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Updated: Jun 18 2021

Fat Embolism Syndrome

Images marrow em_moved.jpg
  • summary
    • Fat Embolism Syndrome is an acute respiratory disorder caused by an inflammatory response to embolized fat globules that may enter the bloodstream as a result of acute long bone fractures or intramedullary instrumentation. Patients present with hypoxia, changes in mental status, and  petechial rash. 
    • Diagnosis is made clinically with presence of hypoxemia (PaO2 < 60), CNS depression, petechial rash, and pulmonary edema.
    • Treatment is focused on prevention with early stabilization of long bone fractures. Mechanical ventilation with high levels of PEEP is the recommended treatment for acute presentation. 
  • Epidemiology
    • Incidence
      • 3-4% with isolated long bone trauma
      • 10-15% with polytrauma
  • Etiology
    • Pathophysiology
      • fat and marrow elements are embolized into the bloodstream during
        • acute long bone fractures
        • intramedullary instrumentation
          • intramedullary nailing
      • pathophysiology
        • two theories regarding the causes of fat embolism include
          • mechanical theory
            • embolism is caused by droplets of bone marrow fat released into venous system
          • biochemical theory
            • lipoprotein lipase induces free fatty acid production with resultant hyperinflammatory response similar to ARDS
  • Diagnosis Criteria
    • Major (1)
      • hypoxemia (PaO2 < 60)
      • CNS depression (changes in mental status)
      • petechial rash
      • pulmonary edema
    • Minor (4)
      • tachycardia
      • pyrexia
      • retinal emboli
      • fat in urine or sputum
      • thrombocytopenia
      • decreased HCT
    • Additional
      • PCO2 > 55
      • pH < 7.3
      • RR > 35
      • dyspnea
      • anxiety
  • Presentation
    • History
      • symptoms usually present within 24 hours of inciting event
    • Symptoms
      • patient complains of feeling "short of breath"
      • patient appears confused
    • Physical exam
      • tachycardia
      • tachypnea
      • petechiae
        • axillary region
        • conjunctivae
        • oral mucosa
  • Studies
    • ABG
      • hypoxemia (PaO2 < 60 mmHg)
  • Treatment
    • Nonoperative
      • mechanical ventilation with high levels of PEEP (positive end expiratory pressure)
        • indications
          • acute fat emboli syndrome
    • Prevention
      • early fracture stabilization
        • indications
          • early fracture stabilization (within 24 hours) of long bone fracture is most important factor in prevention of FES
        • techniques to reduce the risk of fat emboli
          • overreaming of the femoral canal during a TKA
          • use of reamers with decreased shaft width reduces the risk during femoral reaming for intramedullary fixation
          • use of external fixation for definitive fixation of long bone fractures in medically unstable patients decreases the risk
  • Prognosis
    • Fatal in up to 15% of patients
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