CASE PRESENTATION by EZROL & RADHI AEMTC PB1/2013

FAT EMBOLISM SYNDROME

Caused by an inflammatory response Typically manifests 24 to 72 hours after the

initial insult. Rarely <12 hrs or >72 hrs

CAUSES
TRAUMA-RELATED
Long bone # Pelvic # # of other marrow-containing bones Orthopaedic procedures STI (chest compression rib #) Burns Liposuction

NON-TRAUMA RELATED Pancreatitis Osteomyelitis Diabetes mellitus Steroid therapy

PATHOPHYSIOLOGY
MECHANICAL VS BIOCHEMICAL Mechanical FAT AND MARROW ELEMENTS ARE

EMBOLIZED INTO THE BLOODSTREAM DURING

ACUTE LONG BONE FRACTURES (Femur, Tibia,

Humerus), PELVIC and SPINAL #s More frequent in CLOSED > OPEN #s Younger pts (more bone marrow) > Older Pts INTRAMEDULLARY INSTRUMENTATION
INTRAMEDULLARY NAILING HIP & KNEE ARTHROPLASTY

Mechanical

Fat droplets are deposited in the pulmonary capillary beds and travel through arteriovenous shunts to the brain. Systems affected include LUNG, BRAIN and CIRCULATION. Biochemical Hormonal changes caused by trauma and/or sepsis induce systemic release of free fatty acids (FFA) as chylomicron swhich cause the systemic FES.

DIAGNOSIS CRITERIA
MAJOR (1) Hypoxaemia (PaO2 <60) c/o SOB CNS depression confused, altered LOC, headache, seizures, strokes with focal deficits Pulmonary oedema Petechial rash late finding (frequency of 2050% of pts) esp axillary, conjuctivae, oral mucosa

MINOR (4) Tachycardia > 120/min Pyrexia > 38.5 0C Retinal fat emboli Oliguria/anuria Fat in urine or sputum Thrombocytopaenia < 150 X 109/L Decreased HCT

TREATMENT
ATLS protocol High clinical suspicion during clinical

examination
IN ACUTE CASE, FOR MECHANICAL

VENTILATION EARLY FRACTURE STABILISATION ( WITHIN 24H) MAINTAIN INTRAVASCULAR VOLUME TO MAINTAIN CARDIOVASCULAR STABILITY (hypovolemic shock resuscitation)

HISTORY
30 / M / MALE ALLEGED MVA ON 4/4/13 MB VS VAN, HIT A VAN THAT WAS MAKING A

U-TURN C/O PAIN AND SWELLING OVER RIGHT THIGH AND PAIN OVER RIGHT SIDED ANTERIOR CHEST NO OTHER COMPLAINTS

EXAMINATION
GCS E4 V5 M6 VITAL SIGNS STABLE SPO2 99% CVS DRNM LUNGS CLEAR

NO NECK TENDERNESS MILD TENDERNESS AT ANTERIOR CHEST MULTIPLE ABRASION WOUND OVER RIGHT

ARM RIGHT THIGH

CRT <2S TENDER, SWOLLEN WITH DEFORMITY

IMPRESSION
ALLEGED MVA WITH TRO # MIDSHAFT OF

RIGHT FEMUR

PLAN
XRAY
CHEST because c/o chest pain. TRO rib # PELVIC due to high impact MVA FEMUR

IV KETOROLAC 30MG NSAID, for short term relief of moderately severe pain

XRAY R/V
TRANSVERSE # UPPER 1/3 OF RIGHT FEMUR CHEST XR : NORMAL

DIAGNOSIS
ALLEGED MVA WITH CLOSED TRANSVERSE #

OF UPPER 1/3 OF RIGHT FEMUR

REFERRED TO ORTHO TEAM T/O TO HOSP PASIR MAS FOR ORIF & K-NAIL OF

RIGHT FEMUR

7/4/13 REFERRED BACK AFTER C/O

CHEST DISCOMFORT MILD SOB FEVER X 2/7 LOW GRADE RIGHT SIDED PLEURITIC CHEST PAIN NO PALPITATION / NO CALF PAIN

TRO DVT

NO NAUSEA / VOMITING NO ABDOMINAL PAIN NO HAEMOPTYSIS

TRO pulmonary embolism

EXAMINATION
GCS E4 V5 M6 BP 147/76 PR 97, GOOD PULSE VOLUME MILD TACHYPNOEIC, RR 26 HYDRATION FAIR CRT <2S, SPO2 94% RA PETECHIAE OVER UPPER ANTERIOR TRUNK

CVS DRNM LUNGS BIBASAL FINE CREPS PA SNT, NOT DISTENDED NO CALF TENDERNESS BILATERALLY RIGHT LL
ON THOMAS SPLINT DPA PALPABLE & COMPARABLE PERFUSION GOOD SENSATION INTACT

INVESTIGATION
ABG RA pH 7.47 alkalosis (pH > 7.45) PCO2 34.5 slightly PO2 67.3 hypoxaemia HCO3 25.8 normal
INTERPRETATION : RESPIRATORY ALKALOSIS

IMPRESSION
FAT EMBOLISM SYNDROME Common in long bone # Petechiae Sob

DDX : HAP Prolonged stay in hospital fever, bibasal fine creps CXR bibasal haziness

PLAN
IVD 1PINT HARTMANN for maintenance PUT ON V/M 30% START IV ROCEPHINE 2G STAT broad

spectrum, to cover pneumonia REFERRED TO ORTHO/MEDICAL

Thank You