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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]
  • The initial symptoms are nonspecific, such as back and/or abdominal pain, fever, and fatigue, which may rapidly progress to respiratory failure and severe neurologic compromise.[ncbi.nlm.nih.gov]
  • Signs and symptoms of fat embolus include central nervous system dysfunction that may progress to coma or death, irregularities in the heartbeat, respiratory distress, and fever . Anemia and thrombocytopenia (low platelet count) are common.[medicinenet.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]
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]
  • 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
  • […] 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]
  • Respiratory related symptoms such as cyanosis, dyspnea, hypoxemia, and tachypnea onset first.[symptoma.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]
  • The diagnosis is based on symptoms occurring within the first 3 days, including tachycardia, dyspnea and tachypnea. The respiratory issues can develop into adult respiratory distress syndrome (ARDS).[enkivillage.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]
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]
  • […] 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]
  • Symptoms of pulmonary embolism appear suddenly and include : shortness of breath, rapid breathing, or wheezing bloody sputum cough lightheadedness, dizziness, fainting sharp chest pain or back pain Making the Diagnosis There are several tests that may[medbroadcast.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]
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]
  • Diagnosis History Trauma to long bone/pelvis, recent orthopedic procedure, recent lipid infusion Signs Under General Anesthesia Clinical signs may include hypoxia/increased A-a gradient , tachycardia , and a petechial rash on the upper portions of the[openanesthesia.org]
  • 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, apprehension, tachycardia[quizlet.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]
  • Two days later, she developed increasing respiratory distress, confusion, and chest pain. A petechial rash on her upper arms also appeared.[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]
  • 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]
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]
Acute Low Back Pain
  • BACKGROUND: Acute low back pain is a very common symptom and reason for many medical consultations. In some unusual circumstances it could be linked to a rare aetiology.[ncbi.nlm.nih.gov]
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]
  • After this procedure, she presented with the triad of hypoxemia, neurological impairment, and petechiae consistent with the diagnosis of FES. After advanced support measures, she recovered completely.[ncbi.nlm.nih.gov]
  • Two petechiae were evident on the left arm and a single petechia in the right axilla.[nejm.org]
  • 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]
Confusion
  • He was found to have fat embolism syndrome at postoperative day 1 as evidenced by confusion, respiratory symptoms, chest radiograph changes, raised erythrocyte sedimentation rate, thrombocytopenia and fat in the urine and sputum.[ncbi.nlm.nih.gov]
  • Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma.[ncbi.nlm.nih.gov]
  • A diagnosis of FES is often missed because of a subclinical illness or coexisting confusing injuries or disease.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We report a 70-year-old man with an 8-month history of left posterior thigh and leg pain who had sudden confusion after a fall from standing.[ncbi.nlm.nih.gov]
  • Abstract A 23-year-old Indian man presented with shortness of breath and new-onset confusion along with a rash on his chest on Postoperative Day 2, following internal fixation of his femur fracture.[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]
  • His symptoms included unresponsiveness, disconjugate gaze, seizures, respiratory distress, fever, anemia, thrombocytopenia, and visual changes.[ncbi.nlm.nih.gov]
  • After 3 days, the patient had an acute decrease in consciousness level followed by the onset of seizures and right hemiparesis. Brain computed tomography and magnetic resonance imaging showed findings suggestive of CFE.[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]
  • 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
  • Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma.[ncbi.nlm.nih.gov]
  • 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]
Altered Mental Status
  • A 58-year-old woman presented with a seizure episode and altered mental status after suffering a right femur fracture.[ncbi.nlm.nih.gov]
  • 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. A petechial rash is the last sign of the triad to occur.[symptoma.com]
  • His hypoxemia, altered mental status, hypotension, and petechiae resolved completely. Footnotes References 1. Talbot M, Schemitsch EH . Fat embolism syndrome: history, definition, epidemiology.[ahajournals.org]
  • [CrossRef] [PubMed] Raza SS, Noheria A, Kesman RL. 21-year-old man with chest pain, respiratory distress, and altered mental status. Mayo Clin Proc. 2011;86(5):e29-e32. [CrossRef] [PubMed] Capan LM, Miller SM, Patel KP. Fat embolism.[swjpcc.com]
  • Seen within hours of injury, it results in severe physiologic impairment including respiratory failure, and altered mental status. Cause of death, if occurs, is usually due to acute right heart failure.[doi.org]

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

  • 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].

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]

Treatment

  • The early diagnosis and comprehensive treatment can improve prognosis.[ncbi.nlm.nih.gov]
  • Progression of asymptomatic fat embolism with FES frequently represents inadequate treatment of hypovolaemic shock.[ncbi.nlm.nih.gov]
  • Treatment has centred around supportive care and early fracture fixation. Several small clinical trials have suggested corticosteroids benefit patients with FES, but this treatment remains controversial.[ncbi.nlm.nih.gov]
  • Despite advances in treatment strategies regarding the timing of definitive fixation of major fractures, FES still occurs in patients.[ncbi.nlm.nih.gov]
  • Despite a high index of morbidity and mortality, few reports exist about these complications, and although they have the same causal agent, their etiopathogenesis, clinical evolution, treatment, prognosis, and prevention are totally different.[ncbi.nlm.nih.gov]

Prognosis

  • The early diagnosis and comprehensive treatment can improve prognosis.[ncbi.nlm.nih.gov]
  • In most cases, prognosis is good if the condition is detected and treated early. High index of suspicion in polytrauma patient is the key to early diagnosis of this condition.[ncbi.nlm.nih.gov]
  • This article reviews the definition, epidemiology, etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of FES.[ncbi.nlm.nih.gov]
  • Except in fulminant fat embolism syndrome, the prognosis is usually good.[ncbi.nlm.nih.gov]
  • Despite a high index of morbidity and mortality, few reports exist about these complications, and although they have the same causal agent, their etiopathogenesis, clinical evolution, treatment, prognosis, and prevention are totally different.[ncbi.nlm.nih.gov]

Etiology

  • Considering the multifactorial etiology of FES, including mechanical and biochemical pathways, FES cannot be prevented in all patients.[ncbi.nlm.nih.gov]
  • This article reviews the definition, epidemiology, etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of FES.[ncbi.nlm.nih.gov]
  • The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES.[ncbi.nlm.nih.gov]
  • The exact etiology of this condition is not known. Because it occurs more often in patients with compound heterozygous conditions than in sickle cell disease, some patients are unaware of their predisposition.[ncbi.nlm.nih.gov]
  • INTRODUCTION: Little is known about the incidence and etiology of fat embolism in pediatric patients.[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]
  • Talbot M, Schemitsch EH (2006) Fat embolism syndrome: history, definition, epidemiology. Injury 37(Suppl 4):S3–S7 PubMed CrossRef Google Scholar 35.[link.springer.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]
  • Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult.[ncbi.nlm.nih.gov]
  • The aim of this review is to describe the main clinical and imaging aspects of FES, ranging from pathophysiology to treatment with emphasis on pulmonary involvement.[ncbi.nlm.nih.gov]
  • The exact pathophysiology of emboli reaching the arterial circulation is poorly understood.1 It is suggested that this may occur by either 'paradoxical' embolism or microembolism.2 3 Its true incidence is unknown but increases in the presence of multiple[ncbi.nlm.nih.gov]
  • A literature review revealed that the pathophysiologic basis for fat embolism in the absence of any fracture is perhaps a consequence of acutely increased pressure at the trauma site and altered emulsification of blood lipids during shock.[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]
  • The complications experienced by the patient highlight the importance of prevention and early detection of fat embolism syndrome.[ncbi.nlm.nih.gov]
  • The operative time was longer than normal and no preventive strategies for pulmonary embolism were implemented. The patient died 20 days after hospital discharge. The autopsy confirmed pulmonary hemorrhagic infarction.[ncbi.nlm.nih.gov]
  • Despite a high index of morbidity and mortality, few reports exist about these complications, and although they have the same causal agent, their etiopathogenesis, clinical evolution, treatment, prognosis, and prevention are totally different.[ncbi.nlm.nih.gov]
  • QUESTION/PURPOSE: This study was sought to evaluate the (1) efficacy and (2) safety of inhalational Ciclesonide (CIC) in prevention of FES and treatment of hypoxemia in isolated skeletal trauma victims.[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.

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Last updated: 2017-08-09 17:29