Fat embolism syndrome: Difference between revisions

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==Background==
==Background==
-fat globules in pulmonary microcirculation
*Caused by fat globules in pulmonary microcirculation <ref>Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320</ref>
-fat is prothrombotic and pro-inflammatory
*Fat is prothrombotic and pro-inflammatory
-commonly associated w orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
*Commonly associated with orthopedic [[fractures]], especially long bone fractures of lower extremities (eg. [[femur fracture|femur]])
-men>women, highest ages 10-40 y/o
*Occurance in Men > women, highest rates: ages 10-40 y/o
*Typically occurs 12-72 hrs after initial insult
 
==Clinical Features==
==Clinical Features==
-multi-system dysfunction
*Multi-organ system dysfunction
-classic triad: hypoxemia, neurological abnormalities and petechiae
*'''Classic triad: [[hypoxemia]], neurological abnormalities and petechiae'''
-neuro findings included: focal deficits, AMS, coma
*Neuro findings included: [[focal deficits]], [[altered mental status]], [[coma]]
-thrombocytopenia and anemia common
*[[Thrombocytopenia]] and [[anemia]] common
-can progress to DIC
*Can progress to [[DIC]]
-Fulminant cases: RV dysfunction, biventricular failure, ARDS, shock, death
*Fulminant cases: RV dysfunction, [[heart failure|biventricular failure]], [[ARDS]], [[shock]], death
-Other etiologies (uncommon): pancreatitis, sickle cell crisis, alcoholic liver ds, bone marrow harvest/transplant/liposuction
*Other etiologies (uncommon): [[pancreatitis]], [[sickle cell crisis]], alcoholic liver disease, bone marrow harvest/[[bone marrow transplant complications|transplant]]/liposuction


==Differential Diagnosis==
==Differential Diagnosis==
-pulmonary embolism
*[[Pulmonary embolism]]
-ARDS
*[[ARDS]]
-pulmonary edema
*[[Pulmonary edema]]
-alveolar hemorrhage
*[[Diffuse alveolar hemorrhage]]
-other cause of hypoxemia
*Other causes of [[hypoxemia]
-other causes of shock
*Other causes of [[shock]]


==Workup==
==Evaluation==
-clinical diagnosis, no gold standard
Clinical diagnosis, no gold standard
-Gurd's Criteria (need 1 major, 4 minor)
===Gurd's Criteria===
--Major: petechial rash, Resp symptoms w XR changes, CNS signs unrelated to another condition
*Most frequently cited diagnostic criteria
--Minor: tachycardia, pyrexia, retinal changes, renal abnormalities, thrombocytopenia, acute anemia, elevated ESR, fat globules in sputum
*Need 1 major, 4 minor
====Major====
*[[petechiae|Petechial]] [[rash]]
*Respiratory symptoms with [[CXR]] changes
*CNS signs unrelated to another condition
====Minor====
*[[Tachycardia]]
*[[Hyperthermia|Pyrexia]]
*Retinal changes (fat or petechiae)
*Renal abnormalities (oliguria, anuria or lipiduria)
*[[Thrombocytopenia]]
*Acute [[anemia]]
*Elevated ESR
*Fat globules in sputum


-Chest Xray/CT scan chest
*[[CXR]]/CT scan chest
--bilateral patchy infiltrates
**Bilateral patchy infiltrates
-MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
*[[Brain MRI|MRI brain]]: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
-Bronchoalveolar lavage
*Bronchoalveolar lavage
-->30% of alveolar cells staining for fat strongly asso w diagnosis
**30% of alveolar cells staining for fat strongly asso w diagnosis


==Management==
==Management==
-supportive care
===Acute Care===
-heparin and steroids have not shown improvement
*Supportive care
-O2, mechanical ventilation if needed
*[[Heparin]] and steroids have not shown improvement
-frequent neurochecks, consider ICP monitoring
*Supplemental [[O2]], mechanical ventilation if needed
-vasopressors as needed
*Frequent neurochecks, consider ICP monitoring
-refractory hypotension/shock: consider ECMO
*[[Vasopressors]] as needed
*Refractory hypotension/shock: consider [[ECMO]]
 
===Prevention===
*Decreased incidence with orthopedic repair within 24h
*Consider prophylactic [[corticosteroids]] in patients with long bone fractures
**Decreased hypoxemia, no difference in mortality


==Disposition==
==Disposition==
-ICU
*ICU


==See Also==
==See Also==
*[[Pulmonary embolism]]
*[[Hypoxemia]]


==External Links==
==External Links==


==Sources==
==References==
<references/> Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320
<references/>
 
[[Category:Orthopedics]]

Latest revision as of 00:00, 2 October 2019

Background

  • Caused by fat globules in pulmonary microcirculation [1]
  • Fat is prothrombotic and pro-inflammatory
  • Commonly associated with orthopedic fractures, especially long bone fractures of lower extremities (eg. femur)
  • Occurance in Men > women, highest rates: ages 10-40 y/o
  • Typically occurs 12-72 hrs after initial insult

Clinical Features

Differential Diagnosis

Evaluation

Clinical diagnosis, no gold standard

Gurd's Criteria

  • Most frequently cited diagnostic criteria
  • Need 1 major, 4 minor

Major

  • Petechial rash
  • Respiratory symptoms with CXR changes
  • CNS signs unrelated to another condition

Minor

  • CXR/CT scan chest
    • Bilateral patchy infiltrates
  • MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
  • Bronchoalveolar lavage
    • 30% of alveolar cells staining for fat strongly asso w diagnosis

Management

Acute Care

  • Supportive care
  • Heparin and steroids have not shown improvement
  • Supplemental O2, mechanical ventilation if needed
  • Frequent neurochecks, consider ICP monitoring
  • Vasopressors as needed
  • Refractory hypotension/shock: consider ECMO

Prevention

  • Decreased incidence with orthopedic repair within 24h
  • Consider prophylactic corticosteroids in patients with long bone fractures
    • Decreased hypoxemia, no difference in mortality

Disposition

  • ICU

See Also

External Links

References

  1. ↑ Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320
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