ICU and trauma · Core11 / 13
Bilateral femoral fractures and fat embolism21-year-old man, 72 kg, after a motorbike crash; closed fractures of both femoral shafts
Long-bone fractures: fat embolism, intraoperative collapse and the later syndrome
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Know this first
- Early fixation once resuscitated: lactate under 2.5, pH 7.25 or more.
- Clinically significant fat embolism in 3–10% of long-bone fractures.
- Gurd: 1 major plus 4 minor signs; majors are petechiae, hypoxaemia, confusion.
- Bilateral femurs: 1–2 days between sides is an option.
- Treatment is supportive; mortality 10–20%.
The patient
21-year-old man, 72 kg, after a motorbike crash; closed fractures of both femoral shafts, otherwise well.
Resuscitated with 3 units of blood; lactate now 1.6 mmol/L, pH 7.36.
No regular drugs. Listed for intramedullary nailing of both femurs the next morning.
Vitals: BP 122/70, HR 98, SpO2 97% on air, RR 18, temperature 37.4 °C.
The examiner asks
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Consider
What are your considerations?
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- A 21-year-old with bilateral femoral fractures, now resuscitated, for nailing of both femurs. Patient
- As a trauma patient: tertiary survey, looking for missed chest, head and abdominal injuries.
- Early fixation means fewer ventilator days, but only once he's physiologically ready. Surgery
- He is: lactate 1.6, under 2.5, and pH 7.36. Disease
- Fat embolism is a real risk: clinically significant in 3–10% after long-bone fractures.
- Both femurs at once doubles the embolic load; a 1–2 day gap is an option. Surgery
Plan
What is your plan?
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- Agreed with the surgeon: nail one side, reassess, stage the second if he worsens. Surgery
- Arterial line for early warning of embolic hypotension. Disease
- Close watch on ETCO2 and SpO2 during reaming, when marrow fat is forced out.
- Lung-protective ventilation throughout.
- HDU after; the syndrome often appears 24–48 hours later. After surgery
Crisis
During reaming of the second femur, SpO2 falls to 86%, ETCO2 from 38 to 22 mmHg, BP 78/44, HR 128. What do you do?
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- Embolism during reaming: the surgeon stops. Crisis
- A sudden ETCO2 fall says embolism; fat, air or clot, or a big drop in output.
- 100% oxygen, more PEEP, circuit checked.
- Support his RV: noradrenaline 0.1–1 mcg/kg/min to keep systemic pressure up.
- Echo: a dilated, failing RV needs an inotrope, dobutamine 2.5–5 mcg/kg/min.
- Second nail abandoned; external fixation instead. Surgery
Crisis
Next day on the ward he is confused, SpO2 88% on air, BP 132/76, HR 124, RR 28, temperature 38.6 °C, with a petechial rash in the axillae. What do you do?
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- Fat embolism syndrome: hypoxaemia, confusion and axillary petechiae. Crisis
- Gurd needs 1 major and 4 minors: he has three majors, but only two minors, tachycardia and fever.
- Schonfeld scores him 12: rash 5, hypoxaemia 3, then confusion, fever, tachycardia, tachypnoea; 5 or more diagnoses it.
- Not just opioids: gas, glucose and sodium checked, CT head if he worsens.
- Treatment is supportive: oxygen, careful fluids, ventilation if he tires.
- ICU; protective ventilation if ARDS follows; mortality is 10–20%. After surgery
Fatal mistakes
- Nailing both femurs without staging in a deteriorating patient.
- Blaming his confusion on opioids alone.
- No RV support in embolic hypotension.
Checked against: Miller 10e · Barash 9e
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