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.

Cerebral fat emboli in a patient with paraplegia caused by bilateral femur fractures.

Cerebral fat embolism is a rare cause of stroke and therefore an overlooked diagnosis. Often it is seen as a consequence of major bone fractures or after arthroplasty, and can lead to respiratory or circulatory collapse. We present a case of a patient with a history of paraplegia after a thoracic spinal cord injury that developed cerebral fat embolism following a bilateral femur fracture. Since the patient was paraplegic and with an altered mental state upon admission, femoral bone fractures were not initially suspected. The case shows the difficulties in diagnosing this condition.

A diagnostic strategy for pulmonary fat embolism based on routine H&E staining using computational pathology.

Pulmonary fat embolism (PFE) as a cause of death often occurs in trauma cases such as fractures and soft tissue contusions. Traditional PFE diagnosis relies on subjective methods and special stains like oil red O. This study utilizes computational pathology, combining digital pathology and deep learning algorithms, to precisely quantify fat emboli in whole slide images using conventional hematoxylin-eosin (H&E) staining. The results demonstrate deep learning's ability to identify fat droplet morphology in lung microvessels, achieving an area under the receiver operating characteristic (ROC) curve (AUC) of 0.98. The AI-quantified fat globules generally matched the Falzi scoring system with oil red O staining. The relative quantity of fat emboli against lung area was calculated by the algorithm, determining a diagnostic threshold of 8.275% for fatal PFE. A diagnostic strategy based on this threshold achieved a high AUC of 0.984, similar to manual identification with special stains but surpassing H&E staining. This demonstrates computational pathology's potential as an affordable, rapid, and precise method for fatal PFE diagnosis in forensic practice.

Fat Embolism Syndrome After Knee Arthroscopy in a Pediatric Patient.

Fat embolism syndrome describes a constellation of symptoms that follow an insult and that results in a triad of respiratory distress, neurologic symptoms, and petechia. The antecedent insult usually entails trauma or orthopedic procedure, most frequently involving long bone (especially the femur) and pelvic fractures. The underlying mechanism of injury remains unknown but entails biphasic vascular injury with vascular obstruction from fat emboli followed by an inflammatory response. We present an unusual case of a pediatric patient with acute onset of altered mental status, respiratory distress, hypoxemia, and subsequent retinal vascular occlusions after knee arthroscopy and lysis of adhesions. Diagnostic findings most supportive of the fat embolism syndrome included anemia, thrombocytopenia, pulmonary parenchymal, and cerebral pathologic findings on imaging studies. This case highlights the importance of fat embolism syndrome as a diagnostic consideration after an orthopedic procedure, even absent major trauma or long bone fracture.

Rare, fatal pulmonary fat embolism after acupuncture therapy: A case report and literature review.

BACKGROUND: Death from nontraumatic pulmonary fat embolism associated with minor soft tissue contusion, surgery, cancer chemotherapy, hematologic disorders and so on has been reported. Patients often present with atypical manifestations and rapid deterioration, making diagnosis and treatment difficult. However, there are no reported cases of death from pulmonary fat embolism after acupuncture therapy. This case emphasizes that the stress induced by acupuncture therapy, a mild soft tissue injury, plays an important role in pulmonary fat embolism. In addition, it suggests that in such cases, pulmonary fat embolism as a complication of acupuncture therapy needs to be taken seriously, and autopsy should be used to identify the source of fat emboli. CASE PRESENTATION: The patient was 72 years old female and experienced dizziness and fatigue after silver-needle acupuncture therapy. She experienced a significant drop in blood pressure and died 2 h later despite treatment and resuscitation. A systemic autopsy and histopathology examination (H&E and Sudan Ⅲ staining) were performed. More than 30 pinholes were observed in the lower back skin. Focal hemorrhages were seen surrounding the pinholes in the subcutaneous fatty tissue. Microscopically, numerous fat emboli were observed in the interstitial pulmonary arteries and alveolar wall capillaries, in addition to the vessels of the heart, liver, spleen and thyroid gland. The lungs showed congestion and edema. The cause of death was identified as pulmonary fat embolism. CONCLUSION: This article suggests that high vigilance for risk factors and the complication of pulmonary fat embolism following silver-needle acupuncture therapy should be exercised. In postmortem examinations, it should be pay attention that the peripheral arterial system and the venous system draining from non-injured sites should be examined for the formation of fat emboli, which can help distinguish posttraumatic and nontraumatic pulmonary fat embolism.

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.

Devastating neurologic injury associated with fat embolism syndrome.

ABSTRACT: The diagnosis of fat embolism syndrome (FES) may present with a constellation of symptoms and continues to be a diagnosis of exclusion. Fat embolism syndrome is a poorly understood syndrome, which is typically associated with orthopedic trauma, most commonly with long bone fractures. Understanding the presentation of FES is essential to provide timely and appropriate interventions and to ensure optimal patient outcomes. The following is a case report of FES in a 39-year-old man following a motor vehicle collision in which he sustained a comminuted fracture of the right femur. The patient was subsequently diagnosed with FES using Gurd criteria in conjunction with frequent assessment of the patient's clinical picture, as well as exclusion of other differential diagnoses. Nurse practitioners and other providers should understand the constellation of symptoms that may be associated with FES to improve prevention and ensure timely intervention.

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.

Fat Embolism After Plastic Surgery: A Case Report.

Fat embolism is an uncommon but life-threatening postoperative complication. The nonspecific symptoms associated with fat embolism could delay the diagnosis and result in a poor patient outcome. We report the case of a healthy 37-year-old woman who underwent a 6-hr breast and abdominal surgery with liposuction. Postoperatively, she displayed mild dyspnea, decreased oxygen saturation level, chest tightness, and fatigue. On Postoperative Day 3, pulmonary multislice computer tomography showed a fat embolus in her right pulmonary artery. She was treated with an anticoagulant to which she responded well and was discharged on Postoperative Day 7. This case demonstrates the need for surgeons, nurses, and anesthesia professionals to identify potential risk factors, recognize signs and symptoms, and implement effective treatment of pulmonary embolism to ameliorate the prognosis, improve the success of the surgery, and save the life of the patient.

Cerebral Fat Embolism After a Fall.

BACKGROUND: Cerebral fat embolism is a rare diagnosis that can occur after significant long bone trauma. Most patients have evidence of pulmonary involvement, but this case involved a patient with a pure neurologic manifestation of a fat embolism. CASE REPORT: An 89-year-old woman presented to the emergency department as a transfer from an outside hospital with a diagnosis of air embolism after an episode of altered mental status and expressive aphasia. A secondary review of the patient's computed tomography angiography head imaging uncovered a cerebral fat embolism as the cause of the patient's acute neurologic event. The cerebral fat embolism was likely from a remote sacral fracture 6 weeks prior. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When a patient presents with a concern for a stroke-like symptoms and a cerebral fat embolism is diagnosed, a thorough examination of the patient must be performed to identify the primary fracture site. Geriatric long bone fractures have well-known significant morbidity and mortality. An associated cerebral fat embolism can increase that mortality and morbidity and prompt diagnosis is important.

Research Status and Prospects of Non-Traumatic Fat Embolism in Forensic Medicine.

In the practice of forensic pathology, fat embolism is one of the common causes of death, which can be divided into two categories: traumatic and non-traumatic. Non-traumatic fat embolism refers to the blockage of small blood vessels by fat droplets in the circulatory blood flow caused by non-traumatic factors such as underlying diseases, stress, poisoning and lipid metabolism disorders. At present, it is believed that the production of non-traumatic fat embolism is related to the disturbance of lipid metabolism, C-reactive protein-related cascade reaction, the agglutination of chylomicron and very low-density lipoprotein. The forensic identification of the cause of death of non-traumatic fat embolism is mainly based on the case, systematic autopsy, HE staining and fat staining, but it is often missed or misdiagnosed by forensic examiners because of its unknown risk factors, hidden onset, the difficulty of HE staining observation and irregular implementation of fat staining. In view of the lack of attention to non-traumatic fat embolism in forensic identification, this paper reviews the concepts, pathophysiological mechanism, research progress, existing problems and countermeasures of non-traumatic fat embolism, providing reference for forensic scholars.

Fatal Fulminant Fat Embolism Syndrome in Adult Spine Deformity Surgery: A Case Report.

CASE: A 68-year-old woman was scheduled to undergo elective correction of coronal spinal malalignment after a previous lumbar instrumented fusion. In the final stages of the operation, the patient became hemodynamically unstable. Her systemic condition worsened subsequently, leading to cardiac arrest followed by unsuccessful resuscitation. An autopsy revealed a massive fat embolism in the lungs. CONCLUSIONS: The diagnosis of fat embolism syndrome (FES) is clinical, and treatment is supportive, with no clinical or investigative criteria that can facilitate diagnosis in a patient under general anesthesia. This is the first description of FES in adult spinal deformity surgery.

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.

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.

[Cerebral fat embolism syndrome after polytrauma : Complication after fracture treatment of several long bones of the lower extremities]. / Zerebrales Fettemboliesyndrom nach Polytrauma : Komplikation bei Frakturversorgung mehrerer langer Röhrenknochen der unteren Extremität.

In consequence of a car accident a 20-year-old woman with bilateral fractures of the femur and an unilateral lower leg fracture was treated with external fixation. Afterwards she was soporific with signs of impaired consciousness and required intubation and intensive medical care surveillance. A cerebral fat embolism syndrome could be detected as the reason, which was characterized by acute respiratory insufficiency, neurological symptoms and petechiae. Subsequently, definitive treatment was performed by intramedullary nailing. After neurological and orthopedic rehabilitation no performance inhibiting limitations remained.

Embolismo graso fulminante por lipoinyección glútea. Reporte de un caso con enfoque Médico Legal / Fulminant fat embolism due to gluteal lipoinjection. Report of a case with a Medical Legal approach

Resumen La liposucción es uno de los procedimientos estéticos que se realizan con mayor frecuencia a nivel mundial, con una baja incidencia de complicaciones y una mortalidad de 20 por cada 100 000 procedimientos y cuando se realiza en conjunto con una lipoinyección glútea la principal causa de muerte el embolismo graso. Se presenta el caso de una femenina de 32 años, sin patologías crónicas conocidas, la cual se asistió a un centro médico para que le realizaran una liposucción con lipoinyección glútea y falleció casi al finalizar la cirugía; en la autopsia Médico Legal se observó la presencia de material de aspecto adiposo en el tronco principal de la arteria pulmonar y en sus ramificaciones, en las cuales se obstruía por completo el lumen, mediante un estudio histopatológico se confirmó el diagnostico de embolismo graso, el cual se estableció como causa de muerte. Se realizó una revisión de la literatura sobre embolismo graso asociado a liposucción con lipoinyección glútea.

Abstract Liposuction is one of the most frequently performed cosmetic procedures worldwide, with a low incidence of complications and a mortality of 20 per 100 000 procedures, and when it is performed in conjunction with gluteal lipoinjection, the main cause of death is fat embolism. This article presents a case of a 32-year-old female, with no known chronic pathologies, who was attended at a medical center to undergo liposuction with gluteal lipoinjection and died almost at the end of the surgery; In the Medico-Legal autopsy, the presence of adipose-like material was observed in the main trunk of the pulmonary artery and in its ramifications, in which the lumen was completely obstructed, a histopathological study confirmed the diagnosis of fat embolism, which was established as the cause of death. A review of the literature about fat embolism associated with liposuction with gluteal lipoinjection was made.

A Case of Fat Embolism Syndrome with Cerebral Involvement in Sickle Cell Anemia.

Fat embolism syndrome (FES) is a rare condition that can occur as a complication of sickle cell disease. We describe a case of a patient with sickle cell disease (homozygous Hb S or HBB: c.20A>T) presenting with initial signs and symptoms consistent with a vaso-occlusive crisis (VOC). Within 24 hours, the patient developed evidence of coagulopathy, multi organ failure and a reduced level of consciousness (LOC) prompting intubation. A diagnosis of FES was made on the basis of the patient's clinical presentation, in conjunction with magnetic resonance imaging (MRI) of the brain revealing innumerable tiny foci of restricted diffusion, intracytoplasmic microvesicular fat on Sudan Red staining of bronchoalveolar lavage samples and evidence of a pulmonary shunt on echocardiogram bubble study. Red blood cell (RBC) exchange transfusion was initiated 3 days following initial presentation and no further exchange transfusions were needed on the basis of subsequent Hb S (HBB: c.20A>T) levels. The LOC gradually improved and the patient was extubated 12 days following presentation. Neurological improvement was slow, with mild cognitive impairment initially evident at 3 months and no cognitive or neurological deficits remaining within 6 months of admission. This case highlights the importance of understanding the pathophysiology and clinical presentation of FES, as early exchange transfusion may improve survival in patients with sickle cell disease and FES.

[Fat embolism syndrome after liposuction and lipoinjection].

Fat embolism syndrome (FES) after liposuction and lipoinjection especially gluteal augmentation is a rare, but potentially life-threatening complication. Plastic surgeons should only inject fat into the superficial planes and stay away from the gluteal veins. The three main symptoms include respiratory distress, neurological symptoms and petechial rash, but many patients fail to develop the classic triad, and there are no specific laboratory findings. As argued in this review, there is currently no specific therapy, so prevention, early detection and supportive care are the main strategies to prevent and treat FES.