An 87-year-old man is brought to the emergency department with respiratory distress, confusion, and lethargy since this morning. The patient resides in a nursing home and is bedridden. He fell out of bed last night. He had no loss of consciousness prior to the fall or associated trauma, and he was verbally responsive and oriented after the fall. The patient's past medical history is significant for severe osteoarthritis in the knees and hips, hypertension, hyperlipidemia, and mild chronic obstructive pulmonary disease. His medications include amlodipine, simvastatin, and tiotropium. His temperature is 36.7 C (98 F), blood pressure is 148/90 mm Hg, pulse is 102/min, and respirations are 20/min. Oxygen saturation is 92% on room air. Physical examination shows a frail, elderly man in mild respiratory distress with accessory muscle usage. He is oriented to self only. Jugular venous pressure is estimated at 5 cm H₂O. Cardiopulmonary examination reveals irregular tachycardia with bilateral crackles. There are no murmurs or third heart sound. The patient has significant pain with internal rotation of the left lower extremity. Skin examination shows many small (1- to 3-mm) purplish discolorations on the chest that do not blanch with pressure. The remainder of the examination is normal. Laboratory results are as follows: Chest x-ray reveals bibasilar and peripheral haziness. X-rays of the hip reveal left femoral neck fracture. In addition to orthopedic evaluation, which of the following is the best next step in management of this patient?

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11ec193a_969e_f53b_853d_6d71d77e5163_MD0002_00 This patient has the classic triad of fat embolism syndrome (FES) following long bone fracture: Hypoxemia, neurologic abnormalities, and a petechial rash. FES symptoms usually occur 24-72 hours after injury. Patients may present with dyspnea, hypoxemia, or tachypnea, which can progress to acute respiratory distress syndrome. Fifty percent of patients with FES require mechanical ventilation due to severe respiratory symptoms. Neurologic symptoms (confusion, seizures, focal deficits) typically appear after respiratory distress. Petechial rash is present in about 20%-50% of patients and resolves within 5-7 days. FES is diagnosed based on clinical symptoms. Chest x-rays may reveal airspace disease due to edema or alveolar hemorrhage but are frequently normal. CT scan of the chest may show bilateral ground-glass opacities and thickening of the interlobular septa. Ventilation/perfusion scans show perfusion defects with normal ventilatory patterns. Bronchoscopy may be helpful in establishing the diagnosis by detecting lipid-laden alveolar macrophages, although this is controversial. CT scan of the chest Prevention of FES includes early immobilization of fractures and operative correction. Treatment is supportive and includes maintenance of adequate oxygenation, stable hemodynamics, prevention of deep venous thrombosis and gastrointestinal bleeding, and proper nutrition. Most patients with FES recover fully without sequelae. (Choice A) There is no evidence of congestive heart failure in this patient with no jugular venous distension or third heart sound and normal B-type natriuretic peptide. (Choices B, D, and E) Broad-spectrum antibiotics would not be the next best step in management of this patient with no fever, leukocytosis, or signs of infection. Transesophageal echocardiogram also is not needed as there are no signs of stroke, valvular dysfunction, or endocarditis. Deep venous thrombosis, which can occur following fracture and can be diagnosed by ultrasound, would be unlikely within the first few hours following the fall and would not be the most likely explanation for the triad of respiratory manifestations, rash, and neurologic symptoms. Educational objective: Fat embolization syndrome (FES) occurs as a complication of long-bone fractures and presents with the classic triad of respiratory distress, neurologic abnormalities, and a petechial rash 24-72 hours after the traumatic insult. Prevention of FES includes early immobilization of fractures and operative correction. Treatment is supportive. __________ References: Fat embolism due to bilateral femoral fracture: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/22287848) Fat embolism syndrome in a surgical patient. (http://www.ncbi.nlm.nih.gov/pubmed/11458973)

An 87-Year-Old Man Is Brought to the Emergency Department with Respiratory