Fat embolism syndrome: Difference between revisions
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*Caused by fat globules in pulmonary microcirculation <ref>Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320</ref> | *Caused by fat globules in pulmonary microcirculation <ref>Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320</ref> | ||
*Fat is prothrombotic and pro-inflammatory | *Fat is prothrombotic and pro-inflammatory | ||
*Commonly associated with orthopedic fractures, especially long bone fractures of lower extremities (eg. femur) | *Commonly associated with orthopedic [[fractures]], especially long bone fractures of lower extremities (eg. [[femur fracture|femur]]) | ||
*Occurance in Men > women, highest rates: ages 10-40 y/o | *Occurance in Men > women, highest rates: ages 10-40 y/o | ||
*Typically occurs 12-72 hrs after initial insult | *Typically occurs 12-72 hrs after initial insult | ||
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*Multi-organ system dysfunction | *Multi-organ system dysfunction | ||
*'''Classic triad: [[hypoxemia]], neurological abnormalities and petechiae''' | *'''Classic triad: [[hypoxemia]], neurological abnormalities and petechiae''' | ||
*Neuro findings included: [[focal deficits]], [[ | *Neuro findings included: [[focal deficits]], [[altered mental status]], [[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, [[heart failure|biventricular failure]], [[ARDS]], [[shock]], death | ||
*Other etiologies (uncommon): [[pancreatitis]], [[sickle cell crisis]], alcoholic liver | *Other etiologies (uncommon): [[pancreatitis]], [[sickle cell crisis]], alcoholic liver disease, bone marrow harvest/[[bone marrow transplant complications|transplant]]/liposuction | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*[[ARDS]] | *[[ARDS]] | ||
*[[Pulmonary edema]] | *[[Pulmonary edema]] | ||
* | *[[Diffuse alveolar hemorrhage]] | ||
*Other causes of [[hypoxemia] | *Other causes of [[hypoxemia] | ||
*Other causes of [[shock]] | *Other causes of [[shock]] | ||
== | ==Evaluation== | ||
Clinical diagnosis, no gold standard | Clinical diagnosis, no gold standard | ||
===Gurd's Criteria=== | ===Gurd's Criteria=== | ||
*Most frequently cited diagnostic criteria | *Most frequently cited diagnostic criteria | ||
*Need 1 major, 4 minor | *Need 1 major, 4 minor | ||
====Major==== | ====Major==== | ||
*Petechial [[rash]] | *[[petechiae|Petechial]] [[rash]] | ||
* | *Respiratory symptoms with [[CXR]] changes | ||
*CNS signs unrelated to another condition | *CNS signs unrelated to another condition | ||
====Minor==== | ====Minor==== | ||
*Tachycardia | *[[Tachycardia]] | ||
*Pyrexia | *[[Hyperthermia|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 | **Bilateral patchy infiltrates | ||
*MRI brain: star-field pattern of diffuse, punctate, hyperintense lesions on DWI | *[[Brain MRI|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 | ||
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*Supportive care | *Supportive care | ||
*[[Heparin]] and steroids have not shown improvement | *[[Heparin]] and steroids have not shown improvement | ||
*Supplemental 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=== | ===Prevention=== | ||
*Decreased incidence with orthopedic repair | *Decreased incidence with orthopedic repair within 24h | ||
*Consider prophylactic corticosteroids in | *Consider prophylactic [[corticosteroids]] in patients with long bone fractures | ||
** | **Decreased hypoxemia, no difference in mortality | ||
==Disposition== | ==Disposition== |
Latest revision as of 00:00, 2 October 2019
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
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
External Links
References
- ↑ Kosova, E. et al. Fat Embolism Syndrome. Circulation. 2015; 131:317-320