Difference between revisions of "Fat embolism syndrome"

(Background)
Line 9: Line 9:
 
*'''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 causes 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===  
 
===Gurd's Criteria===  
 
*Most frequently cited diagnostic criteria
 
*Most frequently cited diagnostic criteria
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*retinal changes (fat or petechiae)
 
*retinal changes (fat or petechiae)
 
*renal abnormalities (oliguria, anuria or lipiduria)
 
*renal abnormalities (oliguria, anuria or lipiduria)
*thrombocytopenia
+
*[[thrombocytopenia]]
 
*acute anemia
 
*acute anemia
 
*elevated ESR
 
*elevated ESR
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==Management==
 
==Management==
 
*Supportive care
 
*Supportive care
*Heparin and steroids have not shown improvement
+
*[[Heparin]] and steroids have not shown improvement
 
*Supplemental 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
 +
 +
==Disposition==
 +
*ICU
  
 
==Prevention==
 
==Prevention==
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*Consider prophylactic corticosteroids in pts w/ long bone fractures
 
*Consider prophylactic corticosteroids in pts w/ long bone fractures
 
**decreased hypoxemia, no difference in mortality
 
**decreased hypoxemia, no difference in mortality
 
==Disposition==
 
-ICU
 
  
 
==See Also==
 
==See Also==

Revision as of 08:40, 31 January 2015

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

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

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

Disposition

  • ICU

Prevention

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

See Also

External Links

Sources

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