If a person is diagnosed with a fat embolism (or PVC), embolization is carried out with drops of fat in the microvasculature. First of all, the disease-causing process affects the capillaries of the brain and lungs. This is manifested by hypoxemia and the development of acute respiratory failure, diffuse brain damage, ARDS of various degrees of severity. Clinical manifestations are most often observed 1-3 days after injury or other exposure.
If the case is typical, then the clinical signs of fatty embolism of the lungs and brain are characterized by gradual development and reach a maximum approximately two days after the first symptoms. The lightning-fast appearance is rare, but a fatal outcome can occur just a few hours after the onset of the pathology. Younger patients are more likely to have PVCs, but mortality is higher in the elderly.
There is an opinion that when a patient is in a state of extreme intoxication at the time of the injury, it is rareGE develops. There are several theories regarding the mechanism of occurrence of fat embolism (biochemical, colloidal, mechanical), however, most likely, each specific case has different mechanisms that lead to PVC. The fatal outcome is about 10-20%.
Types of diseases
There is a certain gradation. Fat embolism is classified according to the severity of the clinical picture:
- acute: it is characterized by the manifestation of clinical signs for several hours after injury;
- lightning fast: death with this form occurs in a few minutes;
- subacute: this type is characterized by a latent period of up to three days.
According to the severity of signs:
- subclinical;
- clinical.
PV: common causes
In about 90% of situations, skeletal trauma is the cause. Especially often - a fracture of large tubular bones, mainly - a femoral fracture in the middle or upper third. If there are multiple bone fractures, the risk of PVC increases.
Rare causes of pathology
In more rare cases, the reasons are:
- prosthesis in the hip joint;
- closed reduction of bone fractures;
- intramedullary femoral osteosynthesis with large pins;
- major soft tissue injury;
- extensive surgeon interventions on tubular bones;
- liposuction;
- serious burns;
- bone marrow biopsy;
- hepatic fatty degeneration;
- long-term corticosteroid treatment;
- Introduction of fat emulsions;
- osteomyelitis;
- acute pancreatitis.
Symptoms of this dangerous disease
Fat embolism is essentially a fat thrombus, which is either in a calm state, or moves through the vessels, penetrating into various organs. If a fat clot enters the heart, then acute heart failure may develop, failure of this organ may develop in the kidneys, respiratory failure in the lungs, stroke in the brain, etc. exodus.
For fractures
Most often, fat embolism in fractures begins to develop immediately after the injury, when fat particles enter the vessels. Fat drops gradually accumulate in the blood, and therefore, in the first hours after injury, this process passes without obvious symptoms. Signs of it appear 24-36 hours after injury or surgery. By this time, many capillaries are clogged. Small petechial hemorrhages form on the upper chest, on the neck, in the armpits and on the shoulders.
If the capillaries of the lung are clogged, then dry cough, shortness of breath, cyanosis of the skin (cyanosis) appear. Characteristics of a fatty embolism of the heart are heart rhythm disturbance, tachycardia (too rapid heartbeat). Also canconfusion will occur and the temperature will rise.
The main signs of this pathology
Fat embolism manifests itself as a series of symptoms.
- Arterial hypoxemia.
- Symptoms of ARDS (most often with severe illness).
- Disruption of the central nervous system (convulsions, restlessness, coma, delirium), when oxygenation returns to normal, there is no obvious regression of neurological signs.
- Petechial rashes appear 24-36 hours after injury in patients in 30-60% of cases, their localization is in the upper body, even more often in the armpits. It is characterized by outpourings of blood on the oral mucosa, conjunctiva and eye membranes. Most often, rashes go away within a day.
- A sharp decrease in hemoglobin levels on the second or third day.
- Thrombocytopenia, that is, a rapid decrease in the number of platelets and fibrinogen levels.
- Detection of neutral fat in urine, blood, sputum, cerebrospinal fluid (fat is detected in alveolar macrophages).
- Detection on skin biopsy at the site of petechial fat.
- Detection of retinal angiopathy with fat.
Let's look at the diagnosis of fat embolism.
Additional manifestations are of little value. All of them can appear with any serious skeletal injury.
Instrumental examinations
- In many cases, MRI makes it possible to determine the causes of brain fat embolism.
- Pulmonaryradiography confirms the presence of ARDS, makes it possible to exclude pneumothorax.
- Cranial CT allows you to exclude other pathology inside the skull.
- Monitoring. Even with mild PVC manifestations, pulse oximetry should be used as the situation can change very quickly. If the CNS lesions are severe, then it is necessary to control the pressure indicators inside the skull.
Fat embolism treatment
What it is, is interesting to everyone. Numerous therapeutic methods proposed to get rid of PVCs are not effective: administration of glucose to reduce the mobilization of free fatty acids, ethanol to reduce lipolysis. Serious injuries are often accompanied by the occurrence of coagulopathy. Usually, during the first three days, "Heparin" (including also low molecular weight) is prescribed, which increases the risk of bleeding and increases the plasma concentration of fatty acids, and this treatment is mainly not indicated.
There is no evidence that commonly prescribed drugs for the treatment of PVCs, such as sodium hypochlorite, Kontrykal, Gepasol, Lipostabil, Essentiale, nicotinic acid, can positively affect the pathology. Therefore, treatment is predominantly symptomatic.
The purpose of respiratory therapy is to maintain PaO2 values more than 70-80 mm Hg. Art. and 90% ≦ SpO2 ≦ 98%. If the case is mild, then oxygen therapy through nasal catheters is sufficient. Occurrence in patients with ARDSneeds special modes and approaches of mechanical ventilation.
If it is reasonable to limit the amount of infusion treatment and use diuretics, it is possible to reduce the accumulation of fluid in the lungs and reduce ICP. Until the patient's condition stabilizes, saline solutions are used (Ringer's solution, 0.9% sodium chloride), albumin solutions. Albumin contributes to the effective restoration of intravascular volume and to some extent reduces ICP, and also, by binding fatty acids, can reduce the progression of ARDS.
If the patient has serious cerebral manifestations of fat embolism, then sedative treatment, artificial pulmonary ventilation is used. There is some correlation between the level of ICP elevation and the depth of coma. The management of such patients resembles in many respects the management of people with a traumatic brain lesion of a different origin. It is also required to prevent the temperature from rising above 37.5 ° C, in connection with which non-steroidal analgesics are prescribed, as well as physical methods of cooling, if necessary.
Drugs of a wide spectrum of influence are prescribed, most often third-generation cephalosporins - as a starting treatment. If clinically significant coagulopathy develops, fresh frozen plasma is used.
Corticosteroids have also not been shown to be effective in the treatment of fat embolism in hip fractures. However, they are often prescribed because they think that they can prevent the progress of the process in the future. Corticosteroids for PVC desirableadministered in large doses. Bolus - "Methylprednisolone" from 10 to 30 mg per kg for 20-30 minutes. After that - a dispenser of 5 mg / kg / hour for two days. In the absence of "Methylprednisolone", other corticosteroids ("Prednisolone", "Dexamethasone") are used in equivalent doses.
Complications of limb amputation
Due to fat embolism during amputation, disturbances in the activity of internal organs (stroke, respiratory, cardiac, renal failure, etc.) can occur. In one percent, it can lead to a lightning death of the patient due to cardiac arrest.
Prevention of this dangerous pathology
What should be done to avoid this dangerous complication? Prevention of fat embolism is required for patients with fractures of the tubular bones of the legs and pelvic bones (in the amount of two or more). Preventive measures include:
- competent pain relief;
- early and effective elimination of blood loss and hypovolemia;
- early surgical stabilization of pelvic fractures and tubular large bones on the first day is the most effective preventive procedure.
The frequency of complications in the form of ARDS and PVC increases very much if the operation was postponed. It must be said that traumatic brain injury and chest trauma are not considered a contraindication for early intramedullary osteosynthesis of tubular bones. There is also evidence that corticosteroids are effective in preventingfat embolism and post-traumatic hypoxemia, although optimal doses and regimens have not been determined.
