Acute Respiratory Distress

Syndrome, Fat Embolism, &

Thromboembolic Disease in the
Orthopaedic Trauma Patient
Steve Morgan, MD & Scott Adams, MD
Original Authors: Steve Morgan, MD; March 2004;
New Authors: Steve Morgan, MD & Scott Adams, MD; Revised January 2007

Objectives
Define
ARDS
FES
Thromboembolic Disease

Understand Etiology &

Physiology of each
Condition

Understand

Prevention
Diagnosis
Treatment
Outcomes

ARDS
Acute Respiratory Distress Syndrome

Acute respiratory failure in the post traumatic

period characterized by a decreased PaO 2 and
a diffuse and often massive extravasations of
fluid from the pulmonary vasculature to the
interstitial space of the lungs.

ARDS Clinical Definition

Acute onset of symptoms
Ratio of PaO2 to FIO2 of 200 mm Hg or less
Bilateral infiltrates on CXRs
Pulmonary arterial wedge pressure of 18 mm Hg or less
or no clinical signs of left atrial hypertension
American-European Consensus Conference (AECC) on ARDS, 94

ARDS
Incidence 5% 8% after polytrauma
Much lower in isolated fracture

Mortality up to 40%
Uncommon in Children and the Elderly

ARDS
Common Causes

Trauma
Massive Transfusion
Embolism
Sepsis
Aspiration
Abdominal Distension

Pulmonary Edema
Prolonged LOC
Cardiopulmonary
Bypass
Pancreatitis
Major Burns

MULTIFACTORAL

ARDS Etiology
ARDS related to MODS
Trauma

Inflammatory
Mediators

Organ
Injury

Release of inflammatory mediators results

in organ dysfunction

ARDS
PATHOPHYSIOLOGY
Systemic
Inflammatory
Mediators
Damage to Endothelial
Lining
Increased Capillary
Permeability
Fluid Extravasation

Alveolar Collapse
Decreased Pulmonary
Compliance
Ventilation Perfusion
Abnormalities
Arteriolar Hypoxemia

ARDS

Chest Radiograph

Autopsy Specimen

ARDS Chest CT Scan

ARDS
Prevention
Limiting Blood Loss
Decreasing Transfusion
Requirements
Early Stabilization Of
Unstable Fractures
Early Prophylactic
Mechanical Ventilation
Temporary Ex-Fix For Stabilization

ARDS
Treatment
Ventilator Support
Acceptable ABGs
Avoid further alveolar damage
Toxic FIO2
Barotrauma

General Organ Support

Research
Optimal ventilator settings
Pharmalogical agents

ARDS
Outcome
Significant Cause of Mortality
Major Cause of Death in Patients with the
Lowest ISS scores
30% - 40% Mortality Rate
Mortality Rate Slowly Decreasing with
Changing & Improving Therapy

Fat Embolism Syndrome

(FES)
A condition characterized by hypoxia,
confusion and petechiae presenting soon
after long bone fracture and soft tissue
injury.
Diagnosis of Exclusion

FES
Often Placed in the Category of ARDS
May share common pathological pathways

R/O other Causes of Hypoxia & Confusion

Index Patient
young adult with isolated LE injury seen after long
transfer with no supporting therapy or splintage.

FES
Occurs in 0.9 8.5% of all fracture patients
Up to 35% of the multiply injured
Mortality 2.5%
Rare in upper limb injury and children

Etiology
The likely pathogenetic reaction of lung tissue to
shock, hypercoagulability and lipid metabolism

Mechanical Theory
Biochemical Theory

Mechanical Theory
Fracture Liberates Fat
Intravasation - Fat Enters Venous System
Fat Causes Mechanical Obstruction

Mechanical Theory
Systemic Fat Embolization
Patent Foramen Ovale
Pulmonary Pre-Capillary
Shunts
Skin petechiae, CNS signs

FES To Brain On MRI

Biochemical Theory
Neutral Fat and Chemical Mediators
Released at Time of Fracture
Neutral Fat Metabolized by Lipases releases
Free Fatty Acids
Free Fatty Acids Result in Endothelial Lung
Damage

FES Diagnosis
Major Criteria

Hypoxemia
CNS Depression
Petechial Rash
Pulmonary Edema

Minor Criteria

Tachycardia
Pyrexia
Retinal Emboli
Fat in Urine
Fat in Sputum
Thrombocytopenia
Decreased Hematocrit

Gurd et al

FES Diagnosis
Gurd & Wilson Criteria
At least 1 Major Sign
4 Minor Signs

Gurd et al

FES Prevention
Appropriate
Splinting
Early Fracture
Stabilization
Oxygen Therapy

FES Prevention
Therapies

Fluid Loading
Hypertonic Fluid
Alcohol
Heparin
Dextran
Aspirin

None Shown to be Effective

FES Treatment
Supportive
Oxygen Therapy to maintain PaO2
Mechanical Ventilation
Adequate Hydration

FES Treatment Steroids

Steroids
Decrease endothelial damage
30mg/kg initial dose repeated @ 4 Hours, 1gm
dose repeated @ 8 Hours: Total 3 Doses
Complications - Frequent
Infection
GI
Steroid Therapy Avoided Secondary To Poor Risk
Benefit Ratio

Systemic Effects of Trauma

Second Hit in susceptible patients

ARDS
MODS
Threshold

Post Injury
Inflammatory
Response in
2 Patients

24 hours
Injury (First Hit)

48 hours

IM Nailing as a Cause of Secondary Systemic Injury

Fracture Fixation Technique

-Controversial Early Total Care
Definitive Early
Fixation
Nail or Plate

Damage Control
Temporary Stability
External Fixator

Limit Further Blood

Loss
Limit Anesthetic Time
Delay Definitive
Fracture fixation

Effect of IM Nailing
Increased IM Pressure
Embolic Showers On Echocardiograms
Caused by
Canal Opening
Reaming
Nail Insertion (both reamed & unreamed)

Fracture Fixation Technique

-Controversial IM Nail - Reamed vs Un-Reamed
Decreased with Unreamed Technique
Pape et al

No Difference
Keating et al
Canadian OTS

IM Nail Reamed vs Plate Osteosynthesis

No Difference In Pulmonary Dysfunction
Bosse et al

DVT Incidence
DVT occurrence
60% if ISS >9.
35%-60% DVT in
pelvic fracture
PE-Most common
preventable cause of
death in trauma.

Virchow Triad

Hypercoaguability

Tissue Thromboplastin
Activated Procoagulants
Decreased Fibrinolytic Activity
Ineffective Heparin Clearance of Activated
Clotting Factors
Catecholamine Release

Endothelial Injury
Direct Trauma to Vein at time of Injury
Compression of the Vein Secondary to
Fracture Position
Vein Manipulation at Time of Fracture
Fixation

Venous Stasis
Immobilization
Hypotension
Venous Occlusion
Edema
Fracture Position

Tourniquet

DVT Prevention
Goals

Clinically significant events

PE
Post Thrombotic syndrome

Low Complication Rate

High Compliance Rate
Cost Effective

DVT Prevention
Mechanical
Non Pharamcologic

Pneumatic
Compression

Vena Cava
Filter

Elastic
Stockings

DVT Prevention
Pharamcologic

Unfractionated
Heparin

LMWH
Heparin

Warfarin
Oral
Anticoagulants

Pentasacharides

Elastic
Stockings

Prophylaxis
Elastic Stockings
Mechanical
Compression
Devices
Early Mobilization

IVC Filter (PE Prophylaxis)

Pentasaccharide
Low Molecular
Weight Heparin
Heparin
Aspirin
Warfarin

Mechanical Methods
Activity
Compression
Stockings
Sequential
Compression Device
Pedal Pumps
Mechanism of Action
Decrease Stasis
Fibrinolytic Activity

IVC Filter Indications

Anticoagulation
Prohibited
High Risk Patients
DVT Prior to
Necessary Surgery
PE Despite
Anticoagulation

IVC Filter
Advantages
Prevents Major PE
Low Morbidity
96% Patent
8% Migration
4% PE
Filter insertion in the
ICU

Disadvantage

Expensive
Invasive
Does not treat DVT
Venous Insufficiency
Filter Occlusion

Pentsaccharide
Selective Inhibitor of Activated Xa
Decreased DVT rate with no change in major
bleeding rate compared to LMWH
Eriksson B I et al N Engl J Med 2001

Increased risk of minor bleeding

Delay administration for several hours after surgery
and removal of epidural catheter

Low Molecular Weight Heparin

(LMWH)
Potentiates Antithrombin III
Inhibits Factor Xa & II
Minimal effects on other Factors

LMWH
Advantages

No Monitoring
Increased Efficacy
Longer 1/2 life
Predictable
Response
Lower risk of
thrombocytopenia

Disadvantage
Parenteral
Administration
Cost

Heparin
Heparin Potentiates Anti-Thrombin III
Activity
Complex Inhibits
Thrombin (IIa), IXa, Xa
Heparin effect relative short duration
Reversed with Protamine Sulfate
Significant hemorrhage risk

SQ Heparin
Advantages

Low Cost
No Monitoring
Convenient
Relatively Low
Incidence of
Bleeding

Disadvantage
Insufficient
Efficacy in High
Risk Patients
Unpredictable
Responses
Heparin Induced
Thrombocytopenia

Aspirin
Inhibits cyclooxygenase
Decreases Platelet Adherence
? Effectiveness in Musculoskeletal Trauma
Venous clots not typically found to have
Platelet aggregates

Aspirin

Advantages

Disadvantage

Oral Administration
Tolerated well
In-expensive
No Monitoring

? Efficacy when used

alone
GI Intolerance
Prolonged anti-platelet
effect

Warfarin

Blocks Vit K conversion in Liver

Effects Vit K Dependent Factors
Effects the Extrinsic Clotting System
Factor VII Effected first, Short Half Life
Monitored with Pro-Time
INR 2.0-2.5

Reversed With Vitamin K or FFP

Warfarin
Advantages
Effective
Oral Administration
Inexpensive

Disadvantage
Requires Monitoring
Difficult to Reverse
Increased Bleeding
Complications in
Elderly

EAST Guidelines
Guidelines based on
qualitative review of the
current scientific literature
improve uniformity of
opinion and prescribing
practices
Watts JBJS B 05

Risk Factors

Level I Evidence Major

Significance
Spinal Fracture
Spinal Cord Injury

Level II No Major
Significance

Advanced Age
ISS Score
Blood Transfusion
Long Bone, Pelvis, Head
Injury

DVT screening

Physical Exam
Ascending venography
Duplex Ultrasonography
Magnetic Resonance Venography

Physical Examination

Calf Swelling
Palpable Venous Cords
Calf Pain
Homans Sign

All Unreliable

Ascending Contrast Venography

Sensitive for detection
Invasive
Dye Problems
(allergies, renal)
Injection Site Irritation
Poor Pelvic Vein
Evaluation
Gold Standard
*Invasiveness,expense make ACV a poor screening tool

Doppler/Duplex Ultrasound

Comparable to Venogram
Non Invasive
No Morbidity
Poor Axial (i.e Pelvic)
Vein Evaluation
Operator Dependent
Good Screening Tool
Noninvasive, reproducible

Magnetic Resonance Venography

Non Invasive
Good Visualization of
Pelvic Veins
Difficult in Polytrauma
Patient
Excellent specificity and
sensitivity for suspected
DVT
Controversial for screening

Pulmonary Embolism
Clinical
Shortness of breath, agitation, confusion
Laboratory
PaO2, A-a gradient
Diagnostic studies
V/Q scans
Pulmonary Angiogram, CT PA

Ventilation Perfusion Scan

Ventilation Perfusion mismatch
Results
Low probabiltity
15% False Negative

Medium
Need Angiogram

High probability
15% False Positive

Screening Tool

Pulmonary Angiogram
Angiographic Evaluation of
pulmonary vascular tree
Allows Placement of IVC
Filter in same setting if
indicated
Sensitive - Standard in PE
Detection. Diagnostic

Treatment PE
Anticoagulation
Filter for recurrent
event despite
anticoagulation
Thrombectomy
Serious Acute PE
Patient in extremous
Large identifiable PE

Treatment DVT/PE
Heparin
Bolus 10-15K units
Continuous Infusion
1000Units/Hr
Goal PTT 2x Control
Prevent Clot
propagation and
recurrent PE
Discontinue when
Therapeutic on Warfarin

LMWH / Pentasaccharide

Mass related dose SQ inj

Single daily dose
No monitoring necessary
Discontinue when
Therapeutic on Warfarin

Treatment DVT/PE
Warfarin
INR 2.0-3.0
3-6 Month Duration
Contraindicated in:
Pregnancy
Liver insufficiency
Poor Compliance

Prolonged Therapy may decrease recurrence rates

DVT/PE Outcome
No Diagnosis and Treatment
30% Mortality

Correct Diagnosis and Therapy

11% Mortality in First Hour
8% Mortality After First Hour

DVT/PE Outcome
Post Thrombotic Syndrome

Valvular Incompetence
Venous Stasis
Edema
Cutaneous Atrophy

Recurrent DVT
20% of Patients
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