A 32-year-old male was admitted to the orthopedic department after being involved in a motor vehicle accident. His initial injuries included a transverse fracture of the right femur, tibia, fibula, and a comminuted fracture of the left femur shaft. The secondary survey revealed no other fracture or injuries. Thirty-six hours after admission, the patient complains of shortness of breath. His blood pressure is 112/76 mmHg, heart rate is 95/min, respirations are 34/min, and temperature is 37.9 C (100.1 F). His oxygen saturation on 3L per nasal cannula is 88%. Physical examination reveals a petechial rash on his head, neck, anterior thorax, and axilla. He appears confused. The portable chest x-ray reveals a right lower lobe patchy consolidation. Emergency V/Q scan shows a mottled pattern of sub-segmental perfusion defects with normal ventilation. Which of the following would have prevented this complication in this patient?

Question

A 32-year-old male was admitted to the orthopedic department after being involved in a motor vehicle accident.  His initial injuries included a transverse fracture of the right femur, tibia, fibula, and a comminuted fracture of the left femur shaft.  The secondary survey revealed no other fracture or injuries.  Thirty-six hours after admission, the patient complains of shortness of breath.  His blood pressure is 112/76 mmHg, heart rate is 95/min, respirations are 34/min, and temperature is 37.9 C (100.1 F).  His oxygen saturation on 3L per nasal cannula is 88%.  Physical examination reveals a petechial rash on his head, neck, anterior thorax, and axilla.  He appears confused.  The portable chest x-ray reveals a right lower lobe patchy consolidation.  Emergency V/Q scan shows a mottled pattern of sub-segmental perfusion defects with normal ventilation.  Which of the following would have prevented this complication in this patient?

Quizplus · Accepted Answer

Explanation: Fat embolism is a clinical diagnosis. It typically manifests 24-72 hours after severe trauma, and is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash. Other common findings include fever, tachycardia, and altered mental status. The classic petechial rash is most commonly found on the trunk; this is typically a late manifestation, and is described in fewer than 50% of cases. Petechiae result from the occlusion of dermal capillaries by fat globules, thereby leading to extravasation of erythrocytes. No abnormalities of platelet function have been documented. Early immobilization and operative fixation of fractures reduces the chances of fat embolism. Supportive care is the mainstay of therapy for clinically apparent fat embolism. (Choice B)There is no evidence that prophylactic heparin reduces the risk of fat embolism. The use of corticosteroid prophylaxis is controversial, largely because it is difficult to definitively prove its efficacy in a condition with a low incidence, unclear risk factors, low mortality, and a good outcome with conservative management. Educational objective: Always consider the risk of fat embolism in patients with multiple complicated fractures. Fat embolism is a clinical diagnosis that is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash. Early immobilization and operative fixation of fractures reduce the chances of fat embolism. References: Emergency management of fat embolism syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19561953) Fat embolism. (http://www.ncbi.nlm.nih.gov/pubmed/16603016)

A 32-Year-Old Male Was Admitted to the Orthopedic Department After Being