II. Pathophysiology: Pitfalls

  1. Restrictive Lung Disease
    1. Fatty tissue encompassing the trunk restricts chest expansion
    2. Decreased overall Lung Volume and Functional Residual Capacity
    3. High risk of rapid oxygen desaturation with little reserve or apnea tolerance
  2. Obstructive Sleep Apnea
    1. Large Neck Mass and reduced airway caliber
    2. High risk of airway collapse during sedation
  3. Difficult Advanced Airway placement
    1. Airway visualization is made more difficult by upper airway fatty tissue
  4. Difficult Intravenous Access
    1. Fatty tissue obscures veins
  5. Pulseless Electrical Activity
    1. Obese patients with Hypotension may have pulses difficult to palpate and may appear to be in PEA

III. Management: Respiratory

  1. Apneic Oxygenation technique
    1. Oxygen by Nasal Cannula at 15 L/min (in addition to oxygen face mask)
    2. Increases oxygen reserve and apnea tolerance
  2. Raise the head of the bed
    1. Elevate head of bed to 30 degrees (or reverse trendelenburg position)
    2. Reduces work of breathing (diaphragm and chest excursion)
  3. Noninvasive Ventilation (BiPAP, CPAP, High Flow Nasal Cannula)
    1. Overcomes upper airway obstruction and maintains patency
  4. Advanced Airway Placement
    1. Employ Apneic Oxygenation
    2. Consider hyperangulated intubation blade (e.g. glidescope)
    3. Examine patient for Cricothyrotomy landmarks
    4. Consider intubating with head of bed elevated (or sitting position)
    5. Consider Elastic Bougie use
  5. Ventilator Management
    1. Higher PEEP settings are typically required (10 mmHg)
    2. Tidal Volume is calculated based on Ideal Body Weight (6-8 cc/kg Ideal Body Weight)

IV. Management: Cardiovascular

  1. Blood Pressure
    1. May be difficult to obtain (may require ankle or wrist placement of cuff)
    2. Consider Arterial Line placement
  2. Intravenous Access
    1. Use Ultrasound guidance
      1. See Ultrasound-Guided Antecubital Line
      2. Start at antecubital space (esp. basilic vein at medial or ulnar aspect)
      3. Longer IV catheters may be needed (e.g. 1.88 inch)
    2. Consider Central Line catheter placement technique for peripheral access
      1. Line does not need to extend to right atrium for emergency access
    3. Consider Intraosseous Access

V. References

  1. Orman and Mallemat in Herbert (2015) EM:Rap 15(9):12-3

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