Fat embolism syndrome
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
- Multi-organ system dysfunction
- Classic triad: hypoxemia, neurological abnormalities and petechiae
- Neuro findings included: focal deficits, altered mental status, 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 disease, bone marrow harvest/transplant/liposuction
Differential Diagnosis
- Pulmonary embolism
- ARDS
- Pulmonary edema
- Diffuse alveolar hemorrhage
- Other causes of [[hypoxemia]
- Other causes of shock
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
- Tachycardia
- Pyrexia
- Retinal changes (fat or petechiae)
- Renal abnormalities (oliguria, anuria or lipiduria)
- Thrombocytopenia
- Acute anemia
- Elevated ESR
- Fat globules in sputum
- 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
References
- Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320
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