Bariatrics Pt.! What would you do?

I would however state additionally that CPAP certainly has far fewer lethal side effects than RSI, and I think the same could be said for NTG.

With that being said, with clinicians who have planned for failure, this shouldnt be an issue.
 
one thing about this scenario outside of the airway discussion: I noticed you said the hallways were narrow. what about doorways? i have seen some bari pts with specially widened doorways that have been put on 2 lsb lashed together and then placed on tarps and pulled down the hallway, then carried out. if there are narrow doorways, then i think it is time to break out the power saws and sledge hammers and ask which is the least favorite wall.
 
OK - let's say you've decided this patient needs an ETT. How are you going to do it?

These patients are nightmares in a controlled situation in the OR. I wouldn't even consider an RSI on this patient this size in the OR - they'd get an awake fiberoptic intubation with minimal if any sedation. Obviously you don't have that luxury in the field.

So - what's your plan? Position? Drugs? Plan B and C?
 
OK - let's say you've decided this patient needs an ETT. How are you going to do it?
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Surgical airway or a non-visualized airway (Combitube)
 
jwk said:
OK - let's say you've decided this patient needs an ETT. How are you going to do it?

These patients are nightmares in a controlled situation in the OR. I wouldn't even consider an RSI on this patient this size in the OR - they'd get an awake fiberoptic intubation with minimal if any sedation. Obviously you don't have that luxury in the field.
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I have many options in to how I get a tube in to the trachea in the field. It doesn't have to be full blown RSI with Fent, Etomidate and Roc. Heck, I could nebulize some lido and do an NTI. I could do an LMA or a King. I have bougies. I can needle or surgically cric them if need be.


Or I could call in flight, who DOES have video-laryngeoscopy, and use their assistance, even though they can't fly the patient.



That airway is coming under my control if I need it to.
 
usafmedic45 said:
Surgical airway or a non-visualized airway (Combitube)
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Really? 700 lb woman, do you realize how much tissue you are going to need to get through to cric her? Nightmare senario. Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue....I'd stick with PPV, then RSI, and only then your 2 choices, because at that point you are out of options. Not an airway to take lightly, but if it NEEDS securing, then thats what gets done. Just my opinion.
 
700 lb woman, do you realize how much tissue you are going to need to get through to cric her? Nightmare senario.
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Been there...done it. It's not as bad as you might think although far from ideal. The idea of being knuckle deep in someone's neck is not something to be taken lightly but then again neither is the prospect of a dead patient.


Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue.
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Just a quick question: How many 600+ lb people have you dropped airways into just out of curiosity?

As opposed to the same thing definitely happening with PPV without a device? I have used a Combitube on several exceedingly large patients and never encountered the problem you are discussing. Also, if you're using a Combitube and somehow do manage to rupture the oropharyngeal cuff, the air is going to take the path of least resistance and come out the mouth due to there not being a mask being held over it. The same risk you are discussing would theoretically (as is what you're suggesting) exist just the same with a cuffed ETT. Now I would be very hesitant to rely upon an LMA as anything but a way to pass a bougie and then place an ETT, but I have used them as a last resort in a couple of cases in the past.

A helpful hint in these cases when it comes to ventilatory pressures is NOT to lay the patient flat. The more upright you can keep them, the easier they are to ventilate and to place airways into.

then RSI
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That is about the last thing I would do. Maybe some light sedation and a nasal intubation but the last thing I would do is give a morbidly obese patient with an uncontrolled airway a paralytic.
 
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I honestly couldn't tell you, I'd guess a few dozen in excess of 500 lbs, maybe more, and have been lucky in having always secured it with an ET tube. We have a rehab hospital in my city with an entire floor dedicated to bariatric patients, never look forward to going there.

As for supra glottic airways and high airway pressures, my experience is limited to the LMA, having never placed on in the field in this kind of patient I speak from what anesthesia has told me, so take it for what its worth. I have seen problems with high airway pressures and asthma in real life, and can speak, anectdotaly at least that an LMA sucks in a tight asthmatic.

As for the cric, of course it can be done, but been involved in one way or another with several that have gone bad, it would be a last ditch attempt, at least from where i sit.
 
anectdotaly at least that an LMA sucks in a tight asthmatic
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I'll agree with you there. That's one reason why if you're going to use an LMA in someone with a restrictive process you really need to have a ventilator standing by that is able to accurately and effectively deliver an adjustable inspiratory time and pressure.
 
As for the cric, of course it can be done, but been involved in one way or another with several that have gone bad, it would be a last ditch attempt, at least from where i sit.
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Honestly, a cric is a technically more simple procedure than standard intubation. The hardest part about a cric is the decision to pick up the knife and most of the mistakes I have seen or heard about with it are due to lack of practice or excessive stress secondary to a misguided fear of the procedure.
 
boingo said:
Really? 700 lb woman, do you realize how much tissue you are going to need to get through to cric her? Nightmare senario. Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue....I'd stick with PPV, then RSI, and only then your 2 choices, because at that point you are out of options. Not an airway to take lightly, but if it NEEDS securing, then thats what gets done. Just my opinion.
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And I'll ask you...


Do you realize how bad of an idea it is to sit around doing nothing when your patient goes in to respiratory, and than cardiac, arrest, because "It's less than idea" to do a cric or supraglottic airway?


Gotta do what you gotta do when it's gotta get done to get things done.
 
Linuss said:
And I'll ask you...


Do you realize how bad of an idea it is to sit around doing nothing when your patient goes in to respiratory, and than cardiac, arrest, because "It's less than idea" to do a cric or supraglottic airway?


Gotta do what you gotta do when it's gotta get done to get things done.
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I have a pretty good idea, I also realize that no improvement in 5 minutes doesn't equal RSI either. No one is suggesting "doing nothing", perhaps a bit of patience, PPV, TLC and pharmacology is what is needed, padawan....
 
usafmedic45 said:
Honestly, a cric is a technically more simple procedure than standard intubation. The hardest part about a cric is the decision to pick up the knife and most of the mistakes I have seen or heard about with it are due to lack of practice or excessive stress secondary to a misguided fear of the procedure.
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absolutely agree, however in the morbidly obese patient, picking up the knife should probably be the last resort, unless you are very comfortable in opening up a neck. Been there, done that, wouldn't want to do it again.
 
Hey guys...can pt walk and has anyone done 12 lead? Remember....ABC...ambulate before carry..

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Also, sounds like the o2 sat may be off if she is caox's 4. Ntg, bipap at higher settings and maybe some lorazepam for the anxiety could help...not being able to breathe is pretty scary. RSI is a lingering thought but doesnt sound like this one is there yet to me..

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EDIT: Forget it.
 
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Not saying airway shouldnt be a concern, as ppv is a very good treatment for fluid. But, as far as I have read, noone stated that treatments weren't working or pt was digressing. I have performed numerous RSI procedures, all of which were warranted. Not saying you are wrong, but for me, with the info I am seeing, I would hold off.

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absolutely agree, however in the morbidly obese patient, picking up the knife should probably be the last resort, unless you are very comfortable in opening up a neck. Been there, done that, wouldn't want to do it again.
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I'd rather do one in a fat person than someone who is very muscular. Less bleeding.
 
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