FAT EM BO LISM

DR RAMESH VARADHARAJAN

Presentation
29/M
Alleged history of RTA -24th may
Head injury and tibial fracture
GCS -13/15 Pupils BERL
No other comorbities
Effort tolerance prior to RTA - Good

CT BRAIN
Diffuse cerebral edema
Thin temporal SDH Right side
Ventricles in midline

CT thorax at adm ission

Tibialfracture

 IN ICU ( 24th AND 25th )

Monitoring/observation

Head up and oxygen via venturi

face mask
Antibiotics/anti edema measures
Splint applied

Posted for Tibia nailing

on 26 th

pre op assessm ent

Pt conscious oriented obeying commands

afebrile
Vitals stable
Spo2 -85-88% room air , and 97-99% with
oxygen
RR- 30-35/m , mild distress
Blood investigations-wnl ,viral markers
negative
Pt was willing for regional anesthesia
Npo and IVF advised accordingly

In O R
Procedure done under single dose SAB

with standard monitoring

He was maintaining saturation with oxygen
Without it he became tachypnoeic and
desaturated
Lasted around 1.5 hrs
Blood loss minimal ( no tourniquet)
Hemodynamics stable throughout
I/O- 1100/100

Post op in ICU
Evaluated with doppler legs and

CECT thorax
Snow storm opacities b/l lung fields
Pulmonary artery showed no filling
defects

FAT EM BO LISM -G round glass

FAT EM BO LISM

Literature search

Intro-Fat Em bolism
fat globules in the peripheral
circulation and lung parenchyma
fracture of long bones, pelvis or
other major trauma.
It occurs in approximately all/most
patients( >95%) who sustain a
long bone or a pelvic fracture

Intro-Fat em bolism syndrom e

serious manifestation of fat embolism

phenomenon
rare complication occurring in 0.5 to 2%
of patients following a long bone fracture
Toxic effects of free fatty acids
Triad
Dyspnoea (95%)
Petechiae (33%)
Mental confusion ( 60%)

H istory

Von Bergmann ( 1873 )

Injected cats with intravenous oils
a patient who fell off a roof and sustained

a comminuted fracture of the distal femur;

60 hours after the injury, the patient
developed dyspnea, cyanosis, and coma

Cerebralfat em bolism star in d sky

Purtscher-like retinopathy

Risk factors for FES

Young adults
High velocity trauma
Closed fracture
Bilateral
33% for bilateral femur vs 3 % for single

femur

Pathogenesis
Mechanical theory
Fat globules

Biochemical theory
FFA

Coagulation theory
Thromboplastin
Complement /leucocyte activation

TREATM EN T-supportive
Maintain hemodynamics,
blood products
hydration
prophylaxis of deep venous

thrombosis and stress related

gastrointestinal bleeding
nutrition

M edicalm anagem ent

Steroids
Aspirin
Heparin
N-acetylcysteine

Ventilation strategies
Spontaneous ventilation
CPAP NIV
Invasive mechanical ventilation-

PEEP

O xygen M ask-Low PO 2 w ith

no high W O B

CPAP-low po2 w ith increased

W OB

IN VASIVE VEN TILATIO N -ETT

Surgicalstrategies
Early immobilisation
Operative correction
Limit increase in intraosseous

pressure during sx
Venting hole
cementless fixation of prostheses
unreamed intramedullary femoral
shaft stabilization

Prophylaxis
Albumin
Binds FFA
Limits lung injury

Steroids
Methyprednisolone 7.5mg/kg q8h
For high risk patients
No change in mortality

Fix your bones

early

Good day