Edit concept Question Editor Create issue ticket

Fat Embolism

A fat embolism occurs when fat macroglobules or fat tissue circulates through the bloodstream and ultimately lodge within a blood vessel. It is most often a result of trauma to the long bones of the body (e.g., femur, humerus).


Presentation

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.

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]
  • However, it is often confused with post-operative symptoms of fever, pain, and discomfort.[en.wikipedia.org]
  • 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]
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]
  • The most consistent symptom of pulmonary embolism is sudden, acute dyspnea. List ten (10) signs and symptoms of pulmonary embolism in the nonsurgical patient.[quizlet.com]
  • Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first.[symptoma.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]
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]
  • Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first.[symptoma.com]
  • […] 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]
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]
  • 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]
  • Symptoms include progressive dyspnea (most common) over weeks to months, pleurisy, cough, hemoptysis, weight loss, and signs of cor pulmonale (15-20%).[clinicaladvisor.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]
  • Lung auscultation revealed diffuse inspiratory rales. Temperature was 38.5 [degree sign]C.[anesthesiology.pubs.asahq.org]
Tachycardia
  • The major clinical features of FES include hypoxia, pulmonary dysfunction, mental status changes, petechiae, tachycardia, fever, thrombocytopenia, and anemia.[ncbi.nlm.nih.gov]
  • Minor signs are fever, tachycardia, retinal changes, jaundice, and renal changes. The diagnosis of FES is made when one major and four minor signs are present.[eorif.com]
  • The five minor criteria are: (1) tachycardia ( 100 bpm), (2) pyrexia (hyperthermia), (3) retinal fat emboli, (4) jaundice, and (5) renal changes.[quizlet.com]
  • , and anxiety Schonfeld criteria Petechiae 5 Chest X-ray changes (diffuse alveolar infiltrates) 4 Hypoxaemia (PaO2 9.3 kPa) 3 Fever ( 38 C) 1 Tachycardia ( 120 beats min–1) 1 Tachypnoea ( 30 bpm) 1 Confusion 1 Cumulative score 5 required for diagnosis[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]
  • […] into tissues & 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[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]
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]
  • Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first.[symptoma.com]
  • […] 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]
  • 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]
Anisocoria
  • After 24h of intensive treatment, the patient developed anisocoria and coma (Glasgow coma scale 3).[ncbi.nlm.nih.gov]
  • Localizing signs, such as aphasia, anisocoria, apraxia in a patient with poly-trauma warrants a computerized tomography of brain to rule out hematoma, although in FES, a CT brain will be usually non-rewarding.[doi.org]
Petechiae
  • 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]
  • Two petechiae were evident on the left arm and a single petechia in the right axilla.[nejm.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]
  • Some patient will also develop more severe neurological symptoms such as rigidity, seizures, and coma. A petechial rash is the last sign of the triad to occur. It often presents on the chest, axilla, conjunctiva, head and neck.[symptoma.com]
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]
  • Neurologic signs such as confusion, stupor, and coma maybe present. These are usually temporary and does not happen on one side of the body. Respiratory distress can be mild and tend to improve on the third day.[en.wikipedia.org]
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]
Neurologic Manifestation
  • Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma.[ncbi.nlm.nih.gov]
  • The neurologic manifestations of fat embolism. Neurology 1986;36:847-51. [ PUBMED ] 12. Yildiz OK, Delice A, Oztoprak I, Gurelik M, Yildirim A, Bolayir E, et al.[ijoonline.com]
  • 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]
  • 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]

Workup

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

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].

Right Axis Deviation
  • The abnormalities observed are tachycardia with non-specific ST -T changes, right axis deviation and RV strain. [1] Thoracic CT and Lung Scans CT scan of chest may not be of much help other than in picking up small lesions in patients with apparently[doi.org]
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 rate[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]
  • Clinical fat embolism syndrome presents with tachycardia, tachypnea, elevated temperature, hypoxemia(lack of oxygen), hypocapnia, thrombocytopenia(low platelets in blood), and occasionally mild neurological symptoms.[intensivecarehotline.com]
  • Antioedema treatment was instituted, and mild hypocapnia was induced. Retinal examination performed on day 2 demonstrated characteristic cottonwool spots across the vascular beds, which are indicative of fat embolism.[emj.bmj.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]
Decreased Platelet Count
  • 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]
Non Specific ST-T Changes
  • The abnormalities observed are tachycardia with non-specific ST -T changes, right axis deviation and RV strain. [1] Thoracic CT and Lung Scans CT scan of chest may not be of much help other than in picking up small lesions in patients with apparently[doi.org]
Hepatocellular Carcinoma
  • An 81-year-old man with hepatocellular carcinoma associated with alcoholic liver cirrhosis suddenly lost consciousness before transcatheter arterial chemoembolization treatment for his disease and died 5 h after the episode.[ncbi.nlm.nih.gov]

Treatment

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

Prognosis

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

Etiology

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

Epidemiology

  • 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]
  • . - Fat embolism syndrome: history, definition, epidemiology. - Fat embolism: the reaming controversy. - Physical and technical aspects of intramedullary reaming. - Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures[wheelessonline.com]
Sex distribution
Age distribution

Pathophysiology

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

Prevention

  • Our objective was to determine the effect of corticosteroids in preventing FES in patients with long-bone fractures.[ncbi.nlm.nih.gov]

References

Article

  1. Carr JB, Hansen ST. Fulminant fat embolism. Orthopedics. 1990;13:258.
  2. Carr JB, Hansen ST. Unusual forms of pulmonary embolism. Clin Chest Med. 1994;15:561.
  3. Jacobson DM, Terrence CF, Reinmuth OM. The neurologic manifestations of fat embolism. Neurology. 1986;36:847.
  4. Byrick RJ. Fat embolism and postoperative coagulopathy. Can J Anaesth. 2001;48:618–21.
  5. Alho A. Fat embolism syndrome, Etiology pathogenesis and treatment. Acta Chir Scand. 1980;499:75–85.
  6. Kaplan RP, Grant JN, Kaufman AJ. Dermatologic features of the fat embolism syndrome. Cutis. 1986; 38:52-5.
  7. Jones JP Jr. Fat embolism, intravascular coagulation, and osteonecrosis. Clin Orthop Relat Res. 1993.
  8. Murray DA, Racz GB. Fat embolism syndrome: A rational for treatment. J Bone Joint Surg Br. 1974;56:1338–49.
  9. King MB, Harmon KR. Unusual forms of pulmonary embolism. Clin Chest Med. 1994; 15:561-80.
  10. Glas WW, Grekin TD, Musselman MM. Fat embolism. Am J Surg. 1953;85:363.
  11. Umali CB, Smith EH. The chest radiographic examination. In: Intensive Care Medicine, Rippe, JM, Irwin, RS, Alpert, JS, Fink, MP (Eds), Little Brown, Boston 1991. p.596.
  12. Kellogg RG, Fontes RB, Lopes DK. Massive cerebral involvement in fat embolism syndrome and intracranial pressure management. J Neurosurg. 2013;119:1263-70.
  13. Takahashi M, Suzuki R, Osakabe Y, et al. Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations. J Trauma. 1999;46:324.
  14. Guillevin R, Vallée JN, Demeret S, et al. Cerebral fat embolism: Usefulness of magnetic resonance spectrometry. Am Neurol. 2005;57:434–9.
  15. Stoeger A, Daniaux M, Feiber S, Stockhammer G, Aichner F, zur Nedden D. MRI finding in cerebral fat embolism. Eur Radiol. 1998;8:1590–3.
  16. Wenda K, Runkel M, Degrief J, Ritter G. Pathogenesis and clinical relevance in medullary nailing demonstrated by intra-operative echocardiography. Injury. 1993;24:S73–81.
  17. Fourme T, Vieillard-Baron A, et al. Early fat embolism after liposuction. Anaesthesiology. 1998;89:782–4.
  18. Godeau B, Schaeffer A, Bachir D, et al. Am Bronchoalveolar lavage in adult sickle cell patients with acute chest syndrome: value for diagnostic assessment of fat embolism. J Respir Crit Care Med. 1996;153:1691.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 22:19