Fat embolism syndrome: Difference between revisions

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==Background==
==Background==
-fat globules in pulmonary microcirculation
*caused by fat globules in pulmonary microcirculation
-fat is prothrombotic and pro-inflammatory
*fat is prothrombotic and pro-inflammatory
-commonly associated w  orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
*commonly associated w  orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
-men>women, highest ages 10-40 y/o
*men>women, highest rates: ages 10-40 y/o
==Clinical Features==
==Clinical Features==
-multi-system dysfunction
*multi-system dysfunction
-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 cause 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 (need 1 major, 4 minor)
===Gurd's Criteria===
--Major: petechial rash, Resp symptoms w XR changes, CNS signs unrelated to another condition
*Most frequently cited diagnostic criteria
--Minor: tachycardia, pyrexia, retinal changes, renal abnormalities, thrombocytopenia, acute anemia, elevated ESR, fat globules in sputum
*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
*Chest Xray/CT scan chest
--bilateral patchy infiltrates
*Bilateral patchy infiltrates
-MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
*MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI
-Bronchoalveolar lavage
*Bronchoalveolar lavage
-->30% of alveolar cells staining for fat strongly asso w diagnosis
**30% of alveolar cells staining for fat strongly asso w diagnosis


==Management==
==Management==
-supportive care
*Supportive care
-heparin and steroids have not shown improvement
*Heparin and steroids have not shown improvement
-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
 
==Prevention==
*Decreased incidence with orthopedic repair w/i 24h
*Consider prophylactic corticosteroids in pts w/ long bone fractures
**decreased hypoxemia, no difference in mortality


==Disposition==
==Disposition==

Revision as of 02:36, 30 January 2015

Background

  • caused by fat globules in pulmonary microcirculation
  • fat is prothrombotic and pro-inflammatory
  • commonly associated w orthopedic fractures, esp long bone fractures of lower extremities (eg. femur)
  • 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

  • pulmonary embolism
  • ARDS
  • pulmonary edema
  • alveolar hemorrhage
  • other causes of hypoxemia
  • other causes of shock

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

Prevention

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

Disposition

-ICU

See Also

External Links

Sources

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