Difference between revisions of "Fat embolism syndrome"

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==Background==
 
==Background==
-fat globules in pulmonary microcirculation
+
*caused by fat globules in pulmonary microcirculation
-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 w  orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
-men>women, highest ages 10-40 y/o
+
*men>women, highest rates: ages 10-40 y/o
 
==Clinical Features==
 
==Clinical Features==
-multi-system dysfunction
+
*multi-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, AMS, 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, 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 ds, bone marrow harvest/transplant/liposuction
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
-pulmonary embolism
+
*pulmonary embolism
-ARDS
+
*ARDS
-pulmonary edema
+
*pulmonary edema
-alveolar hemorrhage
+
*alveolar hemorrhage
-other cause of hypoxemia
+
*other causes of hypoxemia
-other causes of shock
+
*other causes of shock
  
 
==Workup==
 
==Workup==
 
-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====
 +
*Petechial rash,  
 +
*Resp symptoms w XR changes,  
 +
*CNS signs unrelated to another condition
 +
====Minor====
 +
*tachycardia
 +
*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
+
*Chest Xray/CT scan chest
--bilateral patchy infiltrates
+
*Bilateral patchy infiltrates
-MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
+
*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
+
*Supportive care
-heparin and steroids have not shown improvement
+
*Heparin and steroids have not shown improvement
-O2, mechanical ventilation if needed
+
*Supplemental O2, mechanical ventilation if needed
-frequent neurochecks, consider ICP monitoring
+
*Frequent neurochecks, consider ICP monitoring
-vasopressors as needed
+
*Vasopressors as needed
-refractory hypotension/shock: consider ECMO
+
*Refractory hypotension/shock: consider ECMO
 +
 
 +
==Prevention==
 +
*Decreased incidence with orthopedic repair w/i 24h
 +
*Consider prophylactic corticosteroids in pts w/ long bone fractures
 +
**decreased hypoxemia, no difference in mortality
  
 
==Disposition==
 
==Disposition==

Revision as of 02:36, 30 January 2015

Background

  • caused by fat globules in pulmonary microcirculation
  • fat is prothrombotic and pro-inflammatory
  • commonly associated w orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
  • men>women, highest rates: ages 10-40 y/o

Clinical Features

  • multi-system dysfunction
  • Classic triad: hypoxemia, neurological abnormalities and petechiae
  • neuro findings included: focal deficits, AMS, coma
  • thrombocytopenia and anemia common
  • can progress to DIC
  • Fulminant cases: RV dysfunction, biventricular failure, ARDS, shock, death
  • Other etiologies (uncommon): pancreatitis, sickle cell crisis, alcoholic liver ds, bone marrow harvest/transplant/liposuction

Differential Diagnosis

  • pulmonary embolism
  • ARDS
  • pulmonary edema
  • alveolar hemorrhage
  • other causes of hypoxemia
  • other causes of shock

Workup

-clinical diagnosis, no gold standard

Gurd's Criteria

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

Major

  • Petechial rash,
  • Resp symptoms w XR changes,
  • CNS signs unrelated to another condition

Minor

  • tachycardia
  • 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
  • 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

  • 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 w/i 24h
  • Consider prophylactic corticosteroids in pts w/ long bone fractures
    • decreased hypoxemia, no difference in mortality

Disposition

-ICU

See Also

External Links

Sources

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