19.3 Bariatric Trauma, Medical Care, and Pharmacology
Key Takeaways
- Ramp to ear-to-sternal-notch, preoxygenate, and plan video laryngoscopy; a flat bariatric patient desaturates in seconds.
- High peak pressure often reflects chest wall and abdomen, not automatically bad lung compliance; use PEEP and plateau, not a single PIP panic.
- Hidden problems: DVT and PE, rhabdomyolysis after a prolonged down, pannus infection, delayed peritoneal signs, and binders that do not fit.
- Succinylcholine is usually total body weight; induction agents are usually lean body weight; heparin follows protocol and a written weight definition.
- After bariatric surgery, late dumping is hypoglycemia, and unexplained tachycardia is an anastomotic leak until a surgeon says otherwise.
A 180-kilogram patient desaturates on a clock the cabin cannot pause. Domain 5.D of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests bariatric trauma, medical, and pharmacological care because airway geometry, pleural pressures, drug volumes, and hidden peritonitis do not scale linearly with the stretcher. Transport logistics — weight-and-balance, doors, and destination tables — live in section 19.4.
Airway: ramp, preoxygenate, video
Functional residual capacity (FRC) is already small. The abdomen and chest wall encroach on the lungs when the patient is supine. Desaturation after apnea is measured in seconds, not minutes.
Ramping — blankets, a commercial ramp, or a head-elevated laryngoscopy position (HELP) so the ear canal aligns with the sternal notch — is the first airway intervention. A flat litter is a failed plan. In a narrow cabin you still owe that alignment (19.4).
Preoxygenate sitting up if the spine allows. Use a tight mask and positive end-expiratory pressure (PEEP) or a nasal cannula under the mask. Video laryngoscopy (VL) is the usual first look; the anterior airway and redundant tissue punish a single blind pass. Have a second operator ready for bag-valve-mask (BVM) two-person technique and a staged supraglottic rescue. Do not burn the first attempt on a quick look with no ramp.
Ventilation: high pleural pressure is not automatically bad lungs
The ventilator will show a high peak inspiratory pressure (PIP). That number is not by itself acute respiratory distress syndrome (ARDS). Chest-wall and abdominal mass raise pleural pressure. The lung may still be reasonably compliant. Plateau pressure and driving pressure tell you more than a single PIP alarm. Adequate PEEP keeps FRC open; zero PEEP on a supine bariatric patient is how you grow atelectasis before the next radio call.
Do not automatically dump tidal volume to a child's number because the PIP looks scary. Do use ideal-body-weight (IBW) tidal-volume math (about 6 mL/kg IBW as a starting lung-protective frame — clinical teaching, not a BCEN constant) and then watch end-tidal carbon dioxide (ETCO2) and saturations. If the abdomen is a stone, sit the head up as far as the aircraft allows.
| Finding | What it often means | Trap |
|---|---|---|
| High PIP, acceptable plateau | Chest wall / abdomen, not stiff lung | Paralyzing the ventilator instead of ramping |
| Rapid desaturation | Tiny FRC | Flat, un-ramped apnea |
| High ETCO2 after intubation | Under-ventilation plus CO2 production | Chasing only FiO2 |
| Sudden PIP spike | Tube kink, mainstem, or abdominal compartment | Ignoring the belly |
Trauma and medical: what the wall hides
Deep-vein thrombosis (DVT) and pulmonary embolism (PE) risk is high (Chapter 16). Prolonged down time, surgery, and immobility on a scene add to it. Sudden hypoxia with a decent tube is a PE until you have another explanation.
Rhabdomyolysis follows a prolonged down — found on the floor after hours against a hard surface. Check for tea-colored urine if you can, give volume per protocol, and warn the receiving team about hyperkalemia and renal failure. Dependent muscle can hide a compartment syndrome you cannot palpate through a thick limb. Pain out of proportion and a hard feel still matter.
Skin and pannus infections, yeast, and intertrigo are not cosmetic. Lift the pannus on purpose. Look for pressure ulcers, Fournier-range perineal infection, and a hidden source of sepsis. Dry and separate folds before you strap.
Peritoneal signs are delayed. A thick abdominal wall hides rigidity. Tachycardia, a rising lactate, or a story of handlebar or lap-belt trauma can be a hollow-viscus injury with a soft exam. Do not clear the belly because it is obese.
A standard pelvic binder may not reach, may ride onto the abdomen, or may not generate force across the greater trochanters. If you cannot seat it correctly, do not pretend you have closed the pelvis. Say so. Compartment checks on calves and forearms still belong in the reassessment, even when the tape measure is discouraging.
Dosing: which weight
Weight-based is not one number.
- Succinylcholine is typically dosed on total body weight (TBW) so the fasciculations actually happen.
- Induction agents (propofol, often fentanyl and midazolam) are typically dosed on lean body weight (LBW) so you do not vasodilate a 180-kg circulating volume you do not have.
- Nondepolarizing blockers such as rocuronium are often dosed on ideal or lean body weight; RSI still needs an adequate intubating dose, not a timid underdose.
- Unfractionated heparin infusions are commonly started on actual or adjusted body weight per protocol, often with a stated maximum.
Label every one of those as clinical teaching. Your program's card wins. Write the weight you used and which definition it was.
After bariatric surgery: sugar and leak
Dumping versus anastomotic leak
Roux-en-Y and similar reconstructions change glucose and anatomy.
Dumping syndrome can produce tachycardia, diaphoresis, and then hypoglycemia — especially late dumping. A weak and sweaty month after bypass is a glucose until you prove otherwise. Carry dextrose you can actually give.
Anastomotic leak is a surgical emergency. The most sensitive bedside sign is often unexplained tachycardia. Fever, shoulder pain, oliguria, and a soft exam can follow. This is not gastritis at cruise. Fly to a hospital that can take a bariatric abdomen back to an operating room tonight, not to a community scanner that cannot fit the patient (19.4).
A 170-kg patient needs intubation on the ramp. The litter is flat and the first plan is a single direct-laryngoscopy look. What is the correct sequence?
After intubation a bariatric patient's peak inspiratory pressure is high but the plateau is acceptable and saturations rise with PEEP and a ramp. What does that pattern usually mean?
Two weeks after Roux-en-Y bypass a patient is tachycardic, sweaty, and becoming confused in cruise. Finger-stick glucose is 48 mg/dL. Which statement is correct?