Unusual Evidence of Fat Embolism in the Subclavian Vein Detected by High-Intensity Transient Signals.

Fat emboli may occur in patients after traumatic fractures or orthopedic procedures; however, their clinical detection is a very rare finding. Here, we describe a 77-year-old female who was admitted to the emergency department with a fracture of the right humerus. We diagnosed fat embolism after an ultrasound of the right subclavian vein. The embolism was detected by high-intensity transient signals present on the spectral Doppler. While these signals are well known for microembolization in transcranial Doppler, to our knowledge this is the first case report in the medical literature to observe and describe high-intensity transient signals seen in the upper extremities by spectral Doppler. Although it is unusual to detect a fat embolism in transit, we believe clinicians should be aware of this finding, particularly when evaluating high-risk patients.

[Post-traumatic stroke due to fat embolism]. / Accident vasculaire cérébral post-traumatique sur embolie graisseuse.

Fat embolism syndrome mainly occurs following trauma to the long bones or pelvis. Non-traumatic causes are rarer. Its incidence varies greatly and depends on the number of fractures involved. Two physiopathological theories, one mechanical and the other biochemical, attempt to explain this still poorly understood phenomenon. The complete form of the syndrome results in a combination of pulmonary involvement, neurological disorders and a petechial rash. Given the polymorphism of signs and symptoms, Fat embolism syndrome remains a diagnosis of exclusion. Regarding treatment, the therapeutic strategy combines treatment of the causative process with conservative measures.

Le syndrome d'embolie graisseuse se manifeste majoritairement dans les suites d'un traumatisme des os longs ou du bassin. Les causes non traumatiques sont plus rares. Son incidence varie fortement et dépend du nombre de fractures impliquées. Deux théories physiopathologiques, l'une mécanique et l'autre biochimique, tentent d'expliquer ce phénomène encore mal compris. La forme complète du syndrome se traduit par la combinaison d'une atteinte pulmonaire, de troubles neurologiques et d'une éruption pétéchiale. Étant donné le polymorphisme des signes et des symptômes, le syndrome d'embolie graisseuse reste un diagnostic d'exclusion. Concernant le traitement, la stratégie thérapeutique associe la prise en charge du processus causal combinée à des mesures conservatrices.

Fat embolism syndrome after trauma: What you need to know.

ABSTRACT: Fat embolism syndrome refers to a systemic condition caused by the circulation of fat droplets in the bloodstream, reaching various target organs typically after major bone fractures or related surgical procedures. Although most cases resolve spontaneously, severe instances can lead to significant respiratory failure, neurological damage, and even mortality. Therefore, appropriate prevention, timely diagnosis, and management are crucial for trauma patients at risk. The objective of this review article is to explore the definition, epidemiology, risk factors, clinical presentation, and pathophysiology of fat embolism syndrome. Furthermore, it aims to examine current recommendations for the accurate diagnosis, prevention, and treatment of it, providing a comprehensive guide for the effective management of patients prone to this condition.

Fat embolism: the hidden murder for trauma patients!

INTRODUCTION: fat embolism syndrome (FES) is an acute respiratory disorder that occurs when an inflammatory response causes the embolization of fat and marrow particles into the bloodstream. The exact incidence of FES is not well defined due to the difficulty of diagnosis. FES is mostly associated with isolated long bone trauma, and it is usually misdiagnosed in other trauma cases. The scope of this study was to identify and search the current literature for cases of FES in nonorthopedic trauma patients with the aim of defining the etiology, incidence, and main clinical manifestations. METHODS: we perform a literature search via the PubMed journal to find, summarize, and incorporate reports of fat embolisms in patients presenting with non-orthopedic trauma. RESULTS: the final literature search yielded 23 papers of patients presenting with fat embolism/FES due to non-orthopedic trauma. The presentation and etiology of these fat embolisms is varied and complex, differing from patient to patient. In this review, we highlight the importance of maintaining a clinical suspicion of FES within the trauma and critical care community. CONCLUSION: to help trauma surgeons and clinicians identify FES cases in trauma patients who do not present with long bone fracture, we also present the main clinical signs of FES as well as the possible treatment and prevention options.

[Intervention effect of injury control orthopedic strategy on fat embolism syndrome associated with long shaft fracture of lower limb].

OBJECTIVE: To observe the intervention effect of damage control orthopaedic(DCO) strategy on fat embolism syndrome(FES) associated with long shaft fracture of lower limbs. METHODS: Retrospective analysis was made on the clinical data of 163 patients with FES associated with lower limb long shaft fractures admitted from January 2015 to May 2021. They were divided into two groups based on the time point of implementing DCO strategy in January 2018. Total of 92 patients were admitted from January 2015 to December 2017 as the control group, and other 71 patients were admitted from January 2018 to May 2021 as the intervention group. The hospital mortality, arterial oxygen saturation (SaO2), arterial partial pressure of oxygen (PaO2) and oxygenation index (OI), hemoglobin (Hb), platelet count(PLT), Harris score of hip joint, HSS score of knee joint, AOFAS score of ankle joint, clinical efficacy and complications were observed and compared between two groups. RESULTS: Total of 163 patients were followed up for 12 to 18 months with an average of (16.91±1.22) months. The in-hospital mortality rate in the intervention group was 2.82% (2/71), and that in the control group was 16.30% (15/92), the difference between two groups was statistically significant(χ2=6.455, P<0.05). After the intervention, SaO2, PaO2 and OI in two groups were higher than those before the intervention(P<0.05), and after the intervention, SaO2, PaO2 and OI in two groups were statistically significant(P<0.05). Hb and PLT in two groups after intervention were higher than those before intervention (P<0.001), and there was statistically significant difference in Hb and PLT between two groups after intervention (P<0.05). The Harris score of hip joint, HSS score of knee joint and AOFAS score of ankle joint in both groups after 3 months of treatment were better than those before treatment (P<0.05). The total clinical effective rate of the intervention group was higher than that of the control group(χ2=4.194, P<0.05). The total incidence of complications in the intervention group was lower than that in the control group(χ2=4.747, P<0.05). CONCLUSION: DCO strategy is helpful to reduce the in-hospital mortality of patients with FES associated with long shaft fracture of lower extremities, eliminate FES symptoms and stabilize vital signs, gain time advantage for phase Ⅱ definitive surgery, and has significant clinical intervention effect, which is worth popularizing.

Successful therapeutic plasma exchange for a patient with sickle cell disease and fat embolism syndrome after a failure of a response to red cell exchange transfusion.

BACKGROUND: Fat embolism syndrome (FES) is a rare complication, which was reported mostly with milder forms of heterozygous sickle cell disease (SCD). It may present in a catastrophic way with multi-organ failure, particularly involving the pulmonary and neurological systems. Diagnosis is often missed or delayed; and the standard recommended treatment is red cell exchange (RCE) transfusion, which has sub-optimal results, such as debilitating long-term neurological complications. Recently, few reports suggested that the addition of Therapeutic Plasma Exchange (TPE) might further improve the outcome. CASE DESCRIPTION: A 23-year-old woman with homozygote SCD was admitted with bony pains and vaso-occlusive crises. However, her course evolved to respiratory failure requiring mechanical ventilation, decreased level of consciousness, skin rash, severe anemia and thrombocytopenia and a picture consistent with thrombotic microangiopathy. MRI of the brain showed scattered multi-focal ischemic foci and cytotoxic edema. The patient received RCE on the third day after admission without improvement. On the seventh day, TPE was instituted (2 L/day of fresh frozen plasma for 5 days), following which she regained her consciousness and showed an improvement in her laboratory abnormalities. On follow up, she had gradual full neurological recovery and resolution of the MRI findings within a few months. CONCLUSION: FES remains a diagnostic and therapeutic challenge, with significant morbidity and mortality. Success in the management of this reported case with the addition of TPE to RCE supports the notion that TPE may be a potentially helpful modality that deserves further research.

Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review.

Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients. CONCLUSION: Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable. WHAT IS KNOWN: •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age. WHAT IS NEW: •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis.

Rare Presentation of a Patient with Cardiac Arrest Due to Cerebral Fat Embolization Following Polytrauma.

Cerebral fat embolism (CFE) syndrome is a known complication that can occur following polytrauma, particularly in cases involving fractures of long bones, but cardiac arrest is a rare presentation following cerebral fat embolization.1 Our patient met with a road traffic accident (RTA), sustaining multiple long bones injuries with hypovolemic shock. After 10 hours of admission and achieving hemodynamic stability, the patient developed cerebral fat embolization. He developed sudden cardiac arrest and was resuscitated. We instituted ventilator support, inotropic infusion, antibiotics, and intravenous (IV) fluids. Our patient regained consciousness without neurological deficit over a period of 10 days and underwent surgery for all three major fractures with due precautions. The patient was discharged after 3 weeks of treatment from the hospital. How to cite this article: Rathod N, Rathod V, Parikh B, et al. Rare Presentation of a Patient with Cardiac Arrest Due to Cerebral Fat Embolization Following Polytrauma. J Assoc Physicians India 2023;71(11):89-93.

Cerebral fat embolism syndrome at a single trauma center.

OBJECTIVES: Based on a 16-year case series, we sought lessons about diagnosis and treatment of cerebral fat embolism syndrome. MATERIALS AND METHODS: Using discharge codes at a Level 1 Trauma Center, we performed a retrospective chart review of clinical characteristics, diagnostic studies, treatments, and outcome in cerebral fat embolism syndrome. RESULTS: Thirty-nine (40%) of 97 patients with fat embolism syndrome were diagnosed with cerebral fat embolism syndrome, with 29 (74%) presenting with coma. All had abnormal brain magnetic resonance imaging, with scattered cytotoxic edema (starfield pattern) in 29 (74%). All but two of the 21 patients with dilated fundoscopy showed retinal embolism. Among 29 patients with transcranial Doppler, the presence of microembolic signals in 15 (52%) was associated with fever (p = 0.039), right-to-left intracardiac shunting (p = 0.046) and a trend towards initial coma. In 11 patients with serial transcranial Dopplers and treatment with high-intensity statin therapy, the frequency of microembolic signals tended to decrease after therapy was initiated. Of the 28 (72%) of the 39 patients discharged, 16 (57%) had mild to moderate disability at last follow up. CONCLUSIONS: The recognition of cerebral fat embolism syndrome may be improved with routine inclusion of brain magnetic resonance imaging, dilated fundoscopy, and transcranial Doppler. We share our empiric management algorithm for cerebral fat embolism syndrome using these studies and with consideration of experimental therapies in select patients to prevent ongoing cerebral injury.

Cerebral Fat Embolism via a Patent Foramen Ovale.

Fat embolism syndrome (FES) is a multisystem process predominantly secondary to long bone/pelvic fractures and orthopedic procedures. A 19-year-old man presents after motor vehicle collision with trace right pneumothorax, right grade 3 kidney laceration, left pubic rami, and right femoral shaft fractures. Right femur closed reduction ensued and he underwent intramedullary nailing; his other injuries were managed nonoperatively. Upon awakening in recovery, he was newly aphasic. Despite negative repeat CT brain, he continued to worsen and became tachycardic and hypoxemic. MRI/MRA brain demonstrated innumerable bilateral frontal, parietal, and occipital acute ischemic infarcts in a starfield pattern. Echocardiogram revealed a PFO. With supportive care, he improved and was discharged with planned outpatient PFO closure. One month later, he had complete symptom resolution with return to neurologic baseline. FES is a potentially devastating condition which may include cerebral fat embolism (CFE) with outcomes varying widely from mortality to complete recovery.

Two Cases Surviving Macro Fat Emboli Complications Following Gluteal Fat Grafting.

Media attention has in recent years created an increased patient demand for gluteal contouring and augmentation. Gluteal augmentation and contouring with autologous fat transfer, colloquially referred to as the "Brazilian butt lift" (BBL), can be performed safely and effectively, with an overall complication rate ranging from 1.5% to 6.8%. However, there have been an alarming number of lethal events from intravenous passage of injected fat and fatal pulmonary embolism due to macro-fat emboli (MAFE). MAFE (fat emboli >1 cm in diameter), distinct from micro-fat emboli, can quickly result in catastrophic cardiopulmonary compromise and death. Accurate mortality estimates are limited by difficulties in determining accurate values for the total number of BBL procedures performed because most of these cases are performed at budget clinics. Accurate morbidity estimates are limited by a lack of published outcomes and a low level of evidence in published studies. The first case of survival of MAFE secondary to BBL was reported in 2019 by Peña et al. Few highly morbid complications secondary to MAFE have been reported because such events are almost universally lethal. We present 2 recent cases of survival after MAFE in the setting of gluteal fat transfer following expedient transfer to a tertiary care setting, allowing for timely and successful intervention. We illustrate examples of how MAFE is a highly lethal complication of gluteal fat grafting. Early recognition and immediate aggressive vital support to stabilize the patient are key for survival.

Identifying and Treating Severe Bone Marrow Necrosis and Fat Embolism Syndrome in Pediatric Patients With Sickle Cell Disease: A Case Report.

Fat embolism syndrome after bone marrow necrosis is an extremely rare complication in sickle cell disease associated with significant morbidity and mortality. A high index of suspicion is required for diagnosis. This case report will assist pediatric clinicians and hematologists to recognize this severe complication in patients with sickle cell disease and to promptly initiate treatment. Red flags include severe bone pain, respiratory distress, neurological impairment, decreasing platelet count, peripheral leukocyte left shift, elevated nucleated red blood cells, and significant elevation in plasma ferritin and lactate dehydrogenase. We report a pediatric patient who was diagnosed early, received urgent red cell exchange transfusion and plasma exchange, and ultimately survived this devastating complication.

Fat Embolism After Autologous Facial Fat Grafting.

BACKGROUND: Autologous facial fat grafting has gained popularity in recent years and is considered to be safe. This paper presents the case of a patient who died due to massive cerebral microfat embolism after facial fat grafting. OBJECTIVES: The aim of this study was to raise awareness and provide more evidence on the prevention and treatment of this potentially lethal complication of facial fat grafting. METHODS: A detailed report was made of the case. Two online databases were searched for similar cases of facial fat embolism resulting in neurologic and/or visual symptoms. Thereafter a literature search was conducted to verify the etiology, current treatment options, and preventive measures. RESULTS: Forty-nine cases with similar events were found in the literature. The most common injected area was the glabella (36.1%), and an average of 16.7 mL fat was injected. The main complications were visual impairment, with 88.5% of cases resulting in permanent monocular blindness, and neurologic symptoms, some of which never fully recovered. Including the present patient, 7 cases were fatal. Fat embolism can occur in the veins and arteries of the face. Two possible pathways for fat embolism exist: the macroscopic, mechanical pathway with immediate signs, and the microscopic, biochemical pathway with delayed symptoms. Mechanical embolectomy and corticosteroids are suggested treatment options but evidence for their efficacy is lacking. Several different preventive measures are described. CONCLUSIONS: Although facial fat grafting is considered a safe procedure, one should be aware of the risk of fat embolism. Underreporting of this adverse event is likely. With no effective treatment and often detrimental outcomes, preventive measures are of utmost importance to improve patient safety.

Coma secondary to cerebral fat embolism syndrome due to sickle cell disease fully recovering following red cell exchange transfusion.

A 51-year-old woman known for sickle cell disease presented with 2 weeks of headache and bilateral lower limb pain. During admission, she suffered from multiple generalised tonic-clonic seizures but had an unremarkable CT of the brain. Incidentally, she had worsening baseline renal function. She was admitted to the intensive care unit with an acute confusional state. A bedside electroencephalogram showed triphasic waves and diffuse slow activity suggestive of encephalopathy with no epileptiform discharges. She remained obtunded despite appropriate medical therapy of hydration, antiepileptic and pain control. Lumbar puncture failed to identify an infectious cause. An urgent MRI of the brain was done and revealed features compatible with fat embolism syndrome (FES). Her haemoglobin S was 84.2%. Urgent red cell exchange transfusion was done, and within 3 days she fully regained her orientation and motor function. This represents the first case of such profound obtundation due to FES with a complete response to exchange transfusion.

Bone marrow necrosis and fat embolism syndrome: a near fatal complication in previously undiagnosed sickle beta + thalassaemia.

Prevalence of haemoglobin sickle-ß+ thalassaemia (Hb S/ß+thal) is variable with geography ranging from 0.2% to 10% among sickle cell patients. Clinical presentation of Hb S/ß+thal patients depends on HbA level, with milder disease often going undiagnosed. However, rarely these patients can present with a fulminant vaso-occlusive crisis (VOC). Given VOC can present with non-specific symptoms, the diagnosis and treatment is often delayed. Here, we present a patient who initially developed altered mental status, pancytopenia and multiorgan failure due a critical VOC resulting in bone marrow necrosis and fat embolism. Subsequent workup confirmed that our patient had Sickle-ß+ thalassaemia, which had gone undiagnosed, despite subclinical evidence of haemolysis on routine lab work for years. Following diagnosis and initiation of RBC exchange, he improved significantly and was discharged home. High index of suspicion and bone marrow biopsy is vital for early diagnosis and management of this rare condition.

Prone positioning in a patient with fat embolism syndrome presenting as diffuse alveolar haemorrhage: new perspective.

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. The management is usually supportive with patients being nursed in supine position. The use of prone position ventilation in a DAH has rarely been reported before. We report an interesting case of a 26-year-old male patient diagnosed with DAH caused by fat embolism in whom prone position ventilation improved the lung dynamics and oxygenation.