The bariatric patient: DipIMC practice questions

Answer: E

Follow the standard ALS algorithm, with standard shock energies and drug doses

Resuscitation Council UK Guidelines 2025 (special circumstances) state that obese patients should receive standard resuscitation treatment, with no deviation from standard basic life support (BLS) and ALS, and the adult ALS guideline says to use standard energy levels in obese patients. The first biphasic shock is therefore at least 150 J (130–150 J for pulsed biphasic waveforms), with the energy increased for subsequent shocks if the first is unsuccessful, and adrenaline is 1 mg after the third shock, repeated every 3–5 minutes. Antero-lateral is the pad position of choice for initial placement; an antero-posterior position is considered as a vector change for refractory ventricular fibrillation (VF) after three failed shocks. Up to three stacked shocks are considered only when VF occurs during a witnessed, monitored arrest with a defibrillator immediately available, which is not the situation in a supermarket. What does change is the practical work: ABC of Prehospital Emergency Medicine (Ch. 31) notes that body mass index (BMI) predicts difficulty with face-mask ventilation, so plan airway management, and the extra people and equipment needed to move him, early.

Answer: A

Ramp the head and shoulders until the ear tragus is level with the sternum

In morbid obesity functional residual capacity is significantly reduced and supine positioning exacerbates the problem, resulting in further hypoxia; the patient will rapidly desaturate during even a brief period of apnoea (ABC of Prehospital Emergency Medicine, Ch. 31). The ABC describes the ideal position for airway management as the sternum level with the tragus of the ear, achieved by elevating the head and shoulders with wedges, blankets and pillows or a purpose-made device; it aids laryngoscopy, improves ventilatory function and reduces the risk of aspiration. The AAGBI/SOBA 2015 guideline gives the same ramped position, tragus level with the sternum, during induction of anaesthesia, and says it improves lung mechanics and so assists oxygenation and ventilation. Prolonged pre-oxygenation with a tight-fitting mask, a four-handed bag-valve-mask technique if needed, and difficult-airway equipment to hand complete the preparation. Keeping her flat preserves the position that is worsening her hypoxia, and neither source describes leg elevation, full sitting intubation or the lateral position for induction. The ABC also notes that body mass index (BMI) alone does not necessarily predict a difficult intubation but does predict difficult face-mask ventilation.