A Fatal Fat Embolism

Abstract

Fat Embolism and the associated Fat Embolic Syndrome is a serious and potentially life threatening condition. It tends to occur most frequently after fractures or intramedullary instrumentation of long bones particularly the femur and tibia. Some other nontraumatic conditions such as Diabetes Mellitus sever Burns, SLE and Pancreatitis etc. can also result in Fat Embolic Syndrome. Young adults irrespective of sex are commonly affected. Its classical presentation consists of an asymptomatic interval followed by pulmonary and neurological manifestations combined with petechail haemorrhages. The diagnosis largerly depends on high index of suspicions and exclusion of other conditions. Treatment of this condition remains supportive. Mortality associated with this condition is significant, ranging from 10-20 %. Here is a description of such a fatal case. CASE REPORT This 21 year old, male Yemeni, weighing 89.0 kg was brought to the Accident and Emergency Department by RED CRESCENT after sustaining multiple injuries in a road traffic accident between two cars coming at high speed in opposite directions. The primary injuries were Superficial laceration on forehead 3x4 cm. 1. Two longitudinal parallel burses on right 5th and 2. 6th ribs anteriorly each measuring 2x4 cm . Swelling of left mid thigh. 3. Open wound measuring 5x5cm on right lower leg 4. with exposed tibia and fibula. The patient was thoroughly evaluated by Surgical Trauma Team and management started accordingly. On arrival, the patient was fully awake and well oriented in time, space and person. There was no sign of airway obstruction. He had history of momentary loss of consciousness for 5 minutes at the scene. He had no history of vomiting, convulsions or bleeding from ear, nose and throat. Higher mental functions, all cranial nerves, as well as motor and sensory systems were intact. The neck area was non-tender. The patient was breathing spontaneously at the rate of 22 breaths per minutes. Oxygen Saturation was 95% on room air. The trachea was central and apex beat at its normal position. On auscultation of the chest, breathing was vesicular, equal in intensity with normal vocal resonance on both sides of chest. Pulse was 88/minutes, regular and moderate in volume. All the peripheral pulses were palpable. Blood Pressure was 99/60 mmHg. Temperature was 37.1 ° C. The abdomen was soft. Tenderness and guarding were absent. Blood was sent to the laboratory and the results are shown in the tables. CT Scan brain, X-rays cervical spine, chest and both lower limbs were done and these are shown in figures. Ultrasonography of abdomen revealed normal architecture of liver, spleen and kidneys. There was no evidence of free fluid in peritoneal or pelvic cavity. Figure 1 Table 1: Full Blood Count Figure 2 Table 2: Coagulation Profile A Fatal Fat Embolism 2 of 11 Figure 3 Table 3: Urine Examination Figure 4 Table 4:Serum Biochemistry Figure 5 Table 5: Arterial Blood Gases Figure 6 Figure 1: X-ray chest AP view (portable). This is an AP & expiratory film so we cannot comment on cardiac shadow. However, there is no evidence of lung contusion, pneumo, haemo or pneumohaemothorax. Figure 7 Figure 2: X-rays cervical spine lateral projection (Normal) A Fatal Fat Embolism 3 of 11 Figure 8 Figure 3: X-rays left thigh showing mid shaft fracture of femur. The metallic frame used for splinting (immobilization) can be seen. Figure 9 Figure 4: Fracture right tibia and fibula. Back slab of Plaster of Paris can be seen. Figure 10 Figures 5: CT Scan brain (plain) showing normal brain.