discrimination.
Many obese patients have not been out
of their home for months or years.
When EMS is called these individuals
find themselves the center or attention,
surrounded by emergency vehicles,
curious onlookers and sometimes the
media.
Other Medical Problems
Associated with Obesity
Diabetes
High blood pressure
Elevated cholesterol
Heart disease
Asthma
Sleep apnea
Gallstones
Hepatitis
Heartburn
Skin infections/Ulcers
Infertility
Urinary leakage
Depression
Self-esteem issues
Dementia
Gout
Immobility
Joint Pain
Osteoarthritis
Breast and colon cancer
Cardiac Disease: Seen at Younger
Ages
Overall increase in both morbidity and
mortality
Coronary artery disease
Atherosclerosis
Hypertension
For every 5 lb. weight gain BP increases 3 mm/Hg
CHF
Sudden Cardiac Arrest
Peripheral vascular disease
As weight increases risks increase
Pulmonary Diseases
Decrease in lung volumes
Increased oxygen demand due to size
Increased work of breathing
Higher airway resistance
Decreased respiratory system compliance
Flattened diaphragm
Hypoxia
Pulmonary vasoconstriction
Depressed heart function
Tachypnea
Becomes short of breath easily with only mild
exertion
Pickwickian Syndrome
Obesity hypoventilation syndrome
Unable to take in enough oxygen to meet body’s
needs
5-10% of morbidly obese suffer this
Left and right sided heart failure
Obstructive sleep apnea
Short, thick neck and small oropharyngeal diameter
Symptoms
Cyanosis
Hypoxia
Chronic acidosis
Marked daytime sleepiness
Diabetes
80% of people with Type II diabetes are
obese.
Type II diabetes
Produce adequate amounts of insulin but
Insulin unable to effectively stimulate the cell to admit
glucose
Increases weight = increase size of fat cells
Large fat cells have decreased proportion of insulin
receptors
With weight loss insulin receptors in more appropriate
numbers
Signs and symptoms of Type II diabetes recede
Trauma
Poor mobility due to weight
Interference with activities of daily living,
axial loads and balance issues
Displaced ankle and elbow fractures with
minimal trauma
Less likely to wear seat belts
Subcutaneous fat hides physical findings
Increased length of stay in hospital
Chronic Joint Pain
Morbidly obese patients may overcome
mobility problems by pulling, rocking or
rolling into position.
Constant strain on body structures may
leave them with chronic joint injuries
and/or osteoarthritis
The Bariatric Patient is
first and foremost a
PATIENT.
Management of the Bariatric
Patient
Treat the patient with dignity and respect
Provide thorough and professional
medical care.
Bariatric patients frequently have
complex and extensive medical history
so get a good medical history and
perform a good physical exam
Bariatric patients tend to blame signs and
symptoms of their illness on their weight
Assessment
Remind the patient that their physical and
psychological well being are your priority
Keep the patient upright to facilitate
ventilation
Check for cyanosis inside lips or eyelids
Airway Management
Extra skin and adipose tissue around the
face, bottom of the chin/neck, and
posterior upper chest can interfere with
respiratory function when the patient is
supine.
Extra adipose tissue in the cheeks, lower
jaw and anterior neck place pressure on
the tongue and glottic opening
Airway Management
High risk for aspiration
If BVM ventilation required use 2 person
technique to assure good seal and
adequate ventilation
May need higher volumes to displace
diaphragm
If using CPAP higher pressures (up to 10
cm3) may be needed
Intubation
Pre-oxygenation is critical
Desaturation is quicker because of
decreased reserve and normal tendency
towards hypoventilation
Sitting upright 25 degrees improves
ventilation
Difficult ventilation
Need for higher ventilation pressures
Large tongue and head weight
Intubation challenges
Mallampati Classifications
Used to predict ease of intubation
Extra tissue in airway leads
to higher Mallampati
Classifications and more
difficult intubations
Airway Intubation Techniques
Rolled Towels or Blankets
Between scapulae
Displaces breast tissue
Under occiput to account for fat in back
Sniffing position
Elevate arms to move neck tissue out of the
way
Combi-tube or King Airway frequently the
best option
Breath Sounds
Auscultate lung sounds anteriorly on
chest to avoid dulling of sounds by
adipose tissue
If listening posteriorly stay just below
scapula on either side of spine.
Diagnostic Equipment
Blood Pressure
Inadequate width and circumference cuff
can give elevated readings
If the Velcro “cracks” the cuff is too small.
In general with width of the cuff should be ½
to 1/3 the circumference of the arm.
Pulse Oximetry
Tissue thickness impedes light wave
Consider alternate placement
Earlobe
Smaller fingers
IV Access
Difficult to visualize and palpate
Delay in access
Higher complication rates
Multiple attempts
Wound infections
Phlebitis
Unrecognized extravasation into surrounding tissue
Standard catheters of 1.5 inches may be
inadequate in length
IO needs a longer needle
Cardiac Monitoring
Place monitoring electrodes on arms and
thighs rather than chest
Difficult to find landmarks for 12 lead
placement
Decreased or inconsistent voltage
Changes with obesity
flat/inverted T waves in inferior leads
P, QRS and T axis more leftward
More left ventricular hypertrophy
Prolonged QT interval
Medication uptake
Patients receiving oral medications must
have their dosages and even routes
adjusted for the changes in absorption
capacity with and without Bariatric
surgery
Excess body fat can alter medication
absorption and storage, this does not
seem to have an affect on IV
resuscitation medications
Spinal Motion Restriction
No Bariatric sized equipment currently
available
Concentrate on
Minimizing movement
Keep the patient as still as possible
Attempt to keep patient supine
Moving a Bariatric Patient
Planning
Patience
“Its not if…but when”
Every agency needs to be prepared to
handle a bariatric patient. The right
equipment ensures not only patient
safety but the safety of your crews.
Anticipate it will take up to 10X longer to
extricate an obese patient from their
home.
Pre-planning
Where are the obese patients in your
response area?
Can you communicate with them ahead of an
emergency?
Where do they live in their house? (obese patients
frequently limit their mobility within their home)
What equipment is available in your community.
How quickly can you access it?
How can you get your equipment in and the patient
out?
Moving the Patient
Ask the patient how it is best to move
him/her before attempting to do so.
Avoid trying to lift the patient by only one
limp which could injury overtaxed joints
Have enough providers to move the
patient safely. (4-6 minimum)
Coordinate and communicate all moves
to all team embers prior to starting the lift
If the move becomes uncontrolled at any
point: stop, reposition and resume.
Continually communicate with the patient
regarding the move. Bariatric patients
frequently are scared of moving and/or
being dropped.
Assess for pressure or pinch points from
equipment: can cause skin breakdown
Plan egress routes to accommodate
large patients, equipment and sufficient
numbers of lifting crew members
DO NO HARM
Notify the receiving facility early to allow
for special arrangements to be made to
accommodate the patient.
Bariatric Transport Safety
Planning is essential
Bariatric transport unit
Bariatric assets (cot, lifting/moving
equipment)
Adequate number of personnel
Cots
Ferno
LBS System 1000 lb.
capacity
Stryker Bariatric Cot
1600 lb. capacity
Review
Answer the following questions as a group.
If doing this CE individually, please e-mail your
answers to:
[email protected]
Use “September 2015 CE” in subject box.
You will receive an e-mail confirmation. Print
this confirmation for your records, and
document the CE in your PREMSS CE record
book.
IDPH site code # 067100E1215
Review
How is obesity defined based on Body
Mass Index?
1.
What are two ways to try to manage
obesity without surgery?
2.
3.
What are two surgical procedures that
might be done to control obesity?
4.
5.
What are two ways that obesity might
effect a patient psychologically?
6.
7.
List three medical conditions complicated
by obesity.
8.
9.
10.
List 2 professional ways to approach the
management of an obese patient.
11.
12.
List 3 ways you may need to modify
patient care for someone who is obese.
13.
14.
15.
Consider your own agency and
community
You and your team have been called to help a
woman who weight 500+ pounds. She is
having chest pain and needs to go to the
hospital. She is in the living room of her house
on a large recliner. What decisions to you
need to make in order to move her safely?
What equipment will you need? Where can
you get this equipment? How many people will
it take to move her safely? (There is no right or
wrong answer for this. Brainstorm how your
agency will manage this.)
Answers
1. BMI of greater than 40 kg/m2
2. Reduce caloric intake: food diary,
healthy eating, supplemental shakes;
3. Increase activity; behavior modification,
support groups
4. Lap Band
5. Gastric bypass
6. Embarrassment
7. Fear of ridicule , isolation
8. Heart Disease
9. Pulmonary Disease, Hypoventilation
10. Type II Diabetes
11. Treat the patient with dignity and
respect
12. Provide thorough and professional
medical care; perform a good physical
exam and history
13. Patient needs to sit upright
14. Use 2 people to BVM if needed; use
towel rolls to position airway
15. Listen to breath sounds anteriorly
Place EKG leads on arms and thighs,
Use larger IV catheters, use larger BP
cuffs, pulse oximetry on earlobes, modify
spinal motion restriction.