Difference between revisions of "Fat embolism syndrome"

 
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*Caused by fat globules in pulmonary microcirculation <ref>Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320</ref>
 
*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 with  orthopedic fractures, especially long bone fractures of lower extremities (eg. femur)
+
*Commonly associated with  orthopedic [[fractures]], especially long bone fractures of lower extremities (eg. [[femur fracture|femur]])
 
*Occurance in Men > women, highest rates: ages 10-40 y/o
 
*Occurance in Men > women, highest rates: ages 10-40 y/o
 
*Typically occurs 12-72 hrs after initial insult
 
*Typically occurs 12-72 hrs after initial insult
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*Multi-organ 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]]
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*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
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*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
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*Other etiologies (uncommon): [[pancreatitis]], [[sickle cell crisis]], alcoholic liver disease, bone marrow harvest/[[bone marrow transplant complications|transplant]]/liposuction
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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*[[ARDS]]
 
*[[ARDS]]
 
*[[Pulmonary edema]]
 
*[[Pulmonary edema]]
*Alveolar hemorrhage
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*[[Diffuse alveolar hemorrhage]]
 
*Other causes of [[hypoxemia]
 
*Other causes of [[hypoxemia]
 
*Other causes of [[shock]]
 
*Other causes of [[shock]]
  
==Diagnosis==
+
==Evaluation==
 
Clinical diagnosis, no gold standard
 
Clinical diagnosis, no gold standard
===Gurd's Criteria===  
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===Gurd's Criteria===
 
*Most frequently cited diagnostic criteria
 
*Most frequently cited diagnostic criteria
 
*Need 1 major, 4 minor
 
*Need 1 major, 4 minor
 
====Major====
 
====Major====
*Petechial [[rash]]
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*[[petechiae|Petechial]] [[rash]]
*Resp symptoms w XR changes
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*Respiratory symptoms with [[CXR]] changes
 
*CNS signs unrelated to another condition
 
*CNS signs unrelated to another condition
 
====Minor====
 
====Minor====
*Tachycardia
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*[[Tachycardia]]
*Pyrexia
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*[[Hyperthermia|Pyrexia]]
*retinal changes (fat or petechiae)
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*Retinal changes (fat or petechiae)
*renal abnormalities (oliguria, anuria or lipiduria)
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*Renal abnormalities (oliguria, anuria or lipiduria)
*[[thrombocytopenia]]
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*[[Thrombocytopenia]]
*acute [[anemia]]
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*Acute [[anemia]]
*elevated ESR
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*Elevated ESR
*fat globules in sputum
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*Fat globules in sputum
  
*Chest Xray/CT scan chest
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*[[CXR]]/CT scan chest
 
**Bilateral patchy infiltrates
 
**Bilateral patchy infiltrates
*MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
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*[[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
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*Supportive care
 
*Supportive care
 
*[[Heparin]] and steroids have not shown improvement
 
*[[Heparin]] and steroids have not shown improvement
*Supplemental O2, mechanical ventilation if needed
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*Supplemental [[O2]], mechanical ventilation if needed
 
*Frequent neurochecks, consider ICP monitoring
 
*Frequent neurochecks, consider ICP monitoring
*Vasopressors as needed
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*[[Vasopressors]] as needed
*Refractory hypotension/shock: consider ECMO
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*Refractory hypotension/shock: consider [[ECMO]]
  
 
===Prevention===
 
===Prevention===
*Decreased incidence with orthopedic repair w/i 24h
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*Decreased incidence with orthopedic repair within 24h
*Consider prophylactic corticosteroids in pts w/ long bone fractures
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*Consider prophylactic [[corticosteroids]] in patients with long bone fractures
**decreased hypoxemia, no difference in mortality
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**Decreased hypoxemia, no difference in mortality
  
 
==Disposition==
 
==Disposition==
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<references/>
 
<references/>
  
[[Category:Ortho]]
+
[[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