Management of the obese trauma patient

Patient obesity is associated with severity of proximal humerus fractures, not outcomes

PURPOSE

The purpose of this study is to evaluate the effect of obesity on the outcome of operatively treated proximal humerus fractures.

METHODS

Between December 2003 and October 2020, 240 patients with proximal humerus fractures requiring surgery were prospectively followed and classified according to the international AO/Orthopedic Trauma Association (AO/OTA) and Neer classifications. Patients' body mass indexes (BMI) were calculated and used to identify two groups, BMI ≥ 30 kg/cm (obese) and < 30 kg/cm (non-obese). Independent t tests were used for statistical analysis of continuous variables and χ² tests for categorical variables. Regression analysis was performed to determine if BMI was a predictor of fracture pattern severity as determined by the AO/OTA classification.

RESULTS

Overall, 223 patients who sustained proximal humerus fractures were analyzed. Patient age at time of injury was 60.5 ± 13.7 years. There were 67 AO/OTA 11A, 79 AO/OTA 11B, and 77 AO/OTA 11C fracture types. Seventy-two patients (32.3%) were obese. No significant differences were seen between groups in regard to demographic variables, Neer classification, or functional and clinical outcomes as determined by DASH scores and shoulder ROM, respectively. Statistical analyses confirmed that obesity is associated with more severe fracture patterns of the proximal humerus as categorized by the AO/OTA classification. An independent t test confirmed that BMI was significantly higher in the complex fracture group based on the AO/OTA classification (p = 0.047). Regression analysis also demonstrated that age (p = 0.005) and CCI (p = 0.021) were predictors of more severe fractures, while BMI approached significance (p = 0.055) based on the AO/OTA classification.

CONCLUSION

A significantly higher incidence of complex proximal humerus fracture patterns is observed in patients with higher body mass indexes based on the AO/OTA classification. Age and CCI are also associated with more severe fracture patterns of the proximal humerus as determined by the AO/OTA classification. No differences were seen in outcomes or complication rates between obese patients and non-obese patients.

LEVEL OF EVIDENCE

Level III.

Obesity is associated with a reduced odds for blunt intra-abdominal injuries in children

OBJECTIVES

Children with obesity may possess unique injury characteristics that may affect their emergency care. To better understand this relationship, we investigated the association of obesity in pediatric trauma patients and intra-abdominal injuries (IAIs) and routinely utilized emergency department (ED) diagnostic procedures (computed tomography (CT) scans and ultrasound (US) examinations).

METHODS

This secondary data analysis utilized Pediatric Emergency Care Applied Research Network (PECARN) data from 2007 to 2010. Since height data were not available, children (2-17 years) with obesity were defined using weight-for-age percentiles. Non-parametric testing determined potential confounders. Adjusted odds ratios (aOR) were calculated using binary logistic regression for weight status and IAIs and diagnostic procedures.

RESULTS

There were 3846 patients with actual weight recorded: 3301 (85.8%) children without obesity and 545 (14.2%) with obesity. Children with obesity had decreased odds for IAI after adjusting for race, mechanical force injury (MFI) type, vomiting, and abdominal wall trauma (adjusted odds ratio (aOR)=0.58 (95% CI 0.35-0.97); p-value=0.04). Patients with obesity had reduced odds for a CT examination. No association was found between obesity status and US utilization. African-American patients had decreased odds for IAIs, CT scans and US examinations after adjustment which could be related to MFI type.

CONCLUSIONS

Obesity appears to reduce the odds for pediatric IAIs and CT scans, but not for US examinations. Selection bias is possible due to injury severity and missing or excluded weight data. Further research is needed in other pediatric populations with obesity and blunt injuries.

Obesity Disease and Surgery

Obesity is a medical disease that is increasing significantly nowadays. Worldwide obesity prevalence doubled since 1980. Obese patients are at great risk for complications with physical and psychological burdens, thus affecting their quality of life. Obesity is well known to have higher risk for cardiovascular diseases, diabetes mellitus, musculoskeletal diseases and shorter life expectancy. In addition, obesity has a great impact on surgical diseases, and elective surgeries in comparison to general population. There is higher risk for wound infection, longer operative time, poorer outcome, and others. The higher the BMI (body mass index), the higher the risk for these complications. This literature review illustrates the prevalence of obesity as a diseases and complications of obesity in general as well as, in a surgical point of view, general surgery perioperative risks and complications among obese patients. It will review the evidence-based updates in these headlines.

Effect of body mass index on stroke rehabilitation

OBJECTIVE

To investigate the association between body mass index (BMI) and the functional progress of patients with stroke, admitted to a rehabilitation hospital.

DESIGN

A retrospective cohort study.

SETTING

A freestanding university rehabilitation hospital stroke unit.

PARTICIPANTS

All patients (N=819) admitted to the stroke unit of a rehabilitation hospital during the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary study outcome measure was the FIM efficiency of patients by BMI category.

RESULTS

For the 819 patients admitted during the observation period, BMI was compared with FIM score changes per day (FIM efficiency). After adjusting for age and sex, the FIM efficiency differed by BMI. The underweight group had the lowest FIM efficiency, followed by the obese and normal-weight subgroups. The overweight group had the highest FIM efficiency (P=.05) when compared with the obese subgroup.

CONCLUSIONS

Among patients admitted to an acute rehabilitation hospital for stroke rehabilitation, overweight patients had better functional progress than did patients in the other weight categories.

Complex Interaction between Obesity and Trauma

Trauma and obesity are large-scale epidemics that can be associated with significant morbidity and mortality. In few studies, it has noted that there is the ‘obesity paradox’ (obesity has been found to be protective against mortality) due to certain causes, i.e. heart failure or cardiovascular disease. Subcutaneous fat can show great variability between individuals and increased subcutaneous fat may be protective against injuries by cushioning the internal abdominal organs against injurious forces in road traffic accidents. Many factors including the body fat distribution, body shape, and center of gravity may play an important role in the different injury patterns and severity of injury between men and women. A better understanding of how obesity influences trauma related injuries not only will help to improve the outcome but also foster the development of interventions to address the most salient and modifiable risk factors to reduce obesity related morbidity and mortality. In present article, we review the relevant literature with special considerations to understand the interactions of obesity and trauma with their impact on patient management and outcomes.

How to cite this article

Agrawal A. Complex Interaction between Obesity and Trauma. Panam J Trauma Crit Care Emerg Surg 2014;3(3):109-113.

Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series

Object

The treatment of morbidly obese individuals with spine trauma presents unique challenges to spine surgeons and trauma staff. This study aims to increase awareness of current limitations in the surgical management of spine trauma in morbidly obese individuals, and to illustrate practical solutions.

Methods

Six morbidly obese patients were treated surgically for spine trauma over a 2-year period at a single trauma center in Australia. All patients were involved in high-speed motor vehicle accidents and had multisystem injuries. All weighed in excess of 265 pounds (120 kg) with a body mass index ≥ 40 (range 47.8–67.1). Cases were selected according to the considerable challenges they presented in all aspects of their management.

Results

Best medical and surgical care may be compromised and outcome adversely affected in morbidly obese patients with spine trauma. The time taken to perform all aspects of care is usually extended, often by many hours. Customized orthotics may be required. Imaging quality is often compromised and patients may not fit into scanners. Surgical challenges include patient positioning, surgical access, confirmation of the anatomical level, and obtaining adequate instrument length. Postoperative nursing care, wound healing, and venous thromboembolism prophylaxis are also significant issues.

Conclusions

Management pathways and hospital guidelines should be developed to optimize the treatment of morbidly obese patients, but innovative solutions may be required for individual cases.

Obesity significantly increases the difficulty of patient management in the emergency department

OBJECTIVE

To determine which aspects of ED management are adversely affected by patient obesity, to determine the level of obesity above which management is made more difficult and to make recommendations on how these effects might be mitigated.

METHODS

This was a cross-sectional survey of patients and the staff caring for them in a single ED. Doctors, nurses and radiographers managing consecutive patients, during a range of enrolment periods, completed a self-administered questionnaire. Each was asked to record how the level of their patient's obesity increased the difficulty of specific management items, using a Likert scale. Staff also provided recommendations to mitigate the effects of obesity for each patient, if applicable. For each management item, body mass index (BMI) and management difficulty were correlated (Spearman's rank correlation).

RESULTS

Seven hundred and fifty patients and their ED carers were enrolled. Patient BMI was positively correlated with all aspects of ED clinical management examined (correlation coefficient range 0.28-0.57, P < 0.001). BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture (coefficient > 0.5, P < 0.001). Doctors reported more difficulties than nurses and radiographers. Generally, management difficulty did not increase until the BMI was in the obese or morbidly obese range. Most staff recommendations related to issues of patient mobility including equipment, staffing and bariatric devices.

CONCLUSION

Patient obesity significantly increases the difficulty of ED patient management. Staff recommendations to mitigate these effects were few but may inform changes in ED practice.

Obesity and the orthopedic trauma patient: a review of the risks and challenges in medical and surgical management

The medical and surgical care of obese trauma patients presents a variety of unique and important challenges. Over the past 30 years, this population has increased dramatically in number, and the optimization of their care demands the attention of the medical community. The problems of caring for an obese trauma patient begin before the actual traumatic event occurs due to their substantially higher incidence of serious comorbidities, such as diabetes mellitus, hypertension, and cardiopulmonary issues. In the setting of trauma, important considerations for the obese patient include careful and expeditious preoperative medical optimization; appropriate deep vein thrombosis prophylaxis; planning for and preventing operative and postoperative challenges (eg, pulmonary and wound complications); and ensuring adequate hospital equipment and staffing resources in the acute and rehabilitative phases of care. This article outlines the scope of the obesity epidemic, reviews the medical consequences of obesity, and highlights surgical considerations specific to the care of orthopedic injuries in the obese trauma patient.

Management of upper extremity injuries in obese patients

Upper extremity injuries are more prevalent in obese people than in nonobese people after low-energy falls. Because splinting and casting are inefficient methods of stabilization in the setting of obesity, internal fixation provides stability for mobilization and realignment. Morbid obesity adversely affects positioning, surgical exposures, and complications associated with operative fixation. Avoiding short cuts and complications, morbidly obese patients should be able to return to normal functioning.

[Emergency rescue XXL. Morbidly obese patient in the emergency medical service]

Obesity in Germany is becoming more and more prevalent. Significantly overweight patients (>200 kg) pose an increasing and difficult challenge for emergency medical services, emergency doctors and the hospitals responsible for further treatment. The anatomic and physiological characteristics of patients with extreme obesity must be taken into consideration, particularly the airway, breathing, circulation, disability, exposure and environment of the patient. Furthermore special preparations for medical supplies, concepts and strategies for transport and further treatment in hospital are required. Suitable equipment and coordinated processes are essential for both the safety of the persons involved and the patient's dignity. It is, however, a fact that many organizations and hospitals are poorly prepared for this challenge as the complete infrastructure of a hospital has to be adapted. Emergency transport in a bed should be avoided. Neighboring rescue services must be alarmed at an early stage if the commune concerned does not have adequate means of its own. Politics should guarantee cost-covering remuneration for hospitals and rescue services.