BIG EMERGENCIES
| EMERGENCY CARE OF THE MORBIDLY OBESE —Stephen Schenkel, MD, Assistant Professor, Department of
Surgery and Instructor, Division of Emergency Medicine, University of Maryland School of Medicine, Baltimore
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| Introduction: obese patients have their own set of risks and complications; unlike other scenarios, obesity obvious;
obesity becoming epidemic; people with body mass index (BMI; weight in kg divided by height in m2 ) >40 were
0.8% of population in 1960-1962, 3% in 1988-1994, and 5% in 1999-2000; state of Maryland spent $1.5 billion
and Pennsylvania spent $4.1 billion on obesity care in single year; pretest probabilities change with obese patients,
eg, more likely to have congestive heart failure (CHF), increased mortality, longer hospital stay
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| Syndromes associated with obesity: World Health Organization (WHO) system uses relative risk categories, eg,
patients with highly increased risk have diabetes, insulin resistance, hypertension, dyslipidemia, sleep apnea, and
gallbladder disease; patients with moderately increased risk have coronary artery disease, osteoarthritis, hyperuricemia,
and gout; risk for CHF directly correlated with BMI and how long patient obese; in obese people, relative
risk—of dying from cancer >3 times higher; of dying from coronary artery disease 11 times higher; of death from
all causes 6 times higher than in persons of normal weight; life expectancy—in United States, expected to decrease
due to effects of obesity; many theories, but true mechanism unknown
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| Mental illness: patients surveyed before and after bariatric surgery; depression got better after surgery but personality
disorders stayed
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| Activities of daily living: 1500 morbidly obese patients surveyed; 21% could not wipe themselves after using toilet,
36% could not fit in movie theater seat, 73% could not cut their toenails and would not get undressed in front of
spouse
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| Physical examination: requires large blood pressure cuff; respiratory rate increased up to 40%; if patient’s weight
exceeds scale’s capacity, can have patient stand on 2 scales and add both weights, or stack books even with scale
and have patient put one foot on scale and one foot on stack of books, then double weight on scale; taking weight
on loading dock not recommended; helpful to have assistant holding thighs out of way during pelvic examination;
metal speculum also helpful; abdominal examinations extremely limited, even with help; assume patient has diabetes;
because of decreased innervation, obese patients can have peritonitis without peritoneal signs
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| Diagnostic studies: generally, blood chemistries and liver function tests (LFTs) not altered; brain natriuretic peptide
(BNP) may be falsely low; blood gases should be normal, despite increased respiratory rate; patients with PaO2
<55 mm Hg need further studies
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 | Electrocardiography (ECG): changes due to obesity include—decreased amplitude (because leads farther from
heart); flattening of T waves in leads 2, 3, AVF, V5, V6, and T wave flattening or inversion in 1 and L; some
leftward tendencies in axes; changes not attributable to obesity include—inferior lateral T wave inversion (suggestive
of underlying cardiac deficiency); atrioventricular complexes; sinus or atrioventricular (AV) block; and
fascicular block
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| Lumbar puncture: warn patient that you may not be able to obtain spinal fluid; use sitting position, multiple attempts,
long needle, and assistant; insert needle and ask patient whether needle to left or right of midline; in patient
with BMI of 41, 9.9 cm from skin to spinal canal
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| CT: must know weight limits; girth may be limiting factor; quality of scan often poor because of bulk of patient; for
head CT, if room big enough, patient may be left on stretcher
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| Ultrasonography: can obtain acceptable cardiac ultrasonography in 70% of patients; often requires moving patient
around to get good view
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| General management: ambulances have 1600-lb weight limit; some cities have special heavyweight, oversized
ambulances; operating room (OR) tables big enough to handle large patients (one patient who needed emergency
surgery died because OR did not have table big enough); need specially sized trapezes, wheelchairs, commodes, tables,
bedpans, and hospital gowns
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| Intubation: scoring systems do not work for morbidly obese patients; big neck may suggest difficult intubation; patients
have died because of respiratory compression in lithotomy position; conscious sedation problematic (procedures
ordinarily done in ED may need to be done in OR); positioning—key to intubation; make flat line between
sternum and external auditory meatus; want patient as upright as possible; patients deoxygenate quickly; tilting patient
to left may help; bag-valve-mask may be difficult; if problems occur during intubation—try left lateral decubitus
position; tilting patient gets weight off vena cava; try Combitube, laryngeal mask airway (LMA), continuous
positive airway pressure (CPAP); cricothyrotomy probably not good backup plan because of size of neck
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| Ventilation: CO2 clearance and pH should be similar to normal controls; slightly increased FIO 2 , tidal volume, and
respiratory rate; if patient having trouble, reverse Trendelenburg position may help; lift pannus, and place patient
in lateral decubitus position; holding belly up improves oxygenation
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| Intravenous (IV) access: classic tricks work, ie, extremities lowered, 2 tourniquets (above and below access site),
someone holding skin, IV-over-catheter approach; venous ultrasound-guided technique allows visualization of
needle going into vein (safer and more comfortable for patient than putting in subclavian line)
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| Drug dosing: no good answers; some studies on ranitidine (Zantac), vancomycin, and heparin; some drugs require
dosing based on renal function, ie, creatinine clearance; calculation using actual body weight overestimates clearance,
while use of ideal body weight underestimates clearance (actual clearance somewhere in between); intramuscular
and subcutaneous injections risky
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| Death: “the likelihood of having a huge shroud is pretty low”; morgue drawers may be too small; cremation may not
be option
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| Blunt trauma: big belly protective to some degree in motor vehicle accidents; rib, lower extremity, and pelvic fractures
less likely, ankle and elbow injuries more likely; patients should not be on back board for too long; studies
show morbidly obese patients who stay for >24 hr end up staying much longer with more complications
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| Pregnancy: get help if delivery imminent in emergency department (ED); best to get patient to labor and delivery
suite
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| Bariatric surgery: now being covered by some insurance companies because data show it works; Roux-en-Y gastric
bypass most common procedure; not benign surgery; patients present to ED with complications; look for peritonitis/leakage
and deep venous thrombosis (DVT)/pulmonary embolism; presentations same (patients have back
pain, belly pain, anxiety, and feel “lousy”); long-term complications include cholecystitis, cholestasis, malnutrition,
and small bowel obstruction (need to know procedure that was done in order to recognize anatomy on CT)
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| Counseling patients: difficult to address concerns about patient’s weight; discuss options available to patient
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| AIR AMBULANCE WORTH THE BIG COST? —Marc K. Eckstein, MD, Associate Professor of Emergency Medicine,
Keck School of Medicine of the University of Southern California, Los Angeles, and Medical Director, Los Angeles Fire
Department
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| Prehospital care: helicopter transportation big moneymaker; privately owned helicopter companies fighting over
territories with “payer-rich” areas (patients most likely to have insurance); helicopter transportation costs $5000 to
$10,000 per flight (5 to 10 times charge for ground ambulance); helicopters being used when ambulances might do
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| Inherent risks in helicopter transportation in urban setting: land wherever they can (ie, “helispots” like playgrounds
and freeways, rather than heliports), requiring many ground resources to secure area of civilians and obstacles;
disturbs residents of affected neighborhood; dangerous to fly in adverse weather conditions (when need
highest due to higher likelihood of motor vehicle accidents); unlike planes, helicopters cannot glide after engine
power lost; crash often results in death of patient and medical personnel; increased incidence of accidents
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| Economic concerns: requires 5 hr of maintenance for every hour of use; requires highly trained personnel; strict
regulations for pilots
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| Helicopter vs air ambulance: helicopters multipurpose, air ambulances specifically designed for transporting patients
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| Helicopter vs ground ambulance: noise level limiting factor for managing patients while in helicopter (physical
examination and auscultation impossible); airway interventions should be done on ground before flight; if patient
deteriorates en route, management extremely difficult; air transport times tend to be faster; however, most studies
find no difference in mortality rates; many patients flown by helicopter have relatively minor injuries (low injury
severity scores; 45% of patients transported do not need intensive care unit [ICU] care); should be transporting
high-risk patients by helicopter when medically necessary; study found one third of children transported by helicopter
waiting for discharge by time parents got to ED (very concerning, considering safety and risk factors)
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| Conclusion: helicopters overused in urban settings; risk often involves mortality
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| PANEL: PEDIATRIC CASE —Judith Klein, MD, Assistant Clinical Professor of Medicine, Emergency Services,
San Francisco General Hospital; Lance Brown, MD, MPH, Associate Professor of Emergency Medicine and Pediatrics,
Chief, Division of Pediatric Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital,
Loma Linda, California; Ronald Dieckmann, MD, MPH, Professor of Clinical Medicine and Pediatrics,
University of California, San Francisco, School of Medicine
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| Case: 10-mo-old girl with history of 12 episodes of nonbilious vomiting, 3 episodes of watery nonbloody diarrhea in
last 8 hr; has not taken anything to eat or drink; heart rate 180, BP 75/40 mm Hg, respiratory rate 30/min, rectal
temperature 37.5°C; appears tired but has vigorous cry; mucous membranes dry; has no tears; capillary refill time
on trunk <2 sec; last urine output 8 hr ago
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| Rehydration: Dr. Dieckmann—attempt oral hydration; if vomiting persists, put in IV immediately and give 20 mL/
kg of normal saline or crystalloid solution; Dr. Brown —oral hydration way to go according to literature; families
this works well for are high-maintenance, internet-surfing families that present with list of questions; giving 1 tsp
every minute for 2 hr keeps parents occupied and involved; use IV rehydration in more passive families; nasogastric
(NG) tube unpopular option but would work
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| Antiemetics: Dr. Brown—has had good success with 5HT3 inhibitors like ondansetron (Zofran); comes in oral dissolving
tablet; have not seen any side effects; Dr. Dieckmann—agrees with Dr. Brown; caution about use of antiemetics
in children overblown; ondansetron probably best solution for child like this; NG option might be worth it
in child in which IV or intraosseous (IO) access cannot be started and child will not drink
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| Laboratory work: Dr. Brown—would not get laboratory work; child known to be dehydrated, and gut will balance
electrolytes; speaker orders laboratory tests if using IV route; Dr. Dieckmann—no role for laboratory work in this
patient; clinical evaluation of hydration and perfusion much better than laboratory tests; laboratory work useful
only when child frankly hypotensive (rare)
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| Summary: try oral rehydration; oral ondansetron antiemetic treatment of choice; laboratory work should be reserved
for children who appear toxic or are tachypneic and physician concerned about significant metabolic acidosis, or in
children with persistent vomiting, or children who fail outpatient therapy
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Educational Objectives
| The goal of this program is to educate the listener about obesity, air transport of trauma patients, and the rehydration
of infants. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Illustrate the syndromes associated with morbid obesity.
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| 2. Discuss some pearls in management when evaluating a morbidly obese patient.
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| 3. Describe the electrocardiographic changes associated with obesity.
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| 4. Explain when air transportation should be used.
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| 5. Choose the appropriate route for rehydration of a severely dehydrated infant.
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Discussed on This Program
Albuterol (many trade names)
Heparin sodium injection
Ondansetron HCl [Zofran, Zofran ODT]
Promethazine HCl [Phenadoz, Phenergan]
Ranitidine HCl [Zantac]
Trimethobenzamide hydrochloride [Tigan, others]
Vancomycin [Vancocin, Vancoled]
Programs of Related Interest
Baron RB: Current issues in obesity. Audio-Digest Obstetrics/Gynecology 50:20(Oct 21), 2003; Irons TG, Kaufman
FR: Fat kids. Audio-Digest Family Practice 52:24(Jun 28), 2004; Moody FG, Benotti PN: Surgery for morbid
obesity. Audio-Digest General Surgery 52:01(Jan 7, 2005).
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Asaeda G et al: Utilization of air medical transport in a large urban environment: a retrospective analysis. Prehosp
Emerg Care 5:36, 2001; Bender BJ et al: Intravenous rehydration for gastroenteritis: how long does it really take?
Pediatr Emerg Care 20:215, 2004; Bledsoe BE: Air medical helicopter accidents in the United States: a five-year review.
Prehosp Emerg Care 7:94, 2003; Brunette DD: Resuscitation of the morbidly obese patient. Am J Emerg Med
22:40, (Erratum 22;248) 2004; Eid GM et al: Repair of ventral hernias in morbidly obese patients undergoing laparoscopic
gastric bypass should not be deferred. Surg Endosc 18:207, 2004; Grant P et al: Emergency management
of the morbidly obese. Emerg Med Australas 16:309, 2004; Mathison CJ: Skin and wound care challenges in the
hospitalized morbidly obese patient. J Wound Ostomy Continence Nurs 30:78, 2003; Schwiesow SJ et al: Use of a
modified dosing weight for heparin therapy in a morbidly obese patient. Ann Pharmacother 39:753, 2005; Silbergleit
R et al: Outcome of patients after air medical transport for management of nontraumatic acute intracranial
bleeding. Prehospital Disaster Med 9:252, 1994; Sugerman HJ et al: Conversion of failed or complicated vertical
banded gastroplasty to gastric bypass in morbid obesity. Am J Surg 171:263, 1996; Zalstein S et al: Helicopter
emergency medical services: their role in integrated trauma care. Aust N Z J Surg 67:593, 1997.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the speakers reported no conflict
Dr. Schenkel was recorded May 23, 2005, in Pasadena, California, at USC Trauma/Critical Care Symposium, sponsored
by the Division of Trauma/Critical Care and the Office of Continuing Medical Education, Keck School of Medicine
of the University of Southern California, Los Angeles, and the Institute of Continuing Education for Nurses,
Department of Nursing, Los Angeles-USC Medical Center; Dr. Eckstein, April 17, 2005, in Harrisburg, Pennsylvania,
at PaACEP 32nd Annual Scientific Assembly, sponsored by the Pennsylvania Chapter of the American College of
Emergency Physicians; Drs. Klein, Brown, and Dieckmann, May 11-13, 2005, in San Francisco, at High Risk Emergency
Medicine, sponsored by the University of California, San Francisco, School of Medicine, Department of Emergency
Medicine, and Division of Emergency Services, San Francisco General Hospital. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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