Dr. Faran Mahmood   FCPS Orthop.
   First diagnosed in 1873 by Dr Von Bergmann   Published in 1879 Fenger and Salisbury.
   Fat Embolism:    Traumatic fat embolism occurs in up to 90% of    individuals with severe skeletal injuries, but <    ...
   Incidence: 1-3% femur #, 5-10% if bilateral or    multiple.   Mortality: 5-15%   Clinical diagnosis, No specific lab...
   A high index of suspicion is needed for diagnosis is    to be made.   An asymptomatic latent period - 12-48 hours.  ...
Mechanical Theory   Physical obstruction of the pulmonary & systemic    vasculature with embolized fat.   Temporary rise...
The biochemical theory   Circulating FFAs -directly toxic to Pneumocytes /    capillary Endothelium in the lung - interst...
H/E stain lung –- blood vessel withfibrinoid material and-optical empty space-lipid dissolved duringthe staining process.
TRAUMA
HypoxemiaNeurological    Petechialabnormalities   rash
   Dyspnea,                 Tachypnea   Hypoxemia PaO2 < 60 mm Hg
   Clinically Tachpnea, Dyspnea, Hypoxia, rales, pleural    friction rub & ARDS.   High spiking temperatures.   Hypoxem...
   CNS signs usually occur after respiratory symptoms    - nonspecific - features of diffuse encephalopathy   Acute conf...
   Reddish-brown non-palpable Petechial rash - upper    anterior body, chest, neck, upper arm, axilla,    shoulder, oral ...
   Retinopathy (exudates, cotton wool spots,    hemorrhage)   Lipiduria   Fever   DIC   Myocardial depression (R hear...
Gurd’s criteria   Most commonly used   1 major, plus 4 minor
   Continuous pulse oximetry monitoring - at-risk    patients ( those patients with long bone fractures) -    detecting d...
   The most effective prophylactic measure - operative    reduction/rigid fixation of long bone fractures as    soon as p...
   Albumin has been recommended - not only restores    blood volume / binds fatty acids - may decrease the    extent of l...
   Heparin has also been proposed as it activates    lipase, but no evidence exists for its use in FES.
   Difficult to predict –FES is frequently subclinical or    overshadowed by other illnesses or injuries.   Increased al...
   As in ARDS, pulmonary sequelae usually resolve    almost completely within 1 year.   Residual subclinical diffusion c...
   Clinical diagnosis so high index of suspicion.   Most effective management is prevention with rigid    fixation of fr...
Fatembolism
Fatembolism
Fatembolism
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Fatembolism

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Fatembolism

  1. 1. Dr. Faran Mahmood FCPS Orthop.
  2. 2.  First diagnosed in 1873 by Dr Von Bergmann Published in 1879 Fenger and Salisbury.
  3. 3.  Fat Embolism: Traumatic fat embolism occurs in up to 90% of individuals with severe skeletal injuries, but < 10% of such patients have any clinical symptoms / signs Fat Embolism Syndrome: FE with clinical manifestation .
  4. 4.  Incidence: 1-3% femur #, 5-10% if bilateral or multiple. Mortality: 5-15% Clinical diagnosis, No specific laboratory test is diagnostic Mostly associated with long bone/pelvic #s, and more frequent in closed fractures. Onset is 24-72 hours from initial insult
  5. 5.  A high index of suspicion is needed for diagnosis is to be made. An asymptomatic latent period - 12-48 hours. The fulminant form presents as acute cor pulmonale, respiratory failure, - death within a few hours of injury.
  6. 6. Mechanical Theory Physical obstruction of the pulmonary & systemic vasculature with embolized fat. Temporary rise in I/M pressure - forces marrow into injured venous sinusoids. Cor pulmonale - inadequate compensatory pulmonary vasodilatation. Microvascular lodging - local ischemia and inflammation. Release of inflammatory mediators, platelet aggregation, & vasoactive amines.
  7. 7. The biochemical theory Circulating FFAs -directly toxic to Pneumocytes / capillary Endothelium in the lung - interstitial hemorrhage, edema & chemical pneumonitis. Coexisting shock, hypovolemia and sepsis - reduce liver flow exacerbate the toxic effects of FFAs.
  8. 8. H/E stain lung –- blood vessel withfibrinoid material and-optical empty space-lipid dissolved duringthe staining process.
  9. 9. TRAUMA
  10. 10. HypoxemiaNeurological Petechialabnormalities rash
  11. 11.  Dyspnea,  Tachypnea Hypoxemia PaO2 < 60 mm Hg
  12. 12.  Clinically Tachpnea, Dyspnea, Hypoxia, rales, pleural friction rub & ARDS. High spiking temperatures. Hypoxemia - ventilation-perfusion mismatch & intrapulmonary shunting. Acute cor pulmonale -respiratory distress, hypoxemia, hypotension and elevated CVP. ½ of pts require mechanical ventilation CXR normal early on - later may show ‘snowstorm’ pattern- diffuse bilateral infiltrates CT chest: ground glass opacification with interlobular septal thickening
  13. 13.  CNS signs usually occur after respiratory symptoms - nonspecific - features of diffuse encephalopathy Acute confusion, stupor, coma, rigidity, or convulsions - Transient and reversible in most cases CT Head: general edema – nonspecific MRI brain: Low density on T1 & High intensity T2 signal - correlates to degree of impairment
  14. 14.  Reddish-brown non-palpable Petechial rash - upper anterior body, chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctivae in 20 - 50% patients. Pathognomonic, however, it appears late and disappears within hours. Results from occlusion of dermal capillaries by fat globules - extravasations of RBC
  15. 15.  Retinopathy (exudates, cotton wool spots, hemorrhage) Lipiduria Fever DIC Myocardial depression (R heart strain) Thrombocytopenia Anemia, Decreased Hematocrit Hypocalcemia
  16. 16. Gurd’s criteria Most commonly used 1 major, plus 4 minor
  17. 17.  Continuous pulse oximetry monitoring - at-risk patients ( those patients with long bone fractures) - detecting desaturations early. Consultations recommended include orthopedists, neurologists/ neurosurgeons, trauma care specialists, critical care specialists, pulmonologists, hematologists, and nutritionists.
  18. 18.  The most effective prophylactic measure - operative reduction/rigid fixation of long bone fractures as soon as possible. Higher incidence (5 fold) when fixation delayed greater than 24 hours. Supportive care includes maintenance of adequate oxygenation and ventilation, stable hemodynamics, blood products as clinically indicated, hydration, prophylaxis of DVT and stress-related GI bleeding.
  19. 19.  Albumin has been recommended - not only restores blood volume / binds fatty acids - may decrease the extent of lung injury. High dose corticosteroids have been effective in preventing development of FES in several trials, but controversy on this issue still persists.
  20. 20.  Heparin has also been proposed as it activates lipase, but no evidence exists for its use in FES.
  21. 21.  Difficult to predict –FES is frequently subclinical or overshadowed by other illnesses or injuries. Increased alveolar-to-arterial oxygen gradient and neurologic deficits, including coma, may last days or weeks.
  22. 22.  As in ARDS, pulmonary sequelae usually resolve almost completely within 1 year. Residual subclinical diffusion capacity deficits may exist. Residual neurologic deficits may range from nonexistent to subtle personality changes to memory and cognitive dysfunction to long-term focal deficits.
  23. 23.  Clinical diagnosis so high index of suspicion. Most effective management is prevention with rigid fixation of fractures within 24 hours When developed management is supportive.

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