Okay, so my name is Jose Diaz, I am a trauma and acute care surgeon currently at the University of Maryland, and my topic is again the obese patient, but specifically as it is associated with the care of the trauma patient from the perspective of a trauma patient. I have no disclosures. So this is a gentleman we've been talking about, or lady, you know, you basically, and trauma consists of all range of type of mechanisms of injury, from car accident to falling to actually being shot or stabbed. And the pathophysiology of injury we've heard about today in terms of how the metabolic changes that occur, the respiratory issues, the difficulty in moving these patients back and forth, they are similar but different in terms of this patient population. It is still important that we all use the same language. There are clearly defined BMI categories, and I hate to say I'm in the yellow, I think. I need to keep working on that. There are all type of resources that even pre-hospital personnel uses to be able to mobilize these patients, and there are actually, some of these are, you know, trauma bariatric transport, you know, gurneys that are mechanized, as opposed to the old where you had to actually lift and try to move the patients. And if you haven't seen a lot of our paramedics these days, they're not exactly huge big guys, and I've seen some, you know, little folks that are out there trying to move these patients. In the trauma bay, the gurney is still the same size. So imagine, you know, someone who fell at home is weighing somewhere close to 500, 600 pounds, and now you have to move them onto one of these standard size, you know, emergency department tables. So now let's move over to our initial trauma resuscitation. Okay. It's a standard A, B, C, D, E in terms of the trauma resuscitation. Your patient gets on the gurney, they suffered some type of trauma, and now you're trying to see if you can evaluate these patients. There are all types of difficulty with the initial assessment. We've heard about the airway in the ICU, but what about the airway in the trauma bay, and in terms of trying to intubate this patient? Same thing with breathing. You're trying to assess their degree of compliance, but you may not have an idea how well it is that they're going to be able to breathe while they're laying flat. We just heard that some of these patients don't like to lay flat, but we have now forced them. And then what happens if we're trying to put in a chest tube? Turns into a mini thoracotomy sometimes, just being able to feel the chest. In many emergency rooms, we are able to get a chest x-ray or do an EFAS and then determine that there is a pneumothorax. I would suggest to you, it is probably not this patient who's going to get a percutaneous tube, because that tube is going to end up somewhere in the subcutaneous tissue. Circulation, sometimes the EMS can get an IV in some very challenging patients before they show up. A lot of times you end up with an IO either in the shoulder or in the tibia. What happens if you've got three centimeters or three inches of subcutaneous tissue before you can even get to the bone? Now you're having trouble trying to get access. And in the trial bay, then we're stuck having to figure out whether or not we're going to try some eye central access, whether it's an IJ, except the patient may have a collar and they may have fallen or they may have been in a car accident. We haven't had time to assess their C-spine status, and it's not like you're going to be able to turn their head over, because some of their chest or breast are now up in the upper chest, or be able to get access to their groin, because now you have to have someone hold the penis out to feel the pulse. Disability is still pretty standard and straightforward, except maybe the patient who is a high CO2 retainer, and you're trying to figure out whether or not they have had some traumatic injury to their head, or maybe they're intoxicated or fill in the blank. And then rolling. Can you imagine someone who doesn't fit on the bed and you're having to roll them to check their spine and do a rectal exam? You need to put the long gloves on. So the EFAS, this is your initial assessment. In the trial bay, we use an ultrasound device. We do cardiac windows. We do right upper quadrant, left upper quadrant. We look at fluid in the pelvis, and we do cardiac windows. And the EFAS component also includes looking at thoracic cavities, looking for pneumothorax. It may be difficult to find a good window. And we've heard also about different types of patterns of obesity. There are people who actually appear normal size above the waist, and below the waist they appear as a pair. Or they may carry most of their weight in their buttocks or lower extremities. These are a little bit more easier. But the central obesity can be very challenging. The other is that there are patients that have internal obesity, which means that their abdominal wall is maybe normal, maybe about three, four centimeters thick. And then there are others that are like five or six inches thick. And that type of assessment with the ultrasound can be very difficult. We've already heard a little bit about this paradox, what we call in Baltimore urban armor. And it really kind of depends on where you lie, whether or not you have a little bit of armor or a lot of armor. And that is going to be at least dependent on whether or not you're likely to benefit from it, or whether or not you're likely to not benefit from it. And the real question is, what are you benefiting from? Are we talking about survival? We're talking about hospital-acquired infections? We're talking about certain type of injury patterns? So we're going to go a little bit over that. Now the next step usually after the trauma bay is that we roll the patient over to CT scan, the machine that has all the answers, if you punch in the numbers right. Now I do want to show that this is kind of your standard picture. But this is where I'm standing. And a lot of things can happen between the patient getting on the bed and the next thing, the CT scanner rolling through. And as the gurney starts moving, suddenly the IV or the ET tube may not stay in the place you initially put it in, which really makes my day. So some important things. I'm at a large academic institution. And I get a lot of patients transferred in. I get a call, well, we don't have the resources. Our scanner's not big enough. Please take this patient so maybe we can figure out what's going on. Surprisingly, in this particular survey, I'm going to show you a few of them. Only about 10% of non-academic hospitals and 28% of academic hospitals and emergency departments are actually equipped to be able to assess many of these patients. And a lot of our scanners are newer. And we've adjusted some of the CT scans for the local population. The standard apertures are about 70 centimeters, which, as you can imagine, seems like an appropriate size for most everyone, but sometimes that they're not. And the apertures usually range between 75 and 85 centimeters. There are certain scanners, like the PET scanner, that are a little bit bigger, but they're usually not used for emergencies. Even at the University of Maryland, our PET scanner doesn't work on holidays and doesn't work on the weekends and doesn't work at night. So if I have a super obese patient who's 600 pounds, hopefully they'll be okay till Monday. And the other thing I forgot to mention is that the gantry takes up a significant, you know, almost 20 centimeters of every CT scanner. So even though there is a certain device that's maybe appropriate size, it's still taking up a little bit of room. The actual gantry, that's where the patient lies on. And we'll talk about the weight limit of that in a minute. Imaging quality, the technology has improved, but if you're at a place where you're still using maybe 8, 9, or 16 slice CT scan, as opposed to the current multi-detector CT scans, it may not have what I would call enough horsepower. And your initial images may look like that. The other is the gantry. So the gantry is what the patient actually lays on, and there's usually a weight limit. And the average weight limit is about 450 pounds. And I used to work at Vanderbilt at one point, and I can tell you that in the south, as we have heard, we love our biscuits. So you know, sometimes some of our patients are actually beyond that weight. And again, as I mentioned in this particular survey, the gantries are somewhere between 75 and 85 centimeters. I found this survey, which I was actually very interested, because a lot of times, you know, even when I was at Vanderbilt at Swirls University of Maryland, our cities have zoos, and occasionally somebody comes in that is really large, and the question is, you know, whether or not maybe the zoo happens to have a CT scanner. So let me go through the survey, which I found very interesting. So they looked at, in the U.S. hospitals, emergency departments, as well as EDs, zoos, and veterinary schools. Nationally, 10 percent of hospitals, emergency departments, had large weight capacity CT scanners, as well as large weight MRIs, only eight. Pediatric hospitals, across a large capacity CT scanner, about 28 percent of the time, and similarly, 10 percent of the time. Less than a third of hospitals in the U.S. have a large CT scanner. This is 2008. Rural, even less. Large trauma centers usually had more resources, as well. Stroke centers, bariatric centers. Interestingly, there were only two zoos at this time that had a CT scanner, and would not image humans. Veterinary schools, as well, had 57 percent, obviously, had large CT scanner and equipment, and usually this is, you know, for equine or other large animal learning or care. Twenty percent of the veterinary schools reported specific policies prohibiting imaging humans, and patients larger than 450 pounds usually had access to some emergency CT scanner, so I found this very interesting. You know, even though this is 2008, I don't think this type of survey has been done again, but you can imagine still the challenges of taking care of this patient population. So the cushion effect, we've heard a little bit about this, and I want to mention this a little bit more, and I didn't quote any of my work, but I've also had some work that suggests that obese patients have some degree of benefit and don't have a direct higher mortality associated with just being obese, but define obese. How obese are we talking about? So here are three separate papers, sorry, here are three separate papers, and they define that the cushion effects might increase subcutaneous tissue, may be protective, it depends on what type of trauma. The cushion effect may have been especially important in overweight, but low BMI patients have less. And then overweight patients were actually protected from dying during a motor vehicle crash, but they still had certain type of injuries. What type of injuries were those? Orthopedic injuries. It was about late last decade, 2010, 2011, where the most current motor vehicles had about six airbags, okay, so as long as you had your seatbelt on and the seatbelt came across your lap and your shoulder, all six airbags would deploy with an accident greater than 30, 35 miles per hour. Subsequently, your trunk would stay in the same place you put it when you sat in the vehicle. But your arms and extremities might be injured. And then the other is, depending on how high you sat, the airbag may deploy either right into your chest, sparing some of your facial or neck injuries, or could potentially be up a little bit higher. So depending on the injury pattern and the speed, the direction that the accident occurred, you might likely have different type of injuries. And so what we've noted is in patients with high injury pattern, they're mostly orthopedic injuries. So patients usually sitting in the vehicle, they are hit on the side, likely have pelvic and upper and lower extremity injuries, as well as the associated pattern with various complications associated with their operative management. We'll also go over mentioning the, keep moving forward, the intraoperative estimates of blood loss, because as we heard, this patient population's similar to pregnant females, have an increased volume of blood in there, which is different than the average person. We heard a little bit about ICU mobility. It is still very challenging in the operating room. There are no lifts in most of our trauma bays or trauma operating rooms, just individuals. So we heard a little bit about ICU in terms of their outcome. You've heard a lot about also their pulmonary status associated with trying to ventilate these people, but specifically looking at the outcomes associated in trauma patients. So in this particular study, this was about 2,300 patients, 15, the majority were men, as most typical trauma cohorts tend to be. The critically obese trauma patients had a significantly lower odds of mortality than the non-obese patients. The question is why? And so some of this, the penetrating trauma patients had an increase, so we're gonna talk a little bit about a mechanism of injury associated with either blunt or penetrating trauma and why one is higher and one is not. The increased age, as any other type of injury, was associated with a higher odds of mortality. What about the relationship with massive transfusion? This is one of the things I was mentioning about, and this particular study actually demonstrates that this patient population had a higher need of massive transfusion. So this is defined as more than 10 units of PRBCs within the first 24 hours, and they define BMI as greater than 30. And here are the cohorts, about 120, 791 in non-obese. The rate of MTE, or massive transfusion event, in this study was 10%. The massive transfusion rate tended to be higher in the obese patients at 15 to 10%. Adjusting for the injury severity score, the obesity was significantly associated with the massive transfusion event. And the TRAS score, which is a score that they developed in this particular study, was also calculated higher in this patient population. We've heard a lot about the pathophysiology in this patient population associated with their injury, their lung volume, the airway, ventilator control, and to some extent, blood gas and nutrition and the various comorbidities. And just a couple of things about the actual trauma operative management. So in trauma surgery, our goal is to stop bleeding. Our goal is to stop contamination, depending on the injury, and then begin to either repair, reconstruct, or divert the GI tract if that needs to be done. There are some very specific challenges associated with operating on a morbidly obese patient. Usually the challenges are, when their patient has a lot of central obesity, there is at least sometimes several inches of subcutaneous tissue to get into the abdominal cavity. Sometimes they have, as I mentioned earlier, central obesity, and their abdominal wall thickness may not be very thick, but the omentum may actually be very thick, and trying to mobilize the bowel, as well as the mesentery, may be very difficult. And these patients, they usually have a very significant amount of retroperitoneal fat, which makes sometimes even finding the injury challenging. And then try to imagine bringing out an ostomy through about a six-inch abdominal wall. It is a bear. So what about penetrating trauma? Well, penetrating trauma is defined as usually gunshot wounds, or stab wounds. And in this particular study, they looked at 500 patients, of which, you know, about half were stab wounds, and half were gunshot wounds. They looked at the odds ratio for both the overweight and obese individuals, compared to normal BMI, did not suggest a decrease rate in therapeutic operations. So what that basically says, if the patient presented with a penetrating injury, and they appeared to have a truncal injury that entered a body cavity, then the odds of requiring an operation, a therapeutic operation, were the same. First question, but they did not specifically mention in the study how often the missile, or the stab wound, actually ended within that body cavity. Obese and overweight patients, there was no difference in the rate of operative intervention, significant injuries after penetrating axial, compared to normal BMI populations. On the other hand, obesity was not associated with prolonged stay, increased complications, death, and penetrating injuries. Suggesting that these patients weren't really very obese. Again, the armor phenomenon, I think the injury patterns are obviously gonna be different. Obesity, to some extent, may protect you from stab wounds, primarily because typically it's about a third of stab wounds that end up within the body cavity. It's about another third that end up within the body cavity, but don't actually cause an injury. And only a third of stab wounds that actually enter a body cavity actually cause an injury. So even if you're not obese, those are the numbers, those are the averages. And again, so it's not exactly, to some extent, protective, but you do get some degree of protection, at least from a stab wound. Gunshot wounds is a little bit different. Clearly, the missile is going at a higher rate of speed, and if you get shot towards the truncal area, the odds are that you're likely to have an injury. And then obesity portends an increased risk of pneumonia and death. And I think this is partly because, as we heard earlier, we don't do a good job of mobilizing these patients. We tend to sedate them, we tend to make them supine, and we tend to restrict them from mobility, and especially those patients that end up with either major orthopedic procedures, or even laparotomies, or thoracotomies, that decreases your mobility. The abdominal compartment syndrome during the resuscitation of these patient populations is challenging, especially because a lot of times, they actually have chronic abdominal compartment syndrome. It is not uncommon for some of these patients, if you were to do a bladder pressure, to actually measure an elevated intra-abdominal pressure. So just imagine someone who's gotten several MTEs, maybe for a liver injury that did not get an operation, has a bunch of blood in their abdomen, and you decide that you're gonna follow it. Or if you're following peak airway pressures, because maybe that might be a sign of worsening cardiopulmonary process in relation to their intra-abdominal pressure, and you decide to measure intra-abdominal pressure and it's high, it becomes a little bit challenging whether or not you're actually accurately determining whether or not you're moving towards an abdominal compartment syndrome. And now you really have to just keep an eye on it, and make sure that they, from a clinical standpoint, that you know what's going on. Obesity is associated with a six-fold increase in certain types of blunt mortality, or blunt trauma. Obesity is associated with an increase in complications, and that was an independent risk factor. And so these are 2005 studies, and we've already seen a couple other studies that have not really demonstrated whether or not it's a benefit or worse. What we do know is that the orthopedic injuries, the pelvic injuries, the hospital-acquired infections, those are higher. So these patients may not necessarily die because of trauma, but they end up usually staying in the hospital because of their injury pattern is more likely in a certain type of injury. And there are likely to be certain type of injuries. There have slightly increased pulmonary contusions. They have more rib fractures. The evidence of pelvic injury. A morbidly obese patient because of their weight, or if their ground level falls, sometimes can be increased knee dislocations and extremity fractures, which can be very challenging to manage from an orthopedic standpoint. Injuries that are less likely, as I mentioned earlier, these are head injuries as well as liver injuries just from a protective aspect. This information is, we've kind of gone over this already, but again, they're at higher risk of a bloodstream infection, especially respiratory or UTI. As a result, they tend to stay in your hospital a little bit longer. And for every unit increase in BMI, the functional recovery rate can be reduced up to 4% as a measure of their FEM score. So this plays into your disposition process and why we heard earlier today how important it is to at least get these patients up and moving. And a delayed recovery from trauma is directly influenced by their severity of their obesity. Failure to rescue is, I'm sure, in each of your hospitals, a metric to see how well you're doing. CMS, Joint Commission, utilizes this. And so this is actually a very specific question that they looked at in obese trauma patients. So a large study, 95,000 patients, 15,000, 15% were categorized as obese. 3.4% of these patient population went for a laparotomy. 83% were non-obese, and 17% were obese. Obese patients, 47%, had at least one complication. 28% had two or more complications. And this is compared to 33 and 18% in the non-obese patients. So what complications are we talking about? Pneumonia, sepsis, DVTs. So as we heard earlier today, pharmacology's critical in terms of accurately prescribing the DVT prophylaxis, another hospital metric. Pneumonia, making sure that they're on the right vat bundle or pulmonary toilet or getting them extubated, another hospital-acquired infection hospital metric. And then sepsis. I'm sure that just going to the meeting this week, there's several studies and talks going on about sepsis, and this is being a big metric. So as we talk about rescue, and we're trying to get our arms around what exactly that means, this is what that means. Identifying these type of things that are going on, your complications with your patient, being able to identify them, and then trying to predict who is likely to have a potential bad outcome and trying to see if we can head that off at the pass, so to speak. So in conclusion, as obese patients are out there, they're likely to have some type of injury. Their mechanism of injury can be everything under the sun, from being in a car accident to being at the wrong place at the right time to falling down stairs, whether it's outside or at their home. And really, the big issue here is the morbidity associated with the trauma, which is similar to all other trauma patients, but a little bit different and manifests a little bit different in this patient population. And with that, I thank you for your time. Thank you.

care of obese trauma patients

pathophysiology and metabolic changes

standardized language and resources

trauma resuscitation challenges

obese trauma patient complications

early mobility and infection prevention