FAT EMBOLISMFAT EMBOLISM

SyndromeSyndrome

(FES)(FES)

- -Major cause of mortality and morbity . in Major cause of mortality and morbity . in multiple trauma patientsmultiple trauma patients..

- -Most common 2Most common 2ndnd – 3 – 3rdrd decode decode

- -Decrease on children for different pattern Decrease on children for different pattern palnutin & staerin for against olein on adultpalnutin & staerin for against olein on adult

- -Both genders are equalBoth genders are equal. .

Points :Points :

Points :Points : Cont…Cont…

- -Latend period after trauma 12- 72 hs most Latend period after trauma 12- 72 hs most symptoms within 24 hs , and up a weeksymptoms within 24 hs , and up a week

::FESFESتعریف تعریف

Lung paranchymaLung paranchyma

چربی گلبولهای چربی وجود گلبولهای وجود

Peripheral circulationPeripheral circulation

و بلند استخوانهای شکستگی از و بعد بلند استخوانهای شکستگی از Major MajorبعدTraumaTrauma

CAUSES :CAUSES :

- - TraumaticTraumatic

- - Non traumaticNon traumatic

- - diabetes mellitusdiabetes mellitus

- - collagen diseasecollagen disease

- - burnsburns

- - severe infectionssevere infections

- - inhalation Anesthesiainhalation Anesthesia

CAUSES :CAUSES : Cont…Cont…

- - chronic panceratitschronic panceratits

- - chronic alcoholismchronic alcoholism

- - osteomyelitisosteomyelitis

- - blood transfusionblood transfusion

- - cardiopulmonary bypasscardiopulmonary bypass

- - sickle – cell anemiasickle – cell anemia

- - renal infarctionrenal infarction

- steroid – induced fatty liver- steroid – induced fatty liver

- - acute decompression sicknessacute decompression sickness

- - T . H . AT . H . A

- - Im nailingIm nailing

- - liposuctionliposuction

- - parenteral lipid infusionparenteral lipid infusion

- - Knee arthroplastyKnee arthroplasty

CAUSES :CAUSES : Cont…Cont…

Prevalence of FESPrevalence of FES

- - Exact ,not knownExact ,not known

- - Overall mortalityOverall mortality

) ) %10%10 - - %20%20( (

- - Morbidity , HighMorbidity , High

- - Grave pronostic signGrave pronostic sign: :

- - comacoma

- - ARDSARDS

Prevalence of FES Prevalence of FES ContCont……

- - pneumoniapneumonia

- super imposed congestive- super imposed congestive

heart failureheart failure

PathophysiologyPathophysiology1. Mechanical theory :1. Mechanical theory : Formable Intravasated Formable Intravasated fat globus From marrowfat globus From marrow Disrupted Disrupted vessels circulationsvessels circulations

Lung Capillaries FatemboliLung Capillaries Fatemboli Fat depositionFat deposition ObstructionObstruction

- Other site of emboli- Other site of emboli Kidneys – braim – retina - skin Kidneys – braim – retina - skin

PathophysiologyPathophysiology ContCont……

22 . .Biochemical theoryBiochemical theory: : neutral Lung lipaseneutral Lung lipase

fat hydrolyzesfat hydrolyzes

Chemically Toxic SevereChemically Toxic Severe free fatty acids inflammatoryfree fatty acids inflammatory

reactionreaction

Endothelial ARDSEndothelial ARDS damagedamage

Etiologic factors for the Etiologic factors for the development of Fat Embolismdevelopment of Fat Embolism

A – Movement of unstable A – Movement of unstable

Fx ends + Medullary presure.Fx ends + Medullary presure.

B – Reaming of medullary cavity.B – Reaming of medullary cavity.

Clinical FindingClinical Finding

A – Pulmonary manifestationA – Pulmonary manifestation

B – Cerebral manifestationB – Cerebral manifestation

C – Cutaneous manifestationC – Cutaneous manifestation

D – Retinal manifestationD – Retinal manifestation

A – Pulmonary FindingsA – Pulmonary Findings

- -TachypneaTachypnea

- - DyspneaDyspnea

- - CyonosisCyonosis

- - TachycardiaTachycardia

- - PyrexiaPyrexia

- - Rales & rhonchi with an occasionalRales & rhonchi with an occasional

pleural friction rubpleural friction rub..

B – Cerebral FindingsB – Cerebral Findings

- - HeadacheHeadache

- - IrritabilityIrritability

- - DeliriumDelirium

- - StuporStupor

- - ConvulsionConvulsion

- - ComaComa

C – Cutaneous FindingsC – Cutaneous Findings

- Present after 2 – 3 days occured on- Present after 2 – 3 days occured on

%50%50

- Petechial rach on chest – ant .axilly- Petechial rach on chest – ant .axilly

folds and conjunctivafolds and conjunctiva

D – Retinal FindigsD – Retinal Findigs

- -Exudates , Edematus patchesExudates , Edematus patches

- - Cotton wool spotsCotton wool spots

- - Perivascular or petechial hemorrhagePerivascular or petechial hemorrhage..

- - Intravascular fat globulesIntravascular fat globules

-- --JaundiceJaundice

-- --Renal involvementRenal involvement

Clinical PresentationsClinical Presentations

- - SubclinicalSubclinical

- - Nonfulminant subacuteNonfulminant subacute

- - Fulminant acuteFulminant acute

Lab Findigs & Radiographic Lab Findigs & Radiographic EvaluationEvaluation

- - RBCRBC↓↓ - - HbHb↓ ↓

- - PlatellatePlatellate↓ ↓ - - CaCa↓ ↓

- - Pao2 ↓ …. 50 mmhgPao2 ↓ …. 50 mmhg - - Fat globules on urine / SputumFat globules on urine / Sputum

- - Blood lipidBlood lipid↑ ↑ - - Blood lipaseBlood lipase↑↑

ECGECG: :

- - Right axis deviationRight axis deviation

- - Prominent S wave and QProminent S wave and Q

- - ST segment changesST segment changes

- -Chest X.RayChest X.Ray

- - Diffuse / Bilat infiltrate fat which can beDiffuse / Bilat infiltrate fat which can be

interstitial or alveolarinterstitial or alveolar

) ) Snowstorm patternSnowstorm pattern( (

- - CT ScanCT Scan

- - MRIMRI

for Assessment of cerebral edemafor Assessment of cerebral edema

Treatment of FESTreatment of FES - Respiratory Support use O2- Respiratory Support use O2 Oxygen SaturationOxygen Saturation Must be # %90 – Pao2 90mmHgMust be # %90 – Pao2 90mmHg - If Pao2 < 60 mmHg - If Pao2 < 60 mmHg – – endotracheal intubationendotracheal intubation + Mechanical ventilation+ Mechanical ventilation - ICU- ICU - Transeosophageal echocardiography may - Transeosophageal echocardiography may

be need be need

Treatment Treatment ContCont……

- - Immobilization of lower Extrimity & Immobilization of lower Extrimity & pelvis Fxs pelvis Fxs

Risk of ARDS↓ %7Risk of ARDS↓ %7

Fixation on 24 hsFixation on 24 hs

If delayed %39If delayed %39

Note Im RodNote Im Rod

Exclude from thisExclude from this

TreatmentTreatment ContCont……

- -Dx ShockDx Shock: :

- - Systolic blood pressure 100 mmHgSystolic blood pressure 100 mmHg↓ ↓

- - HR > 120 / MinHR > 120 / Min

- - CVP CathitersCVP Cathiters

- - Crystalloid Blance ElectrolyteCrystalloid Blance Electrolyte

- - Albumin Free fatty↓ lungAlbumin Free fatty↓ lung↓ ↓

acid damageacid damage

TreatmentTreatment ContCont……

- -Neurologic SupportNeurologic Support

- - Oxigen therapyOxigen therapy

- - Avoid HypercarbiaAvoid Hypercarbia

) ) Pco2 = 30 mmHgPco2 = 30 mmHg( (

- - BP over 100 mmHgBP over 100 mmHg

TreatmentTreatment ContCont……

- -Additional therapiesAdditional therapies:: 11 . .SteroidsSteroids

Prophylactic methylprednisdoneProphylactic methylprednisdone 1010 mg / Kg / 8 hsmg / Kg / 8 hs

22 . .AlcoholAlcohol 33 . .HeparinHeparin

ControversyControversy 44 . .DextranDextran

55 . .Hypertonic glucoseHypertonic glucose

The EndThe End