CASE PRESENTATION by EZROL & RADHI AEMTC PB1/2013
FAT EMBOLISM SYNDROMECaused by an inflammatory responseTypically manifests 24 to 72 hours after the
initial insult. Rarely <12 hrs or >72 hrs
CAUSESTRAUMA-RELATED
Long bone #Pelvic ## of other marrow-containing bonesOrthopaedic proceduresSTI (chest compression ± rib #)BurnsLiposuction
PATHOPHYSIOLOGYMECHANICAL VS BIOCHEMICALMechanicalFAT AND MARROW ELEMENTS ARE
EMBOLIZED INTO THE BLOODSTREAM DURINGACUTE LONG BONE FRACTURES (Femur, Tibia,
Humerus), PELVIC and SPINAL #’s•More frequent in CLOSED > OPEN #’s•Younger pt’s (more bone marrow) > Older Pt’s
INTRAMEDULLARY INSTRUMENTATION INTRAMEDULLARY NAILING HIP & KNEE ARTHROPLASTY
Mechanical–Fat droplets are deposited in the pulmonary
capillary beds and travel through arteriovenous shunts to the brain. Systems affected include LUNG, BRAIN and CIRCULATION.
Biochemical–Hormonal changes caused by trauma and/or
sepsis induce systemic release of free fatty acids (FFA) as chylomicron swhich cause the systemic FES.
DIAGNOSIS CRITERIAMAJOR (1)
Hypoxaemia (PaO2 <60) c/o SOBCNS depression confused, altered LOC,
headache, ±seizures, ±strokes with focal deficits
Pulmonary oedemaPetechial rash late finding (frequency of 20-
50% of pt’s) esp axillary, conjuctivae, oral mucosa
MINOR (4)Tachycardia > 120/minPyrexia > 38.5 0CRetinal fat emboliOliguria/anuriaFat in urine or sputumThrombocytopaenia < 150 X 109/LDecreased HCT
TREATMENTATLS protocolHigh clinical suspicion during clinical
examination
IN ACUTE CASE, FOR MECHANICAL VENTILATION
EARLY FRACTURE STABILISATION ( WITHIN 24H)
MAINTAIN INTRAVASCULAR VOLUME TO MAINTAIN CARDIOVASCULAR STABILITY (hypovolemic shock resuscitation)
HISTORY30 / M / MALEALLEGED MVA ON 4/4/13MB VS VAN, HIT A VAN THAT WAS MAKING
A U-TURNC/O PAIN AND SWELLING OVER RIGHT
THIGH AND PAIN OVER RIGHT SIDED ANTERIOR CHEST
NO OTHER COMPLAINTS
NO NECK TENDERNESSMILD TENDERNESS AT ANTERIOR CHESTMULTIPLE ABRASION WOUND OVER
RIGHT ARMRIGHT THIGH
CRT <2STENDER, SWOLLEN WITH DEFORMITY
PLANXRAY
CHEST – because c/o chest pain. TRO rib #PELVIC – due to high impact MVAFEMUR
IV KETOROLAC 30MGNSAID, for short term relief of moderately
severe pain
DIAGNOSISALLEGED MVA WITH CLOSED
TRANSVERSE # OF UPPER 1/3 OF RIGHT FEMUR
REFERRED TO ORTHO TEAMT/O TO HOSP PASIR MAS FOR ORIF & K-NAIL
OF RIGHT FEMUR
7/4/13REFERRED BACK AFTER C/O
CHEST DISCOMFORTMILD SOBFEVER X 2/7 – LOW GRADERIGHT SIDED PLEURITIC CHEST PAINNO PALPITATION / NO CALF PAIN
TRO DVTNO NAUSEA / VOMITINGNO ABDOMINAL PAIN NO HAEMOPTYSIS
TRO pulmonary embolism
EXAMINATIONGCS E4 V5 M6BP 147/76PR 97, GOOD PULSE VOLUMEMILD TACHYPNOEIC, RR 26HYDRATION FAIRCRT <2S, SPO2 94% RAPETECHIAE OVER UPPER ANTERIOR
TRUNK
CVS DRNMLUNGS BIBASAL FINE CREPSPA SNT, NOT DISTENDEDNO CALF TENDERNESS BILATERALLYRIGHT LL
ON THOMAS SPLINTDPA PALPABLE & COMPARABLEPERFUSION GOODSENSATION INTACT
INVESTIGATIONABG RA
pH 7.47 alkalosis (pH > 7.45)PCO2 34.5 slightly ↓PO2 67.3 hypoxaemiaHCO3 25.8 normal
INTERPRETATION : RESPIRATORY ALKALOSIS
IMPRESSIONFAT EMBOLISM SYNDROME
Common in long bone #Petechiae Sob
DDX : HAPProlonged stay in hospitalfever, bibasal fine crepsCXR bibasal haziness
PLANIVD 1PINT HARTMANN – for maintenancePUT ON V/M 30%START IV ROCEPHINE 2G STAT – broad
spectrum, to cover pneumoniaREFERRED TO ORTHO/MEDICAL