Symptoms from a fat embolism (commonly called fat embolism syndrome) typically onset 24 to 72 hours after the insult [1] [2]. In some cases symptoms appear as soon as 12 hours and as late as 2 weeks following injury. The severity of symptoms depends on the location of the blocked vessels. Patients present with the "classic triad" of symptoms, which consists of respiratory distress, petechial rash, and neurological abnormalities.

• Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first [3]. The severity of respiratory distress varies based on the size and location of the fat embolism; they may progress to acute respiratory failure requiring mechanical ventilation, similar in presentation to acute respiratory distress syndrome.
• Neurologic abnormalities occur after the onset of respiratory distress. They are characterized by drowsiness, confusion, and altered mental status. Some patient will also develop more severe neurological symptoms such as rigidity, seizures, and coma [4].
• A petechial rash is the last sign of the triad to occur. It often presents on the chest, axilla, conjunctiva, head and neck [5] [6]. The rash resolves in about one week in most patients.

Less common symptoms of fat embolism include: pyrexia, cardiac depression, Purtscher's retinopathy, fever, coagulopathy (resembling disseminated intravascular coagulation), and kidney dysfunction (e.g., lipiduria, oliguria, proteinuria, hematuria) [7] [8].

• Fever

  His symptoms included unresponsiveness, disconjugate gaze, seizures, respiratory distress, fever, anemia, thrombocytopenia, and visual changes. [ncbi.nlm.nih.gov]

  Fever Tachycardia Purtscher’s retinopathy: cotton wool exudates macular oedema macular haemorrhage retinal haemorrhages visible fat droplets on ophthalmoscopy Jaundice Renal impairment Anaesthetists often note a sudden drop in end-tidal CO 2 concentration [derangedphysiology.com]

  However, it is often confused with post-operative symptoms of fever, pain, and discomfort. [en.wikipedia.org]

• Unconsciousness

  An immediate endotracheal intubation was performed because of unconsciousness and respiratory insufficiency. The patient was transferred to the intensive care unit (ICU) and mechanical ventilation initiated. [emj.bmj.com]

  The patient arrived in Ahwaz in an unconscious state. There was no paralysis, no fever. The fundi were examined and showed haziness of the inner margins of the discs with engorged veins, the pupils were reacting to light. [ijo.in]

• Acutely Ill Patient

  The plasma lipase concentration is increased in some patients. Serum from acutely ill patients has been shown to have the capacity to agglutinate chylomicrons, low-density lipoproteins, and liposomes of nutritional fat emulsions. [academic.oup.com]

• Dyspnea

  For patients with the limb fractures, who developed coma without chest distress, dyspnea or other pulmonary symptoms 12 or 24 h post injury, cerebral fat embolism should be highly suspected, except for those with intracranial lesions, such as delayed [ncbi.nlm.nih.gov]

  […] traumatic skeletal injury From-Bone Marrow Fractures that most often cause FES long bones,ribs, tibia & pelvis Can occur following joint replacement, spinal infusion, liposuction, crash injuries & bone marrow transplantation Chest pain, tachypnea, cyanosis, dyspnea [quizlet.com]

  Besides trauma, fat embolism may be seen in acute pancreatitis, burns, joint surgery, liposuction and cardiopulmonary bypass Clinical Findings Diagnosis is based mainly on clinical findings beginning 24-72 hours after trauma, surgery or long bone fracture Dyspnea [learningradiology.com]

  Early Signs  Dyspnea,  Tachypnea  hypoxemia UMY 15. [slideshare.net]

• Tachypnea

  This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. [ncbi.nlm.nih.gov]

  […] organs after traumatic skeletal injury From-Bone Marrow Fractures that most often cause FES long bones,ribs, tibia & pelvis Can occur following joint replacement, spinal infusion, liposuction, crash injuries & bone marrow transplantation Chest pain, tachypnea [quizlet.com]

  Signs include pyrexia, tachycardia, tachypnea, rales rhonchi, and friction rub. CNS symptoms: confusion, restlessness, stupor, delirium Skin symptoms: petechiae along the anterior axillary folds and in the conjunctiva and retina. [eorif.com]

  Lungs and Heart Rapid heart rate (tachycardia) Rapid breathing (tachypnea) Breathlessness Chest pains Brain Restlessness Confusion Stupor Seizures Coma Skin The characteristic skin rash seen in fat embolism syndrome is a petechial rash. [healthhype.com]

  Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first. [symptoma.com]

• Cough

  Seven days later he returned presenting with coughing, hemoptysis, elevated leucocytes, and increased C-reactive protein. Chest radiograph revealed basal infiltrations. Suspecting pneumonia, the patient was discharged with antibiotics. [ncbi.nlm.nih.gov]

  However, throughout the surgery she had persistent cough. All 3 surgical procedures were finished in 2½ hours, with a blood loss of about 800 ml. Patient was shifted to SICU following surgery for further management. [apicareonline.com]

  Respiratory symptoms: cough, dyspnea, hemoptysis, and pleural pain;. Signs include pyrexia, tachycardia, tachypnea, rales rhonchi, and friction rub. [eorif.com]

  Ten signs and symptoms of pulmonary embolism in the nonsurgical patient are: (1) acute dyspnea, (2) tachypnea (>20 breaths per minute), (3) tachycardia (>100 bpm), (4) pleuritic chest pain, (5) rales, (6) nonproductive cough, (7) accentuation of pulmonic [quizlet.com]

  […] syndrome, oral contraceptives, heart failure, pregnancy and older age Small infarcts usually have minimal symptoms; if bronchial circulation is inadequate (so reduced collateral circulation), then have shortness of breath, tachycardia, pain, fever, cough [pathologyoutlines.com]

• Rales

  Signs include pyrexia, tachycardia, tachypnea, rales rhonchi, and friction rub. CNS symptoms: confusion, restlessness, stupor, delirium Skin symptoms: petechiae along the anterior axillary folds and in the conjunctiva and retina. [eorif.com]

  Ten signs and symptoms of pulmonary embolism in the nonsurgical patient are: (1) acute dyspnea, (2) tachypnea (>20 breaths per minute), (3) tachycardia (>100 bpm), (4) pleuritic chest pain, (5) rales, (6) nonproductive cough, (7) accentuation of pulmonic [quizlet.com]

  Pulmonary  Hypoxia, rales, pleural friction rub  ARDS may develop  ½ of pts with FES require mechanical ventilation (Bulger, Archives of Surgery 1997; 132: 435-9)  CXR usually normal early on, later may show ‘snowstorm’ pattern- diffuse bilateral [slideshare.net]

  Lung auscultation revealed diffuse inspiratory rales. Temperature was 38.5 [degree sign]C. [anesthesiology.pubs.asahq.org]

• Vomiting

  He had no history of vomiting, convulsions or bleeding from ear, nose and throat. Higher mental functions, all cranial nerves, as well as motor and sensory systems were intact. The neck area was non-tender. [ispub.com]

• Tachycardia

  Diagnostic Criteria for Fat Embolism Gurd's Criteria Major criteria Axillary or subconjunctival petechiae Hypoxaemia PaO 2 2 =0.4 Central nervous system depression disproportionate to hypoxaemia Pulmonary oedema Minor criteria Tachycardia Pyrexia Emboli [derangedphysiology.com]

  The major clinical features of FES include hypoxia, pulmonary dysfunction, mental status changes, petechiae, tachycardia, fever, thrombocytopenia, and anemia. [ncbi.nlm.nih.gov]

  ’s criteria criteria Score Petechiae 5 Infiltrates on x-ray 4 Hypoxemia 3 Fever 1 Tachycardia 1 Tachypnea 1 Confusion 1 Lindeque et al suggested that FES can be diagnosed on the basis of respiratory system involvement alone using the criteria in Table [apicareonline.com]

  […] typically develops within 24-72 hours post injury associated with trauma or surgery RESP – hypoxia, hypotension, sudden tachypnoea, haemoptysis, crackles, globules of fat in sputum NEURO – confusion, drowsiness, seizures, retinal exudates CVS – tachycardia [lifeinthefastlane.com]

• Cyanosis

  He developed global cyanosis and metabolic acidosis with significant decrease of oxygen pressure in the blood. Control chest radiograph showed typical "snow-storm" like pulmonary infiltrations. [ncbi.nlm.nih.gov]

  […] after traumatic skeletal injury From-Bone Marrow Fractures that most often cause FES long bones,ribs, tibia & pelvis Can occur following joint replacement, spinal infusion, liposuction, crash injuries & bone marrow transplantation Chest pain, tachypnea, cyanosis [quizlet.com]

  Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first. [symptoma.com]

  Signs of fat embolism Respiratory features are present in 95%: moist crepitations over all lung fields, hypoxia, cyanosis. ARDS-like picture develops Fat globules may be seen in the sputum! [derangedphysiology.com]

• Chest Pain

  His acute post-operative period was complicated by an episode of chest pain and hypotension. This was treated as acute coronary syndrome. [ncbi.nlm.nih.gov]

  pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, decreased partial pressure of PaCO2 (32-48 norm) Change in mental status, restlesness, confusion O2, NS isotonic, Call Dr,Pulse ox, correct acidosis, replace blood loss On neck, chest wall [quizlet.com]

  While in recovery, the woman experienced chest pain, shortness of breath, and an elevated heart rate. She told the nurse that she did not feel well. The woman also had a purple colored rash on her leg. [theexpertinstitute.com]

• Retinal Hemorrhage

  [16] Retinal hemorrhages with intra-arterial fat globules are visible upon funduscopic examination. [emedicine.medscape.com]

  Retinal hemorrhages with intra–arterial fat globules are visible upon fundoscopic examination. [ispub.com]

  Fundoscopy showed retinal hemorrhages. Blood workup showed drop in platelet counts and hemoglobin level, with increased coagulation profile. He received blood and blood products accordingly. [ijccm.org]

  Fundoscopic evaluation may reveal macular edema and retinal hemorrhages, and fat droplets may occasionally be detected in retinal vessels. [clinicaladvisor.com]

• Petechiae

  Two petechiae were evident on the left arm and a single petechia in the right axilla. [nejm.org]

  Abstract Cerebral fat embolism (CFE) causes microinfarcts, vasogenic edema, and petechiae in the brain. Conventional magnetic resonance imaging has been reported to effectively visualize microinfarcts and vasogenic edema in CFE, but not petechiae. [ncbi.nlm.nih.gov]

  Subacute FES (non-fulminant FES) - The three characteristic features of fat embolism are present: respiratory distress, neurological signs, and skin petechiae. Petechiae are seen on the chest, axilla, shoulder, and mouth. [en.wikipedia.org]

• Fracture

  as well as right pneumothorax with associated rib fractures. [healio.com]

  We need to be aware of the possibility of fat embolism syndrome as a complication of spinal fractures, including isolated vertebral body fractures. [ncbi.nlm.nih.gov]

  Risk of fat embolism Conditions Associated with Fat Embolism (from Jain et al, 2008 ) Traumatic Unrelated to trauma Long bone fractures Pelvic fractures Fractures of other marrow-containing bones Orthopaedic procedures Soft tissue injuries (e.g. chest [derangedphysiology.com]

• Oliguria

  […] sputum NEURO – confusion, drowsiness, seizures, retinal exudates CVS – tachycardia, myocardial depression, right heart strain SKIN – petechial rash (conjunctival, anterior chest, axillae) HAEM – DIC, anaemia (e.g. due to alveolar haemorrhage) RENAL – oliguria [lifeinthefastlane.com]

  Less common symptoms of fat embolism include: pyrexia, cardiac depression, Purtscher's retinopathy, fever, coagulopathy (resembling disseminated intravascular coagulation), and kidney dysfunction (e.g., lipiduria, oliguria, proteinuria, hematuria). [symptoma.com]

  Renal - oliguria, haematuria, anuria. Drowsiness with oliguria is almost pathognomonic. One study reported that 98% of the patients presented with mental status changes, whereas only 22% had focal signs and/or seizures [ 7 ]. [patient.info]

• Anuria

  T79 Certain early complications of trauma, not elsewhere classified T79.0 Air embolism (traumatic) T79.1 Fat embolism (traumatic) T79.1XXS …… sequela T79.2 Traumatic secondary and recurrent hemorrhage and seroma T79.4 Traumatic shock T79.5 Traumatic anuria [icd10data.com]

  Kidney Little or no urine (oliguria or anuria) Blood in the urine (hematuria) Other symptoms Headache from low blood oxygen levels (hypoxia) or injury to the vessels or linings of the brain. Fever with high spiking temperatures. [healthhype.com]

  Renal - oliguria, haematuria, anuria. Drowsiness with oliguria is almost pathognomonic. One study reported that 98% of the patients presented with mental status changes, whereas only 22% had focal signs and/or seizures [ 7 ]. [patient.info]

  Decreased urine output[oliguria], blood in urine[hematuria ] and failure of the kidneys to produce urine [anuria] are associated features. Diagnostic criteria The diagnosis of FES is mainly clinical. [boneandspine.com]

• Renal Insufficiency

  insufficiency, myocardial dysfunction, and an otherwise unexplained drop in hematocrit or platelet count. [the-hospitalist.org]

• Confusion

  A diagnosis of FES is often missed because of a subclinical illness or coexisting confusing injuries or disease. [ncbi.nlm.nih.gov]

• Seizure

  A 58-year-old woman presented with a seizure episode and altered mental status after suffering a right femur fracture. [ncbi.nlm.nih.gov]

  Central nervous system symptoms from FES may range from drowsiness to seizures to coma. There's no definitive treatment for FES. [newsnetwork.mayoclinic.org]

• Stupor

  He developed stupor and coma within 24 hours from his injury. His acute recovery was characterized by marked frontal dysfunction. [ncbi.nlm.nih.gov]

  CNS symptoms: confusion, restlessness, stupor, delirium Skin symptoms: petechiae along the anterior axillary folds and in the conjunctiva and retina. [eorif.com]

  Subconjunctival and oral hemorrhages and petechiae can also appear. [8] Central nervous system dysfunction initially manifests as agitation or delirium but may progress to stupor, seizures, or coma and is frequently unresponsive to correction of hypoxia [emedicine.medscape.com]

  Lungs and Heart Rapid heart rate (tachycardia) Rapid breathing (tachypnea) Breathlessness Chest pains Brain Restlessness Confusion Stupor Seizures Coma Skin The characteristic skin rash seen in fat embolism syndrome is a petechial rash. [healthhype.com]

• Neurologic Manifestation

  Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma. [ncbi.nlm.nih.gov]

  However, this model did not account for the neurological manifestations, so it was proposed microfat emboli are small enough to escape the sieve of the pulmonary capillary bed and cause systemic manifestations. [healio.com]

  Cases where the neurological manifestations are predominant are referred to as cerebral fat embolism syndrome. [5], [11] Cerebral manifestations are highly variable and nonspecific. [ijoonline.com]

  Jacobson DM, Terrence CF, Reinmuth OM (1986) The neurologic manifestations of fat embolism. Neurology 36:847 PubMed Google Scholar 6. Van Besouw JP, Hinds CJ (1989) Fat embolism syndrome. Br J Hosp Med 42:304–311 PubMed Google Scholar 7. [link.springer.com]

• Agitation

  Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma. [ncbi.nlm.nih.gov]

  Symptoms include: an altered mental state – that might show up as irritability, agitation, headache, confusion, seizures or a coma lung problems such as rapid breathing, shortness of breath, difficulty breathing and a low oxygen level a rash on the skin [aci.health.nsw.gov.au]

  Symptoms usually occur 1–3 days after a traumatic injury and are predominantly pulmonary (shortness of breath, hypoxemia or lack of oxygen), neurological (agitation, delirium, or coma), dermatological (petechial rash), and haematological (anaemia, low [intensivecarehotline.com]

  Subconjunctival and oral hemorrhages and petechiae can also appear. [8] Central nervous system dysfunction initially manifests as agitation or delirium but may progress to stupor, seizures, or coma and is frequently unresponsive to correction of hypoxia [emedicine.medscape.com]

The diagnosis of fat embolism syndrome can be made based on clinical presentation; for example, when the "classic" petechial rash occurs alongside hypoxemia and neurologic impairment, fat embolism syndrome should be suspected. A recent history of trauma resulting in the fracture of or surgery on a large bone (e.g., femur or humerus) should raise the index of suspicion for a fat embolism [9].

Laboratory studies

• Arterial blood gas findings often demonstrate hypoxia, PaO2 <60 mmHg, and hypocapnia
• Hematologic studies may show non-specific findings such as thrombocytopenia, anemia, hypofibrinogenemia, and an elevated erythrocyte sedimentation rate.
• Cytological evaluation of urine, blood, and sputum may reflect fat globules.

Imaging

• The initial chest radiograph will be essentially normal in the majority of patients [10]. Occasionally, there may be air space disease or alveolar hemorrhages visualized [11]. Subsequent radiographs, however, will show progressive diffuse bilateral pulmonary infiltrates, fleck-like pulmonary shadows (often referred to as a 'snow storm'), and dilatation of the right heart.
• Ventilation-perfusion scans may show a mottled pattern of subsegmental perfusion defects and a normal ventilatory pattern.
• Chest computed tomography (CT) often depicts areas of ground glass opacities with interlobar septal thickening. Parenchymal changes of the lungs which are indicative of acute lung injury, pulmonary contusion, or adult respiratory distress syndrome may also be seen on CT.
• Magnetic resonance imaging (MRI) of the brain may reveal high intensity T2 signal and white matter changes along the boundary zones of major vascular territories [12] [13] [14]. Neurological findings have been correlated with a "starfield" pattern on brain magnetic resonance imaging [15].
• Transesophageal echocardiography (TEE) can be used intraoperatively to detect release of marrow contents into the bloodstream during orthopedic surgery (e.g., intramedullary reaming and nailing) [16].

Procedures

Staining of bronchoalveolar lavage (BAL) contents (alveolar macrophages for fat) will demonstrate fat droplets, allowing diagnosis of a fat embolism [17]. Findings should be interpreted with caution since fat droplets in BAL may also be present in patients with sepsis, hyperlipidemia, and patients on lipid feeding infusions. The use of BAL for diagnosis of fat embolism is controversial and its sensitivity and specificity are not well studied [18].

• Chest X-Ray Abnormal

  Jaundice Kidney dysfunction Low platelet count (thrombocytopenia) Low hemoglobin (anemia) Elevated ESR (erythrocyte sedimentation rate) Chest X-ray abnormalities (diffuse alveolar infiltrates) Fat macroglobulinemia Tests Diagnostic investigations help [healthhype.com]

• X-Ray Abnormal

  Jaundice Kidney dysfunction Low platelet count (thrombocytopenia) Low hemoglobin (anemia) Elevated ESR (erythrocyte sedimentation rate) Chest X-ray abnormalities (diffuse alveolar infiltrates) Fat macroglobulinemia Tests Diagnostic investigations help [healthhype.com]

• Hypocapnia

  Laboratory studies Arterial blood gas findings often demonstrate hypoxia, PaO2 <60 mmHg, and hypocapnia Hematologic studies may show non-specific findings such as thrombocytopenia, anemia, hypofibrinogenemia, and an elevated erythrocyte sedimentation [symptoma.com]

  Arterial hypoxemia with hypocapnia (decreased ETC02) are generally associated with a pulmonary embolus(Barash). Bronchospasm (Morgan and Mikhail) explains the increase in peak inspiratory pressure (PIP ). The patient is undergoing a hip replacement. [quizlet.com]

  Arterial blood gases will show hypoxia, pO 2 usually less than 8 kPa (60 mm Hg) and hypocapnia. [patient.info]

  Arterial Blood Gas Examination Blood gases will show low oxygen [hypoxia] and higher carbon dioxide levels [hypocapnia]. [boneandspine.com]

• Decreased Platelet Count

  platelet counts Decreased red blood cell counts Elevated ESR (blood marker for inflammation) Fat macroglobulinemia (fat particles in the blood) Pneumonia and heart failure can often cause some of these same symptoms (sleepiness, shortness of breath) [parentprojectmd.org]

  platelet count], anemia, and hypofibrinogenemia are indicative of fat embolism syndrome. [boneandspine.com]

  Major Criteria Axillary/subconjuctival petechiae Hypoxemia (PaO2 Central Nervous System depression (disproportionate to hypoxia) Pulmonary edema Minor Criteria Tachycardia (>120/minute) Hyperthermia Retinal fat emboli Urinary fat globules Decreased platelet [ispub.com]

• PaO2 Decreased

  SUB CLINICAL FES  Around 3 days post trauma  Probably occurs in almost all long bone fractures of the lower extremity and fractures of the pelvis  Characterised by decreased PaO2, decreased Hb% and decreased platelets. [slideshare.net]

• Creatinine Increased

  increasing to 4.2 from her baseline of 1.1. [swjpcc.com]

• Hypertriglyceridemia

  Vedrinne et al. [14] reported that bronchoalveolar lavage is not a reliable method for diagnosis of FES and that many conditions are associated with fat droplets in alveolar macrophages (multiple organ failure, sepsis, trauma, neoplasia, lipid infusion, or hypertriglyceridemia [anesthesiology.pubs.asahq.org]

Progression of asymptomatic fat embolism with FES frequently represents inadequate treatment of hypovolaemic shock. [ncbi.nlm.nih.gov]

Prompt supportive treatment of the patient’s respiratory system and additional pharmaceutical treatment provided the positive clinical outcome. [dovepress.com]

The early diagnosis and comprehensive treatment can improve prognosis. [ncbi.nlm.nih.gov]

This article reviews the definition, epidemiology, etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of FES. [ncbi.nlm.nih.gov]

This article reviews the definition, epidemiology, etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of FES. [ncbi.nlm.nih.gov]

Patient Population: Prevalence and Epidemiology Knee // Shoulder & Elbow // Hip // Spine // Foot & Ankle // Hand & Wrist Fragility Fractures: Diagnosis and Treatment Shoulder & Elbow The Characteristics of Surgeons Performing Total Shoulder Arthroplasty [amjorthopedics.com]

Fat Embolism Syndrome ICD-10 T79.1XXA - Fat embolism (traumatic), initial encounter T79.1XXD - Fat embolism (traumatic), subsequent encounter T79.1XXS - Fat embolism (traumatic), sequela Fat Embolism Syndrome ICD-9 Fat Embolism Syndrome Etiology / Epidemiology [eorif.com]

He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. [lifeinthefastlane.com]

This article reviews the definition, epidemiology, etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of FES. [ncbi.nlm.nih.gov]

In the present study, we investigated the clinical manifestations, and biochemical and pathophysiological changes, in subjects associated with FES and ARDS, to elucidate the possible mechanisms involved in this disorder. [clinsci.org]

The complications experienced by the patient highlight the importance of prevention and early detection of fat embolism syndrome. [ncbi.nlm.nih.gov]

Prevention of fat embolism syndrome. [wheelessonline.com]

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