CASE PRESENTATIONby 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

NON-TRAUMA RELATEDPancreatitisOsteomyelitisDiabetes mellitusSteroid therapy

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

EXAMINATIONGCS E4 V5 M6VITAL SIGNS STABLESPO2 99%CVS DRNMLUNGS CLEAR

NO NECK TENDERNESSMILD TENDERNESS AT ANTERIOR CHESTMULTIPLE ABRASION WOUND OVER

RIGHT ARMRIGHT THIGH

CRT <2STENDER, SWOLLEN WITH DEFORMITY

IMPRESSIONALLEGED MVA WITH TRO # MIDSHAFT OF

RIGHT FEMUR

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

XRAY R/VTRANSVERSE # UPPER 1/3 OF RIGHT

FEMURCHEST XR : NORMAL

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

Thank You