fat embolism syndrome
TRANSCRIPT
![Page 1: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/1.jpg)
![Page 2: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/2.jpg)
It is one of the causes of morbidity and
mortality following # in patient with multiple
injury+
FES is an important cause of ARDS
![Page 3: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/3.jpg)
Fat embolism syndrome is defined -- Post
Traumatic Respiratory Distress Syndrome
occurring within 72hrs of skeletal trauma
Earliest manifestations are-- Tachycardia-- Elevation of temperature above 38
deg -- falling PaO2
![Page 4: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/4.jpg)
Fat embolism - this indicates presence of
fat globules in lung parenchyma and
peripheral circulation after fractures of
long bones and other major trauma
![Page 5: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/5.jpg)
Fat embolism Syndrome-A serious manifestation of the
phenomenon of emboli resulting in a
variety of symptoms
![Page 6: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/6.jpg)
Historical Review
In 1861, Zenker described fat droplets in the
lung capillaries of a railroad worker who
sustained a fatal thoracoabdominal crush
injury.
![Page 7: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/7.jpg)
In 1865, Wagner described the pathologic features of fat embolism.
![Page 8: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/8.jpg)
However, in 1873,Von Bergmann became the first to establish the clinical diagnosis of fat embolism syndrome.
![Page 9: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/9.jpg)
In a 38-year-old patient who sustained a comminuted fracture of the distal femur.
Postmortem examination revealed a large amount of pulmonary fat
![Page 10: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/10.jpg)
Button – stated that 10% of battle casualities
in World War 1 suffered from FES
World War 2 postmortem study revealed
incidence of FES in 65% of patients.
![Page 11: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/11.jpg)
Causes TraumaticNon-traumatic
![Page 12: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/12.jpg)
Traumatic # long bonesMultiple #ssurgical instrumentation of the medullary
canal
![Page 13: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/13.jpg)
Non traumaticHaemoglobinopahyCollagen vascular diseaseDiabetes mellitusSevere infectionNeoplasmOsteomyelitisBlood transfusionCardiopulmonary bypassRenal infarctionDecompression syndrome owing to altitudeRenal hemotransplantation
![Page 14: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/14.jpg)
Prevalence
Estimated to be 90% after major traumaClinical prevalence is said to range
from .25% to 1.25%Overall mortality is said to be between 10%
and 20%
![Page 15: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/15.jpg)
Physiochemical theory of FES postulate
![Page 16: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/16.jpg)
Pathophysiology
![Page 17: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/17.jpg)
Mechanical theory
![Page 18: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/18.jpg)
1. Presence of torn blood vessels to permit fat to enter the circulation
2. Liberaration of free fat
1. A transient rise in marrow pressure above venous pressure to allow fat droplets to enter the circulation
![Page 19: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/19.jpg)
Biochemical theoryToxic Obstructive
![Page 20: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/20.jpg)
Toxic theory
![Page 21: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/21.jpg)
Recent work by Barie and colleaguesBarie and colleagues
demonstrates that free fatty acids are bound rapidly by albumin
and transported through the bloodstream and lymphatic channels in this benign form.
![Page 22: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/22.jpg)
Obstructive theory
![Page 23: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/23.jpg)
What is the effect of along bone fractureAn abundance of tissue thromboplastin is released with the marrow elements after long-bone fracture
![Page 24: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/24.jpg)
![Page 25: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/25.jpg)
These blood elements, along with leukocytes,
platelets, and fat globules, combine to increase
pulmonary vascular permeability, both by their
direct actions on the endothelial lining and
through the release of numerous vasoactive
substances.
In addition, these same substances activate
platelet aggregation.
![Page 26: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/26.jpg)
Clinical Findings
most common etiologic factor –
-a high-energy Trauma to long bone or pelvis,
including orthopedic
2nd or 3rd decade of life
or in a patient in the 6th-7th decade of life, when
low-energy fractures of the hip are frequent.
![Page 27: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/27.jpg)
Physical: Cardiopulmonary
Early persistent tachycardia
Patients become febrile with high-spiking temperatures
Patients become tachypneic, dyspneic, and hypoxic due to ventilation-perfusion abnormalities 12-72 hours after injury.
![Page 28: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/28.jpg)
Subconjunctival and oral hemorrhages and petechiae also appear.
![Page 29: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/29.jpg)
Dermatologic
• Alert clinicians may
notice reddish-brown
nonpalpable petechiae
developing over the upper
body, particularly in
•only 20-50% of
patients and
resolve quickly• virtually diagnostic
virtually diagnostic
•axillae,
within 24-
36 hours
of insult or
injury.
![Page 30: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/30.jpg)
Neurologic
Central nervous system dysfunction initially manifests as agitated delirium but may progress to stupor, seizures,
or coma and frequently is unresponsive to correction of hypoxia.
Retinal hemorrhages with intra-arterial fat globules are visible upon funduscopic examination.
![Page 31: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/31.jpg)
Signs Raise in temprature (39-40deg C)Tachypnea 30min or higherTachycardia-- > 140min or higher, BP is
usually WNLLong tract signs extensor posturing and
deceribrate rigidityUrinary incontinencehealthy patient with
long bone # showing urinary incontinence needs to be ruled out for FES
![Page 32: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/32.jpg)
Sub clinical
Nonfulminant subacute
Fulminant types
![Page 33: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/33.jpg)
Sub clinicalOnset after injury 12-72 hrsMortality rate 0 %Clinical presentation -
nonspecific or absent symptoms moderate hypoxemia(Pao2 <80mm Hg in room air)
moderate hypocapnia (Paco2<=30 mm Hg during spontaneous breathing) moderate decrease of platelet count (<200,000 micro L)
![Page 34: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/34.jpg)
Nonfulminant subacuteOnset after injury 12-96 hrsMortality rate 0 -5%Clinical presentation
dyspnea, tachypnea ,fever, tachycardia ,petechiaecerebral signshypoxemia (Pao2 <60mm Hg in room
air) anemiathrombocytopenia and coagulation
abnormalities lung opacities on chest radiograph
![Page 35: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/35.jpg)
Fulminant typesOnset after injury few hrsMortality rate >50%Clinical presentation
frank pulmonary edemamoderate to severe
hypotension cerebral signssevere hypoxemia
and acidosis
![Page 36: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/36.jpg)
Management of Fat Embolism
Lab.Findings & Radiographic evaluation.
Treatment
![Page 37: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/37.jpg)
Lab. Findings1. 1.ABGa)Hypoxemia(pO2<60mm Hg).2. b) Acidosis(pH<7.3).3. 2.HAEMATOLOGY-4. a)Hb-low. b)Platelets- low 5. C)6. d)PT/PTTK-high7. e)ESR-elevated.
![Page 38: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/38.jpg)
Biochemistry1.Fat macroglobinemia2.Urine & Sputum fat globules.3.Serum FFA’s-Increased.4.Hypocalcemia(relative).5.Levels of Cortisol,Glucagon &
Catecholamines increase in proportion to the stress response to injury.
![Page 39: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/39.jpg)
ECGRight axis deviation.
S-waves in lead –II.
Q-waves in lead –III.
ST-segment changes.
![Page 40: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/40.jpg)
Radiographic EvaluationCHEST X-RAY-initially
appears normal.Dysnea -within 72 hours
diffuse B/L infilterates(SNOWSTORM appearance)
s/o—ARDS.
SNOWSTORM
![Page 41: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/41.jpg)
CT-HEAD-Cerebral edema & Haemorrhagic infarcts in white matter may be seen.
![Page 42: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/42.jpg)
Diagnosing FES
Gurd‘criteria
one sign from major and at least
four signs from the minor criteria category
![Page 43: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/43.jpg)
Gurd major‘criteria
petechiae in a “vest” distribution
hypoxia, with a PaO 2 less than 60 mm Hg
pulmonary edema
cerebral manifestations.
![Page 44: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/44.jpg)
Gurd‘minor criteriatachycardia, with a
heart rate greater than 110 beats/minute
pyrexia, with a temperature higher than 103° F (39.4° C)
retinal changes
fat in urine or sputum
an unexplained drop in hematocrit or platelet count
an increasing erythrocyte sedimentation rate
jaundice
renal changes.
![Page 45: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/45.jpg)
TREATMENT 3 CORNERSTONES OF TREATMENT
![Page 46: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/46.jpg)
RESPIRATORY SUPPORTRanges from O2 admn to full resp. support
with mechanical ventilation.On pulse oximetry— a)If PaO2<90mm=ABG analysis.
b)If PaO2 b/w 60-90mm=O2 by mask,serial ABGs,wait &watch for any deterioration. c)If PaO2<60mm=INTUBATE & VENTILATE. PEEP if required.
![Page 47: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/47.jpg)
TREATMENT OF SHOCK
SEVERITY OF FAT EMBOL. IS DIRECTLY PROPORTIONAL TO DEGREE OF SHOCK.
![Page 48: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/48.jpg)
ADDITIONAL THERAPIES1)STEROIDS--they also decrease inflam.reaction in
lungs caused by FFAs. Decrease capillary leakage by stabilizing
lysosomal & capillary membranes.
Prophyllactic dose of Methyl Pred.in high risk patients=10mg/kg body wt./q8h i.v(in 100ml saline).
![Page 49: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/49.jpg)
2)ALCOHOL-Decreases ser. Lipase activity,limits lipolysis of fat & decr.FFAs
3)APROTININ-Protease inhibitor.Decr. Plat. Aggreg.& serotonin release.Decr. Incidence of fat emb. From 15% to 5%.
4)HYPERTONIC GLUCOSE-Metabol. Decreases production of FFAs.
.
![Page 50: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/50.jpg)
TIMING OF # STABILIZATIONRIGID EARLY IMMOBILIZATION.
Seibel et al-10 days of skeletal traction of fracture femur with respect to early definitive # treatment-
a) x2 duration of ventilatory failure. b) x4 no. of fracture complications. c) x10 no. of positive blood cultures.
![Page 51: Fat embolism syndrome](https://reader037.vdocuments.net/reader037/viewer/2022102901/556b05a7d8b42ae47d8b4639/html5/thumbnails/51.jpg)
TYPE OF STABILIZATIONReamed v/s Unreamed Femoral nailing.
Pape et al-In patients with thoracic injury reaming has high rates of ARDS(33% v/s 8% for unreamed).
Many studies disproove/attempt to disproove it.
So it is INCONCLUSIVE/DEBATABLE.