MORBIDLY OBESE PATIENT TRAUMA

Trauma in morbidly obese patient
Differences in the mechanisms of injury and associated injury patterns have been described, and obesity has been identified as an independent premorbid risk factor in trauma.

Excessive weight interferes with activities of daily living, therefore increasing the risk of injury. Moreover, the presence of obesity-related diseases such as diabetes, heart disease, and somnolence secondary to sleep apnea may contribute to accidents.

A higher incidence of displaced ankle and elbow fractures has been described in obese patients sustaining minimal trauma (stumbling, low-energy falls). Obese patients have also been noted to be less likely to wear seat belts because of poor fit or discomfort.

Obesity appears to protect the blunt trauma victim from head injury, but is associated with a significantly higher incidence of injuries to the chest, primarily rib fractures and pulmonary contusions. It is hypothesized that the larger torso serves as a physiologic airbag, and although this offers some protection from head injury, there is an associated increase in thoracic injury.

This may partly explain the dramatically higher mortality rate due to respiratory causes in morbidly obese trauma patients. The impact of morbid obesity on mortality in blunt trauma was seen in a study that found a 42.1 percent mortality rate in severely overweight patients, compared with 5.0 and 8.0 percent in the average and overweight groups.

Despite the logistical difficulties the obese patient presents, the principles of trauma management apply, with necessary spinal precautions and full exposure. The presence of subcutaneous fat obscures physical findings in thoracic and abdominal injuries. The limitations of physical findings are further compounded by poor quality portable chest radiographs in this population. A more aggressive approach to airway management with early intubation and assisted ventilation may be indicated.

The incidence of pelvic fractures is higher in the obese trauma victim. Portable films are often of a poorer quality in the obese patient, therefore clinical suspicion of a pelvic fracture should be pursued by repeat views or computed tomography, despite a negative portable pelvic radiograph.