While fes was later clinically diagnosed and often reported in the literature over the next 100 years, gurds clinical description of the fes renewed interest in studying this syndrome. The diagnosis of fat embolism syndrome fes is a clinical one and related to the release of fat droplets into the systemic circulation after for example an orthopedic intervention. Fat embolism syndrome fes is a constellation of symptoms and signs subsequent to orthopedic trauma. Gurd s diagnostic criteria for fat embolism syndrome save. Fat embolism occurs in almost all lower extremity trauma and intramedullary surgery. Fat embolism is a wellknown complication of long bone and pelvic fractures. The use of prone position ventilation in a dah has rarely been. A case of acute fulminant fat embolism syndrome after. The characteristics of fat embolism syndrome fes, and the complications occurring in fractures of long bones or pelvic bones are considered.
Fes occurs as a complication after trauma or procedures such as surgery. Over 150 years ago, zenker described the first case of fat embolism syndrome fes in a patient suffering from crush injury. As the former can occur without the latter, it is sensible to define each entity, acknowledging that there may be some overlap in clinical practice. This syndrome denotes clinical or subclinical respiratory insufficiency, and usually runs a mild course and responds well to measures for ventilatory support.
Fes has no specific treatment and requires supportive care, although it can be prevented by early fixation of bone fractures. The incidence of fes among all patients with long bone and pelvic fractures was 0. Gurd s criteria are named for the physician who established this system of detecting fat embolism syndrome fes. Fat embolism fe is defined by the presence of fat globules in the pulmonary microcirculation regardless of clinical significance. Fat embolism syndrome fes has been recognized since the late1800s and extensively described following traumatic, surgicaland atraumatic conditions. The lungs are usually the most affected organs with rapidly progressing tachypnea and hypoxemia as the primary clinical symptoms 3, 6. The diagnosis of fat embolism is made by clinical features alone with no specific laboratory findings. It remains a diagnostic challenge for clinicians, but prompt recognition is important so that supportive therapy can be instituted early. Fat embolism syndrome presenting as diffuse alveolar. Microglobulinemia is a required diagnostic test based on gurds criteria. Fat embolism and the accompanying fat embolism syndrome fes are conditions that develop when droplets of fat act as emboli. However, despite its original description hundreds of years ago, it remains a difficult diagnosis to establish and the process by which a fat embolism leads.
The majority 95% of cases occur after major trauma. Note that urinary fat stains are not felt to be sensitive or specific enough for diagnosing fat embolism or for detecting a risk of it, and. The absence of a diagnostic gold standard makes it impossible to evaluate the value of these clinicallybased evaluation systems. Gurd s criteria, consisting of major and minor clinical features, is the most commonly used diagnostic tool in the literature. Table 2 gurds diagnostic criteria for fat embolism syndrome adapted from wheelesstextbook of orthopaedics hypoxemia cns depression that is disproportionate to hypoxemia,and pulmonary edema axillary or subconjunctival petechiae occurs within 46 hours of skeletal trauma tachycardia greater than 110 beats per minute. Although the authors recognise that the respiratory signs and symptoms of tachypnoea and dyspnoea are a feature. View additional options to gain access to this content. If a person has at least one of gurds major criteria and at least four minor criteria, a diagnosis can comfortably be made. Unusual presentation of more common diseaseinjury fat. The term fat embolism indicates the often asymptomatic presence of fat globules in the lung parenchyma and peripheral circulation after long bone or other major trauma. Fat embolism syndrome fes is a lifethreatening complication in patients with orthopedic trauma, especially long bone fractures. We considered esr of 44 mmh and 15% reduction in platelet count in our case to have ful. Exact incidence of fat embolism syndrome is not known, but fabian et al. The multisystem disorder can also affect the heart, kidneys, eyes, and skin.
Gurds criteria is handy for diagnosing fat embolism when trauma causes large fat droplets enter the circulation fractures to long bones and the pelvis. The first clinical case of fat embolism was described over 100 years ago and significant progress has been made in the understanding of this condition since then. Basic theories of fes pathophysiology are analyzed. This occurs transiently over 46 h in 50%60% of patients 2 hypoxemia pao2 criteria 1 tachycardia 110 beatsmin. Gurds criteria have been criticised for being unreliable.
In the original description of gurds criteria, the actual numerical value of high esr and thrombocytopenia was not provided. Fat embolism syndrome is a serious condition with 15% mortality left untreated and is diagnosed by non specific tests and universal criteria therefore clinical judgment in individual cases should trump. Fat embolism syndrome fes is a not common subacute syndrome caused by fat droplets and bone marrow entering systemic circulation and thus causing obstruction of pulmonary, cerebral and cutaneous. Prone positioning in a patient with fat embolism syndrome. It is believed to be caused by the toxic effects of free fatty acids. The clinical profile of fes in the trauma population was studied over 2 years and 8 months. The reported incidence varies greatly in the literature depending on diagnostic criteria. No investigation is 100% specific for the syndrome. Clinical picture classically develops after lucid space, then appear pulmonary and neurological manifestations combined with petechial hemorrhage. Fat embolism syndrome is most often caused by trauma and orthopaedic injuries and is a condition with 15% mortality rates if left untreated.
Gurds criteria for fat embolism poem by daya nandan. Fat embolism syndrome fes occurs most commonly following orthopedic trauma, particularly fractures of the pelvis or long bones, however nontraumatic fat embolism has also been known to occur on rare occasions. Emboli composed of fat are common, relatively innocuous and may occur in alcoholism, bm biopsy, cardiopulmonary bypass, compression injury, dm, lymphangiography, pancreatitis, sickle cell anemia, corticosteroid therapy. Fat embolism syndrome in duchenne muscular dystrophy. Chest xray shows a diffuse bilateral infiltrate that is hard to differentiate from pediatric acute respiratory distress syndrome. Diffuse alveolar haemorrhage dah is a rare complication of fat embolism syndrome leading to severe hypoxaemia due to the effusion of blood into the alveoli from the damaged pulmonary microvasculature. Cerebral fat embolism cfe is an incomplete type of fat embolism syndrome fes, a rare clinical condition caused by embolization of fat particles into multiple organs, characterized by purely cerebral involvement. Fat embolism syndrome fes is a rare syndrome that, when severe, is associated with respiratory failure, neurocognitive deficit, and death. Positive diagnosis after gurd s and wilsons criteria requires at least one major criteria and four minor criteria being present.
Fat embolism syndrome and elective knee arthroplasty. The fat droplets become impacted in the microvasculature, especially of the lungs and brain. The management is usually supportive with patients being nursed in supine position. The diagnostic criteria of fes have not yet been established, so clinical criteria are used for its diagnosis. The dissipation of fat emboli will disrupt the capillary bed and affect microcirculation, causing a systemic inflammatory response syndrome. While fes was later clinically diagnosed and often reported in the literature over the next 100 years, gurd s clinical description of the fes renewed interest in studying this syndrome. Gurds criteria for the diagnosis of fat embolism syndrome major criteria 1 axillary or subconjuctival petechia. Fat embolism syndrome fes is a clinical manifestation that consists of multiple organ dysfunction due to fat emboli. Gurds criteria major criteria petechial rash one necessary for diagnosisrespiratory insufficiency cerebral involvement. Gurds criteria most common for diagnosis, requiring 1 of 3 major criteria and 4 minor criteria. The use of clinical criteria gurd s, lindeques or schonfelds criteria helps the diagnosis of fat embolism, although none of them have been validated yet.
Fat emboli tend to be small and multiple, causing numerous signs and symptoms. The fat embolism criteria calculator consists of two diagnosis models. Fat emboli are common and typically resolve on their own, but rarely they can lead to fat embolism syndrome fes, a serious condition that can result in respiratory failure. Fat embolism syndrome renu saigal, m mittal, a kansal, y singh, pr kolar, s jain abstract fat embolism syndrome is a rare complication occurring in 0. Fat embolism syndrome fes is thought to occur most commonly in patients who suffer severe trauma and orthopedic injuries and may be associated with potentially lifethreatening pulmonary complications. Fat embolism describes both fat in the circulation and a clinical syndrome. Positive diagnosis after gurds and wilsons criteria requires at least one major criteria and four minor criteria being present. Although it was observed centuries ago that intravenous injection of oil resulted in mechanical obstruction of small vessels, 1 the exact pathophysiology of fat embolism syndrome fes remains uncertain. Fat embolism fe and fat embolism syndromefes are a clinical phenomenon that are characterized by systemic dissemination of fat emboli within the system circulation.
The diagnosis is based on gurds and wilsons criteria which require the presence of at least one major and at least four minor criteria table 1. Fat emboli can be detected in the lungs in up to 90% of individuals with longbone fractures, but fes occurs in only 0. The diagnosis is confirmed if the patient has one majorthree minor criteria or two majortwo minor criteria. Login now to access all of your entitled content or. Fat embolism is a process by which fat particles pass into the bloodstream and settle within a blood vessel eventually blocking a blood vessel. Soni chelsea and westminster hospital, fulham road, london sw10 9nh, uk summary fat embolism syndrome is a collection of respiratory, haematological, neurological and cutaneous. Gurd and wilson criteria or the schonfeld fat embolism.
839 673 268 1575 1024 1440 1559 1468 1261 121 7 1046 19 1274 920 1453 1228 111 1595 1000 236 533 43 762 50 1177 435 1013 1066 1297 1406 604 68