8.Fat Embolism

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FAT EMBOLISM

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• It is an early complication of bone

#,commonly in closed pelvis and long bone #• The fat embolism syndrome (FES) is a rare

clinical condition in which circulating fatemboli or fat macroglobules lead to

multisystem dysfunction

• It is usually asymptomatic, but a few patientswill develop signs and symptoms of

multiorgan dysfunction, particularly involvingthe triad of lungs, brain, and skin 

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Causes 

• Traumatic # of long bones, pelvis and postoperatively after

intramedullary nailing and pelvic and knee arthroplasty

Massive soft tissue injury

Severe burn Bone marrow biopsy/transplant

Liposuction

•

Non traumatic Acute pancreatitis Fatty liver

Corticosteroid therapy – fat deposition

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Risk factors

• Young age

• Closed #

•

Multiple #• Conservative for long bone #

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Mechanism

1. Direct embolization of fat globules from the #

site

2. Circulating triglycerides splits into glycerol

and fat generating many small particles of

circulating fat

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Mechanical theory

Large fat droplets are released into the venous system.

deposited in the pulmonary capillary beds

travel through arteriovenous shunts to the brain.

Microvascular lodging of droplets

produces local ischemia and inflammation, withconcomitant release of inflammatory mediators,

platelet aggregation, and vasoactive amines.

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Biochemical theory

• Hormonal changes caused by trauma and/or

sepsis induce systemic release of free fatty

acids as chylomicrons and create the

physiologic reactions

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Mechanism

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Clinical features

• Pulmonary dysfunction

Tachypnea,

Dyspnea,

Cyanosis

• Cerebral changes

Confusion/drowsiness

Convulsion

Coma

• Skin dysfunction

Petechial rashes

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Prevention

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 • Prompt immobilization of all long-bone fractures

Reduces the intravasation of intramedullary fat and other

debris, and may reduce the incidence of FES .

• Observation (all patients who have sustained a

long-bone fracture )  Frequent arterial blood gas level readings will allow early

detection in patients in whom hypoxemia is developing

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•

Prophylactic corticosteroids The use of corticosteroids prophylactically is controversial

because FES is uncommon and most patients recover with

supportive care alone. We favor prophylactic corticosteroids for

patients who are at high risk for developing FES (patients withlong bone or pelvic fractures, especially closed fractures)

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Management 

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1. High flow rate oxygen is given

Maintain the arterial oxygen tension in the normal range.

Early intubation and mechanical respiration, when

indicated by abnormal arterial gas levels.

Positive end-expiratory pressure (PEEP) in mechanical

respiration is usually necessary to open collapsed alveoliand decrease intrapulmonary shunting

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2. Fluid replacement

Maintenance of intravascular volume is important, becauseshock can exacerbate the lung injury caused by FES.

Albumin has been recommended for volume resuscitation in

addition to balanced electrolyte solution, because it not only

restores blood volume but also binds with the fatty acids and

may thus decrease the extent of lung injury.

Heparin is another agent that has been advocated

because of its lipemic clearing capability. However, because

of the increased bleeding problems associated with

trauma, heparin has not been extensively used for this

syndrome.

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3. Corticosteroids

Reversing the toxic effect of free fatty acids appears to

be anti-inflammatory property Experimental studies with fat embolization have shown

that corticosteroids reduce hypoxia secondary to thisprocess

4. Rigid fixation of bone # in cases of multipleinjury

5. Chest physiotherapy

To reduce the risk of secondary pulmonary infection

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THANK YOU

REFERENCES1. Essential Orthopaedics and Trauma

2. Pocketbook of Orthopaedics and Fractures (McRae)

3. http://www.onlinejets.org/article.asp?issn=0974-

2700;year=2009;volume=2;issue=1;spage=29;epage=33;aulast=Shaikh 

4. http://www.annualreviews.org/doi/pdf/10.1146/annurev.me.28.020177.000505