FAT EMBOLISM Syndrome(FES)

- Major cause of mortality and morbity. in multiple trauma patients. - Most common 2 nd – 3 rd decode - Decrease on children for different pattern palnutin & staerin for against olein on adult - Both genders are equal. Points : Points :

Points : Cont… Points : Cont… - Latend period after trauma hs most symptoms within 24 hs, and up a week

تعریف FES: Lung paranchyma Lung paranchyma وجود گلبولهای چربی Peripheral circulation Peripheral circulation بعد از شکستگی استخوانهای بلند و Major Trauma

CAUSES : CAUSES : - Traumatic - Traumatic - Non traumatic - Non traumatic - diabetes mellitus - diabetes mellitus - collagen disease - collagen disease - burns - burns - severe infections - severe infections - inhalation Anesthesia - inhalation Anesthesia

CAUSES : Cont… CAUSES : Cont… - chronic panceratits - chronic panceratits - chronic alcoholism - chronic alcoholism - osteomyelitis - osteomyelitis - blood transfusion - blood transfusion - cardiopulmonary bypass - cardiopulmonary bypass - sickle – cell anemia - sickle – cell anemia - renal infarction - renal infarction

- steroid – induced fatty liver - steroid – induced fatty liver - acute decompression sickness - acute decompression sickness - T. H. A - T. H. A - Im nailing - Im nailing - liposuction - liposuction - parenteral lipid infusion - parenteral lipid infusion - Knee arthroplasty - Knee arthroplasty CAUSES : Cont… CAUSES : Cont…

Prevalence of FES - Exact,not known - Exact,not known - Overall mortality - Overall mortality ( %10 - %20 ) ( %10 - %20 ) - Morbidity, High - Morbidity, High - Grave pronostic sign : - Grave pronostic sign : - coma - coma - ARDS - ARDS

Prevalence of FES Cont… - pneumonia - pneumonia - super imposed congestive - super imposed congestive heart failure heart failure

Pathophysiology 1. Mechanical theory : Formable Intravasated Formable Intravasated fat globus From marrow fat globus From marrow Disrupted Disrupted vessels circulations vessels circulations Lung Capillaries Fatemboli Lung Capillaries Fatemboli Fat deposition Fat deposition Obstruction Obstruction - Other site of emboli - Other site of emboli Kidneys – braim – retina - skin Kidneys – braim – retina - skin

Pathophysiology Cont… 2. Biochemical theory : neutral Lung lipase neutral Lung lipase fat hydrolyzes fat hydrolyzes Chemically Toxic Severe Chemically Toxic Severe free fatty acids inflammatory free fatty acids inflammatory reaction reaction Endothelial ARDS Endothelial ARDS damage damage

Etiologic factors for the development 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 Finding A – Pulmonary manifestation A – Pulmonary manifestation B – Cerebral manifestation B – Cerebral manifestation C – Cutaneous manifestation C – Cutaneous manifestation D – Retinal manifestation D – Retinal manifestation

A – Pulmonary Findings - Tachypnea - Tachypnea - Dyspnea - Dyspnea - Cyonosis - Cyonosis - Tachycardia - Tachycardia - Pyrexia - Pyrexia - Rales & rhonchi with an occasional - Rales & rhonchi with an occasional pleural friction rub. pleural friction rub.

B – Cerebral Findings - Headache - Headache - Irritability - Irritability - Delirium - Delirium - Stupor - Stupor - Convulsion - Convulsion - Coma - Coma

C – 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 conjunctiva folds and conjunctiva

D – Retinal Findigs - Exudates, Edematus patches - Exudates, Edematus patches - Cotton wool spots - Cotton wool spots - Perivascular or petechial hemorrhage. - Perivascular or petechial hemorrhage. - Intravascular fat globules - Intravascular fat globules -- Jaundice -- Renal involvement

Clinical Presentations - Subclinical - Subclinical - Nonfulminant subacute - Nonfulminant subacute - Fulminant acute - Fulminant acute

Lab Findigs & Radiographic Evaluation - RBC↓ - RBC↓ - Hb ↓ - Hb ↓ - Platellate ↓ - Platellate ↓ - Ca ↓ - Ca ↓ - Pao2 ↓ …. 50 mmhg - Pao2 ↓ …. 50 mmhg - Fat globules on urine / Sputum - Fat globules on urine / Sputum - Blood lipid ↑ - Blood lipid ↑ - Blood lipase↑ - Blood lipase↑

ECG : - Right axis deviation - Right axis deviation - Prominent S wave and Q - Prominent S wave and Q - ST segment changes - ST segment changes

- Chest X.Ray - Chest X.Ray - Diffuse / Bilat infiltrate fat which can be - Diffuse / Bilat infiltrate fat which can be interstitial or alveolar interstitial or alveolar ( Snowstorm pattern ) ( Snowstorm pattern ) - CT Scan - CT Scan - MRI - MRI for Assessment of cerebral edema for Assessment of cerebral edema

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

Treatment Cont… - Immobilization of lower Extrimity & pelvis Fxs - Immobilization of lower Extrimity & pelvis Fxs Risk of ARDS↓ %7 Risk of ARDS↓ %7 Fixation on 24 hs Fixation on 24 hs If delayed %39 If delayed %39 Note Im Rod Note Im Rod Exclude from this Exclude from this

Treatment Cont… - Dx Shock : - Dx Shock : - Systolic blood pressure 100 mmHg ↓ - Systolic blood pressure 100 mmHg ↓ - HR > 120 / Min - HR > 120 / Min - CVP Cathiters - CVP Cathiters - Crystalloid Blance Electrolyte - Crystalloid Blance Electrolyte - Albumin Free fatty↓ lung ↓ - Albumin Free fatty↓ lung ↓ acid damage acid damage

Treatment Cont… - Neurologic Support - Neurologic Support - Oxigen therapy - Oxigen therapy - Avoid Hypercarbia - Avoid Hypercarbia ( Pco2 = 30 mmHg ) ( Pco2 = 30 mmHg ) - BP over 100 mmHg - BP over 100 mmHg

Treatment Cont… - Additional therapies: - Additional therapies: 1. Steroids 1. Steroids Prophylactic methylprednisdone Prophylactic methylprednisdone 10 mg / Kg / 8 hs 10 mg / Kg / 8 hs 2. Alcohol 2. Alcohol 3. Heparin 3. Heparin Controversy Controversy 4. Dextran 4. Dextran 5. Hypertonic glucose 5. Hypertonic glucose

The End