History

The history of a patient with fat embolism may include the following:

Major blunt trauma, usually resulting in long-bone fractures, pelvic fractures, or both
Elective long-bone orthopedic procedures or cardiothoracic procedures
Parenteral lipid infusion
Recent corticosteroid administration

Physical Examination

Gurd and Wilson outlined an approach to diagnosing fat embolism syndrome (FES) on the basis of major and minor criteria.^[19]One major criterion, four minor criteria, and the presence of macroglobulinemia are required for the diagnosis.

Major criteria for diagnosing FES are as follows:

Symptoms and radiologic evidence of respiratory insufficiency
Cerebral sequelae unrelated to head injury or other conditions
Petechial rash

Minor criteria are as follows:

Tachycardia (heart rate >110 beats/min)
Pyrexia (temperature >38.5° C)
Retinal changes of fat or petechiae
Renal dysfunction
Jaundice
Acute drop in hemoglobin level
Sudden thrombocytopenia
Elevated erythrocyte sedimentation rate
Fat microglobulinemia

Early signs of the systemic inflammatory response syndrome (SIRS) may herald the onset of FES. Tachypnea, dyspnea, and hypoxia appear as a result of ventilation-perfusion abnormalities 12-72 hours after injury.

Alert clinicians may notice reddish-brown nonpalpable petechiae developing over the upper body, particularly in the axillae, within 24-36 hours of insult or injury. These petechiae occur in 20-50% of patients and resolve quickly, but they are virtually diagnostic in the right clinical setting. Subconjunctival and oral hemorrhages and petechiae can also appear.^[9]

Central nervous system dysfunction initially manifests as agitation or delirium but may progress to stupor, seizures, or coma and is frequently unresponsive to correction of hypoxia.^[20]Retinal hemorrhages with intra-arterial fat globules are visible upon funduscopic examination.

Differential Diagnoses

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Media Gallery

Hematoxylin-eosin stain of section of lungs showing blood vessel with fibrinoid material and optical empty space indicative of presence of lipid dissolved during staining process. This 55-year-old woman died of massive fat embolism after developing pancreatitis due to endoscopic retrograde cholangiopancreatography. Image courtesy of Wikimedia Commons. Originally published in Kanen BL, Loffeld RJLF. Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report. Journal of Medical Case Reports. 2008;2:215.
Frozen section of lung stained with oil red O showing multiple orange red fat globules of varying sizes in septal vasculature. Image courtesy of Dr AVC Rao, Senior Lecturer in Pathology, The University of the West Indies at St Augustine, Trinidad and Tobago. Originally published in Journal of Orthopaedics (http://www.jortho.org/2008/5/4/e8/).

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Fat Embolism Clinical Presentation

History

Physical Examination

References

Tables

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