Showering of fat emboli to pulmonary and systemic circulations in trauma and orthopedic surgical patients usually results in subclinical symptoms 1-5% are associated with clinical symptoms termed FES Cause: 2 theories Mechanical theory: injuries or surgeries of long bones or pelvis increase intramedullary pressure force large fat droplets into systemic circulation Enters Rt heart and lungs mechanical obstruction of pul microcirculation acute pulmonary HTN & localized ischemia and inflammation fat induced ac lung injury May enter systemic arterial circulation through intracardiac shunts or by traversing pul capillary bed cerebral and cutaneous embolization Biochemical theory: obstructive and toxic Biochemical (sp hormonal) changes occur with trauma and sepsis systemic release of FAs as chylomicrons coalesce (obstructive theory) Free FAs directly toxic to pneumocytes and pul capillary endothelium interstitial Hge and chemical pneumonitis (toxic theory) Esp attractive when FES occurs in the absence of trauma Clinical findings in FES Fat embolism is primarily a clinical diagnosis Missed b/c of subclinical sym, delay in onset of 24-72hrs, presence of additional traumatic injuries Predisposing conditions Risk assessment Orthopedic surgery of lower extremities, esp hip and knee arthroplasty and intramedullary nailing of femoral shaft ( increases medullary pressure to 1000mm Hg predisposes to FES)
More frequently in closed/undiaplced than open/displaced fractures vent for
medullary fat Very less likely to occur in children compared to adults Delayed stabilization (>24hrs) increases the risk Intramedullary rod placement Joint replacement surgery esp revisions or b/l Femoral metastasis Alcohol-induced fatty liver, blunt injury to liver Acute FES High index of suspicion: classic triad of Petechial rash Pulmonary dysfunction Cerebral dysfunction Early persistent tachycardia 1st sign of impending problems Rash: reddish brown, nonpalpable petechial rash on head, neck, ant thorax, axillae in 20-50% pts Easily missed b/c it resolves quickly Pul dysfunction: Within 24-72hrs of insult tachypnea, dysnpea, hypoxemia (ventilation-perfusion abnormalities) may progress to ARDS Cerebral dysfunction: confusion, sedation and coma Other: Retinal Hges, with intra-arterial fat droplets on fundoscopy Fulminant FES Encountered in the operating room during joint replacement procedures Large amounts of fat from medullary cavity into venous circulation In pts with limited cardiac reserve, Ac pul HTN ppt Rt VF with hypotension, bradycardia, hypoxemia and CV collapse Subacute FES Secondary to toxic effects of free FAs from hydrolysis of embolized fat droplets Investigations Support the clinical diagnosis but not pathognomonic Hematologic: Alveolar Hge & mild hemolysis Hb decrease Platelets and fibrinogen decrease Fat macroglobulinemia from pul capillary sample Marked rise in ESR Radiologic: Diffuse bilateral infiltrates snowstorm appearance CT chest and CT head Diagnosis Management Treatment as well as prevention centered on the support of failing organ systems Oxygen administered immediately by mask and severity of pulmonary insufficiency assessed with ABG CPAP, intubation with mechanical ventilation may be necessary Adequate intravascular volume Resp failure directly related to degree and duration of hemodynamic instability Albumin therapy Binds to oleic acid decreasing FAs inflammatory effect on target organs Meticulous pain control Decrease catecholamine release and attenuate the rise of FFA FES is best avoided by Minimizing the extent of intramedullary HTN when preparing the femoral canal, During cementing of prosthetic devices During intramedullary nailing Prognosis Mortality 5 and 15% Due to resp failure and assoc injuries Long-term morbidity Neurologic defects Persistent cognitive dysfunction Commonest site of fracture leading to fat embolism is - (AI 99) a) Tibia# b)Femur# c) Humerus # d) Ulna# Factors favoring fat embolism in trauma patient (PGI Dec 07) a) Diabetes Mellitus b) Mobility of joint c) Resp. failure d) Hypovolemic shock True about Posttraumatic fat embolism syndrome - (PGI Nov. 10, June 09) a) Fracture mobility is a risk factor b) Associated diabetes pose a risk c) Bradycardia occurs d) Thrombocytopenia e) On ABG Pa02 < 60 mm Hg on FI02 < 0.4 The management of fat embolism includes all of the following except (AI 04 a) Oxygen b) Heparinization c) Low Molecular weight dextran d) Pulmonary Embolectomy A person with multiple injuries develops fever, restlessness, tachycardia, tachypnea and periumbilical rash. The likely diagnosis is - (AIIMS Nov 08) a) Air embolism b) Fat embolism c) Pulmonary embolism d) Bacterial pneumonitis Ramesh singh, a 40 yrs old man, was admitted with fracture shaft femur following a road traffic accident. He was tachypnoeic, and had conjunctival petechiae. Most likely diagnosis is - (A102) a) Pulomary embolism b) Sepsis syndrome c) Fat embolism d)Hemothorax A 30 year old man had road traffic accident and sustained fracture of femur. Two days later he developed sudden breathlessness. The most probable cause can be - (AI05) a) Pneumonia b) Congestive heart failure c) Bronchial asthma d) Fat embolism Clincial feature of fat embolism includes all excepts- (PGINov.10) a) Tachypnoea b) Systmic hypoxia may occur c) Fat globules in urine are diagnostic d) Manifests after several days of trauma e) Petechiae in the anterior chest wall A 64 year old hypertensive obsese female was undergoing surgery for fracture femur under general anaesthesia. Intra-operatively her end- tidal carbon dioxide decreased to 20 from 40 mm of Hg, followed by hypotension and oxygen saturation of 85%. What could be the most probable cause? (DPG 09, AI 03) a) Fat embolism b) Hypovolemia c) Bronchospasm d) Myocardial infarction True about fat embolism - (PGI Dec 07) a) Petechia in the anterior chest wall b) Bradycardia c) Fat globules in urine d) Occurs after 1st week of polytrauma e) Thrmbocytopenia