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Fat embolism of lungs treatment. Fat embolism - description, causes, diagnosis and treatment

Fat embolism of lungs treatment. Fat embolism - description, causes, diagnosis and treatment

Fat embolism- a frequent pathological finding after trauma. This condition occurs during orthopedic surgery, and is also observed in multiple injuries associated with an explosion. Symptoms are quite common with liver injury, cardiopulmonary bypass, bone marrow transplantation, oil (fat) aspiration. At the same time, respiratory failure is observed in 75% of patients.

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Definition

Fat embolism syndrome (FES) is a complex disorder of homeostasis that occurs as a result of a fracture of the pelvic or tubular bones, its clinical manifestations are acute respiratory failure. Any case where fat droplets are found in the lung parenchyma (fat embolism of the lungs) or the vascular system of the peripheral microcirculation (arterioles, capillaries) is considered as "fat embolism". The classic presentation of this syndrome is an asymptomatic interval after injury followed by pulmonary and neurologic manifestations in association with petechial hemorrhages (small hemorrhages in the skin).

Orthopedic procedures- intramedullary pins, knee arthroplasty.
Massive soft tissue injury(for example, fat embolism during amputation of limbs).
severe burns.
Bone marrow biopsy.
Non-traumatic conditions and procedures can also cause a fat embolism:

liposuction;
fatty degeneration of the liver;
long-term corticosteroid therapy;
acute pancreatitis;
osteomyelitis;
pathologies that can lead to bone infarction, such as sickle cell anemia.

Prevalence (epidemiology)

In 67% of orthopedic patients, fat globules (balls) are found in the blood. The frequency of their detection increases to 95% when the sampling is made in the immediate vicinity of the fracture site. However, the presence of fat globules in the blood does not automatically lead to FES. In men, the syndrome is more common than in women, and in children under 9 years old it is practically not diagnosed, the peak of diagnosis falls on the age range of 10-39 years.

Manifestation of the syndrome

There is usually a latency period that lasts 24 to 72 hours between trauma and the onset of the main symptoms. You can usually suspect fat embolism syndrome by the following manifestations:

Dyspnea± vague chest pain. Depending on the severity of the syndrome, respiratory failure can progress, manifesting itself as an increase in shortness of breath, the appearance of tachypnea (rapid shallow breathing), signs of hypoxia (lack of oxygen in the blood).
Fever. The temperature rises above 38.3 ° C, while there is a disproportionately high pulse rate.
, which is usually found on the skin of the upper half of the trunk, arms and neck, as well as on the oral mucosa and conjunctiva. The rash, as a rule, is observed for a short time, disappears after 24 hours.
Symptoms associated with damage to the central nervous system, which range from minor headache to manifestations of severe cerebral dysfunction (restlessness, disorientation, confusion, convulsions, stupor or coma).
Renal symptoms(fat embolism of the renal capillaries) is manifested by oliguria (little urine), hematuria (blood in the urine), anuria (lack of urine).
Association of drowsiness with oliguria - feature fat embolism syndrome.

There is a transient form of pathology that manifests as acute cor pulmonale, respiratory failure, and/or systemic embolism leading to death within hours of injury.

Diagnostic criteria to confirm the presence of fat embolism syndrome:

Main:

respiratory failure;
cerebral symptoms;
petechial rash.

Small Criteria:

fatty macroglobulinemia;
high ESR;
anemia;
thrombocytopenia (few platelets);
symptoms associated with kidney damage;
jaundice;

Jaundice due to fat embolism

changes in the retina: exudates and small hemorrhages, sometimes fat globules are determined in the blood vessels of the retina;
a constant respiratory rate > 35 breaths/min despite rest;
persistent RO<8 кПа;
confusion (disorientation);
hyperthermia (usually> 39 ° C);
tachycardia;
diffuse darkening of the lung on x-ray, a symptom of "snowstorm".

One study concluded that at least two major criteria, or one major and four minor criteria, must be present in order to make a diagnosis.

Diagnostics

Only tests will help to reliably determine the presence of pathology.

Laboratory research, mostly non-specific (not indicative):

As a rule, aggressive resuscitation is carried out in order to maintain adequate circulation. Corticosteroids are prescribed when there are symptoms of cerebral edema. In case of respiratory failure, an oxygen mask is used.

Forecast

Mortality in FES is 5-15%. Even the severe respiratory failure seen in this syndrome is rarely fatal. The duration of neurological symptoms or coma usually does not exceed a few days or weeks. Such manifestations of the disease associated with brain damage, such as personality changes, memory loss and impaired thinking, can persist in a patient for a long period of time. Pulmonary complications usually disappear within a year.

Prevention

Immobilization for a fracture of the leg bones

Early immobilization of fractures, according to many doctors, is the most effective way prevention of fat embolism. Corticosteroids are sometimes used to prevent FES during orthopedic surgery, such as intramedullary osteosynthesis. But at the moment there is no convincing evidence that this approach is effective in preventing the syndrome.

For more than 100 years after its first description, fat embolism syndrome remained a poorly understood pathology and a serious diagnostic problem for physicians. And only in the last decade has there been significant progress in understanding this relatively rare phenomenon. At present, as a result of the emerging improved scientific technologies, new information about this pathology has been obtained, which will significantly reduce the morbidity and mortality of fat embolism.

What is it?

In medicine, fat embolism refers to any pathological process in which without fail fat cells may appear in the blood. The slightest amount of fat in the vessel can lead to disastrous consequences.

Like a blood clot that leads to a heart attack and stroke, fat, moving through the human venous or arterial system, clogs the vital ducts. It also creates a life-threatening situation.

Usually, with such clinical pictures, the following factors of the onset of the disease can be detected in patients:

large blood loss;
dizziness;
overweight;
nausea.

In the international classification, this disease can be categorized as T79.1. With delayed surgery, fat embolism can be repeated several times.

In what forms does it appear?

This disease has several main forms, the most common in modern medical practice:

lightning embolism - this type is one of the most dangerous forms, because it is almost impossible to save the patient due to the fact that the development of a fat embolism occurs in a matter of minutes, and it takes much more time to determine it;
acute embolism - development begins to occur within 2-3 hours after the patient receives an injury, and continues for 1-2 days. It occurs more often than other forms;
subacute embolism - development occurs from a day to 3 days after a person is injured. One of the most favorable forms of disease development.

How is it classified?

According to the conditional classification, depending on the manifestations, fat embolism is pulmonary, cerebral or mixed. And also it can be divided, depending on the foci, into cerebral embolism, pulmonary embolism, with development in the liver.

Among other things, it is also classified according to the reasons due to which it could arise. This can occur during surgery or after amputation of limbs, during open fractures, surgical interventions, and even due to improper medical treatment.

To date, doctors have only a couple of theories at their disposal and a lot of speculation about how it appears and what are the reasons for the development of fat embolism. All this is further complicated by the fact that two main types are distinguished - mechanical and biochemical embolism, with a corresponding, characteristic, onset of the disease.

According to the first theory, increased bone marrow pressure during trauma and surgery may be the main cause of fat embolism. It is because of this that fat cells penetrate into the patient's blood vessels, where, by binding to platelets or ordinary blood cells, they can form a microthrombus, which will go further through the bloodstream.

In the worst cases, such blood clots reach the brain or heart, clogging, for example, valves in the latter. Under more favorable circumstances, they gradually fall apart on their own, but this does not happen so often.

biochemical theory

According to the biochemical theory, cell injuries leading to fat embolism occur due to changes in the endocrine system and, accordingly, the hormonal background of the patient. If at the same time the hormonal imbalance will take place at the same time as sepsis, then the penetration of lipoprotein bodies into the blood becomes extremely likely.

Those, in turn, begin to cling to the vessels of the lungs, because of this, the bronchi and the blood ducts themselves are damaged, blood circulation is disturbed, respectively, and the chance of a fat embolism increases several times.

The cause of a fat embolism is trauma. But this pathology also occurs with various errors during surgery in the area of tubular bones.

Among other things, the pathology can also manifest itself against the background of such actions as: prosthetics, various closed fractures with internal bleeding and open fractures, respectively, as well as any intervention in the fatty layers, be it liposuction or plastic surgery on the dermis and lower epithelial layers.

And also the cause of a fat embolism can be not only an injury and an incorrectly performed operation, but also various intravenous drugs.

Such as corticosteroids or various fat emulsions. That is why it is worth making sure that when using steroids, it is the professional who injects the patient.

What are the symptoms?

One of the most dangerous aspects of this disease is that there may be no symptoms at all for several days. But the worsened condition of the patient is usually perceived by both the patient and the doctors themselves as a reaction of the body to the operation. Developing pathologies are manifested as follows:

increased heart rate;
increased breathing or lack of air;
various small hematomas and small red spots in the place where subcutaneous bleeding could occur;
a vague state of awareness, disorientation in space;
fever and intense thirst, turning into febrile attacks.

Patients usually complain of increased fatigue, and often there are migraines and pain in the heart, and with high blood pressure severe dizziness may occur. Tellingly, other symptoms are easily confused with a microstroke or microinfarction, which are already the consequences of this disease.

It is precisely the fact that it is extremely difficult to diagnose and makes fat embolism a very dangerous disease, especially when it comes to fat accumulations in the lungs, when the patient complains of rapid breathing.

How is it diagnosed?

All that is present in the primary diagnosis is an analysis of the anamnesis of the general symptoms of the disease. The whole picture is very similar with strokes and heart attacks in a milder form, so this can be both a problem with the central nervous system and other symptoms.

One of the most serious and rare manifestations is the patient's entry into a coma, while there may not be any prerequisites for this at all. Before an exacerbation, a person will look completely healthy, and his condition may even improve if an operation has been performed.

If, during the initial diagnosis, the appearance of a pulmonary embolism or some other type was suspected, then the doctors refer the patient for an additional examination:

a general analysis of urine and blood, with which you can cover the largest number of possible diseases, including fat embolism;
a biochemical blood test, which is performed with specific suspicions and in the case when this disease is not associated with injuries;
x-ray of the cranium, due to which blockage of cerebral vessels and subsequent hemorrhages can be excluded;
other studies that would allow us to exclude diseases similar in symptoms (of which there are actually quite a lot);
MRI, which will identify the focus of inflammation and determine the causes of its occurrence.

But what to do when the doctor has made a diagnosis? How to treat an embolism and prevent life-threatening complications?

How is an MRI performed?

How is the treatment going?

Under no circumstances should an embolism be treated with folk remedies, which stimulates its development. This disease is too dangerous and difficult for such activities, the usual blood-thinning solutions do not help the patient.

Initially, the patient undergoes conventional therapy, the course of which must necessarily include oxygen therapy using nasal catheters. If it was not possible to identify the pathology in time, this method of treatment is ineffective, a waste of precious time for the patient.

If conventional therapy has not yielded any results, respiratory therapy is started, in which they try to keep the oxygen pressure in the vessels at a high level. All this only allows you to save a person's life for a little longer and keep the patient in a stable condition. But after all these enterprises, drug therapy is mandatory to be carried out to eliminate the blood clot.

Here, there may already be several methods of treatment, depending on whether doctors are dealing with a pulmonary embolism, or with another form of the disease. And also depending on general rules clinics and approved drugs in certain countries.

Fat embolism is an extremely dangerous and difficult to detect disease, fortunately, according to statistics, with symptoms, the disease manifests itself quite rarely. But it is worth remembering that the most common is a fat embolism in a fracture, so appropriate tests should be carried out to identify this disease.

How long it takes for treatment can only be determined by doctors, it all depends on what signs the patient has. Treatment of fat embolism in fractures takes place in stages. If detected in time, it is quite harmless, however, in a neglected state, it can cause a lot of trouble and lead to disastrous consequences.

Video: Fat embolism syndrome

Severe early complications of fractures includefat embolism. The frequency of fat embolism (FE) in trauma is observed in 3-6%, and after multiple trauma - 27.8%. Among those who died with a diagnosis of shock, the incidence of fat embolism reached 44%, depending on the severity of the injury. Fat embolism most often occurs in 20-30 years (with a fracture of the lower leg) and between 60-70 years (fracture of the femoral neck). There are several theories about the origin of fat embolism, but two of them have been leading until recently, although they are in certain contradictions. The question of the mechanical or metabolic origin of fat embolism is controversial.

Mechanical theory of fat embolism suggests that after a mechanical effect on the bone tissue, the fatty particles of the bone marrow are released and the emboli spread through the lymphatic and venous channels into the pulmonary capillaries. Particles of bone marrow are found in the lungs within a few seconds after the fracture.

Second theory, which is followed by most scientists, is based on biochemical changes in circulating blood lipids. In this case, the normal lipid emulsion in the plasma changes and it becomes possible to merge chylomicrons into large fat droplets, followed by vascular embolization. This theory finds support in the fact that fat embolism occurs not only in bone fractures, and the chemical composition of fat particles more often corresponds to circulating blood lipids than bone marrow fat. The suction effect of the chest is of some importance. Raise blood pressure when the patient comes out of shock or after replenishment of blood loss, it also helps to push the thrombus into the vessels of the systemic circulation.

It has been established that if an amount of fat enters the lungs, turning off 34 pulmonary circulation, this leads to rapid death from acute right heart failure.

Due to the small size of fat droplets and their high elasticity, they can pass through the capillary network, spreading through the systemic circulation, resulting in a cerebral form of fat embolism. Thus, there are pulmonary and cerebral forms of fat embolism and their combination - a generalized form.

Features of a fat embolism is that it develops and grows gradually, since fat from the site of damage does not penetrate into the blood immediately, there is a gap between the moment of injury and the development of embolism. Fat embolism is often the cause of death, but is rarely recognized during life.

Clinical fat embolism manifested by a variety of low-specific symptoms, allowing only to suspect it. The appearance of a petechial rash and small hemorrhages on the chest, abdomen, inner surfaces of the upper extremities, albuminous and mucous membranes of the eyes, mouth, and the appearance of fat in the urine are considered a pathognomonic symptom. However, the last sign can be found only on the 2-3rd day. Therefore, a negative urinalysis for fat cannot rule out a fat embolism. Laboratory and chemical tests to confirm the diagnosis of fat embolism are often non-specific and difficult in the clinical setting. Often the first sign of a fat embolism is a drop in hemoglobin, caused by lung hemorrhage. ECG changes indicate myocardial ischemia or overload of the right heart.

The pulmonary form of fat embolism is characterized by the appearance of shortness of breath, cyanosis, cough, tachycardia, and a drop in blood pressure. With blockage of large branches of the pulmonary artery, a picture of acute respiratory failure develops, often fatal. The respiratory form of fat embolism does not exclude brain disorders: loss of consciousness, convulsions.

The cerebral form of fat embolism develops when emboli are pushed into the systemic circulation. The cerebral form of fat embolism is characterized by dizziness, headache, blackout or loss of consciousness, general weakness, vomiting, the appearance of topical convulsions, sometimes paralysis of the limbs, and the presence of a light interval from the moment of injury to the appearance of these signs is of diagnostic value.

Fat embolism treatment. For the treatment of fat embolism, various methods are used, including anti-shock measures, anticoagulant therapy, strict bed rest, the use of protease inhibitors of trasilol, contrical, epsilon-aminocaproic acid, rheopolyglucin, hemodez, hydrocortisone, eufillin, cocarboxylase, cordiamine, strophanthin for one week . Intravenous administration of glucose-salt solutions and dextran solutions, the appointment of antihistamines.

In the respiratory form of fat embolism, oxygen inhalations, bloodletting of 300-400 ml are indicated. Massive intravenous infusions of blood and blood-substituting fluids are contraindicated, as they can cause an increase in blood pressure and push emboli from the pulmonary artery pool into the systemic circulation and contribute to the development of a cerebral form of fat embolism.

Great importance have preventive measures: rest of the patient, restriction of transportation, measures to combat shock. In operations involving manipulations on the bones, and especially with the removal of bone marrow, care must be taken to ensure that it does not get into the wound, for which gauze pads should be wrapped around the bones.

Prevention of fat embolism also comes down to good immobilization of the fracture, anesthesia of the fracture area. In closed fractures with extensive hematoma, puncture of the hematoma and suction of blood and fat are necessary.

When operating on tubular bones (metal osteosynthesis), an open technique is recommended. For osteosynthesis, it is better to use grooved pins. Before the osteosynthesis operation and after it, it is necessary to examine the urine for free fat.

Traumatology and orthopedics. Yumashev G.S., 1983

In a fat embolism (FE), the microvasculature is embolized by fat droplets. First of all, the capillaries of the lungs and brain are involved in the pathological process. What is manifested by the development of acute respiratory failure, hypoxemia, ARDS of varying severity, diffuse brain damage. Clinical manifestations usually develop 24-72 hours after injury or other exposure.

Common causes of PVC
Rare causes of PVC
PVC diagnostics
The main manifestations of fat embolism
Treatment
Prevention of fat embolism

In typical cases, the clinical manifestations of PVC develop gradually, reaching their maximum approximately two days after the first clinical manifestations. The fulminant form is rare, but death can occur within a few hours after the onset of the disease. In young patients, PVC is more common, but mortality is higher in older patients.

It is believed that if the patient at the time of the injury was in a state of deep alcohol intoxication, PVC rarely develops. There are several theories on the mechanism of occurrence of fat embolism (mechanical, colloidal, biochemical), but, most likely, in each case, different mechanisms are implemented that lead to PVC. Mortality, from the number of diagnosed cases, is 10-20%.

Common causes of PVC

Skeletal injury (about 90%) of all cases. Most common cause- a fracture of large tubular bones, and first of all, a fracture of the femur in the upper or middle third. With multiple bone fractures, the risk of PVC increases.

Rare causes of PVC

Prosthetics of the hip joint;
Intramedullary osteosynthesis of the femur with massive pins;
Closed reposition of bone fractures;
Extensive surgical interventions on tubular bones;
Extensive soft tissue injury;
severe burns;
Liposuction;
Bone marrow biopsy;
Fatty degeneration of the liver;
Long-term corticosteroid therapy;
Acute pancreatitis;
Osteomyelitis;
The introduction of fat emulsions.

PVC diagnostics

Fat embolism symptoms:

Patients may complain of vague chest pain, shortness of breath, headache.
There is an increase in temperature, often above 38.3º C. Fever in most cases is accompanied by a disproportionately high tachycardia.
Most patients with PVC are drowsy, oliguria is characteristic.

If in patients, 1-3 days after the skeletal injury, the body temperature has increased, drowsiness and oliguria are noted, then the presence of PVC should be assumed first of all.

The main manifestations of fat embolism

Arterial hypoxemia (PaO2<60-70 мм рт. ст., SрO2 < 90-92%);
Signs of ARDS (usually in severe PVC);
CNS dysfunction (motor restlessness, convulsions, delirium, coma). Characteristically, after normalization of oxygenation, there is no noticeable regression of neurological symptoms;
Petechial lesions develop 24–36 hours after injury in 30–60% of PVC patients. They are localized in the upper half of the body, more often in the axillary region. Hemorrhages on the mucous membrane of the mouth, the membranes of the eyes and the conjunctiva are also characteristic. Rashes usually disappear within 24 hours;

Sudden decrease in hemoglobin for 2-3 days;
Thrombocytopenia, or a rapid decrease in the number of platelets, a decrease in the level of fibrinogen;
Detection of neutral fat in blood, urine, cerebrospinal fluid, sputum (fat is detected in alveolar macrophages);
Detection of fat in a skin biopsy in the area of petechiae;
Detection of fatty angiopathy of the retina.

Additional manifestations of PVC

However, the independent value of additional manifestations is small. All of them can occur with any severe skeletal injury.

Instrumental Research

MRI in many cases allows you to establish the etiology of cerebral embolism;
CT of the skull allows to exclude other intracranial pathology;
X-ray of the lungs - confirms the presence of ARDS, allows you to exclude pneumothorax.

Monitoring

Pulse oximetry should be used even in mild PVCs, as the situation can change rapidly. In severe lesions of the central nervous system, control of intracranial pressure is required.

Treatment

Many therapies that have been proposed for the treatment of PVCs have proven ineffective: administration of glucose to reduce the mobilization of free fatty acids, administration of ethanol to reduce lipolysis. Severe injuries are often accompanied by the development of coagulopathy. In the first few days (usually within three days), the appointment of heparin (including low molecular weight heparins) increases the risk of bleeding, increases the concentration of fatty acids in the plasma, and, in most cases, is not indicated.

There is no evidence that commonly prescribed PVC drugs such as Essentiale, lipostabil, nicotinic acid, hepasol, contrical, sodium hypochlorite can improve treatment outcomes. So the treatment is mostly symptomatic.

Maintaining PaO2 > 70-80 mmHg Art., SpO2 ≥ 90 ≤ 98% - the goal of respiratory therapy. In mild cases, oxygen therapy through nasal catheters is sufficient. The development of ARDS in patients requires special approaches and modes of mechanical ventilation.

Reasonable restriction of the volume of fluid therapy and the use of diuretics can reduce the accumulation of fluid in the lungs, and help reduce ICP. Until the patient's condition stabilizes, saline solutions (0.9% sodium chloride, Ringer's solution), albumin solutions are used. Albumin not only effectively restores intravascular volume and slightly reduces ICP, but by binding fatty acids, it may be able to reduce the progression of ARDS.

In severe cerebral manifestations of PVC, sedative therapy and artificial lung ventilation are used. There is a definite correlation between the depth of coma and the degree of increase in ICP. The management of these patients is in many respects similar to the management of patients with traumatic brain damage of another origin. It is necessary to prevent an increase in body temperature above 37.5 ° C, for which non-steroidal analgesics are used, and, if necessary, physical methods cooling.

Broad-spectrum antibiotics are prescribed, usually 3rd generation cephalosporins, as initial therapy. With the development of clinically significant coagulopathy, the use of fresh frozen plasma is indicated.

The effectiveness of corticosteroids in the treatment of PVCs has not been proven. But they are often prescribed, hoping that they can prevent further progression of the process. High doses of corticosteroids are recommended for PVCs. Methylprednisolone 10-30mg/kg bolus over 20-30 minutes. Then 5 mg / kg / hour with a dispenser for 2 days. If methylprednisolone is not available, other corticosteroids (dexamethasone, prednisolone) are used in equivalent dosages.

Prevention of fat embolism

PVC prophylaxis is indicated in patients with fractures of two or more long bones lower extremities, pelvic fractures. Preventive measures include:

Effective and early elimination of hypovolemia, blood loss;
Adequate anesthesia;
Early, in the first 24 hours, surgical stabilization of fractures of the pelvis and large tubular bones is the most effective preventive measure.

The frequency of complications in the form of PVC, ARDS significantly (4-5 times) increased if surgery was postponed until a later time. It should be noted that chest trauma and craniocerebral trauma are not a contraindication to early intramedullary osteosynthesis of tubular bones. The effectiveness of corticosteroids for the prevention of PVC and post-traumatic hypoxemia has been proven, although the optimal regimens and doses of drugs have not been established. More often, methylprednisolone is used - 15-30 mg / kg / day. within 1-3 days. But there is data confirming the effectiveness of lower doses: methylprednisolone at a dose of 1 mg / kg every 8 hours for 2 days. The appointment of corticosteroids is especially indicated if early stabilization of fractures has not been performed.

Why and how pathology develops

Particles of fat clog small vessels - capillaries - of various organs: first of all, the lungs, then the brain, kidneys, and heart.

Fat embolism develops against the background of the following pathologies:

There are several versions of the mechanism of development of fat embolism. Here are the main ones:

Forms of fat embolism

Depending on the severity of the condition and the rate of development of the embolism, physicians distinguish the following forms:

Lightning. Embolism develops very quickly, and the death of the patient occurs in just a few minutes.
Acute. It develops within the first hours after the onset of the cause (trauma, shock).
Subacute. It proceeds in a latent form for 12-72 hours, and only then symptoms appear.

Depending on the location, fat embolism is divided into pulmonary (capillaries of the lungs are affected), cerebral (capillaries of the brain), mixed (capillaries of the whole body, including the lungs, brain, heart, kidneys, skin, retina, etc.) . Most often, it is the mixed form that appears.

In the photo - damage to the pulmonary capillaries after a fracture of the lower leg and fibula. It can be judged on the pulmonary form of fat embolism or, if other organs are affected, on mixed fat embolism

Symptoms

Manifestations different types fat embolism:

Pulmonary	Compressive, stabbing pain behind the sternum, respiratory disorders (shortness of breath, suffocation, respiratory arrest), palpitations, sometimes coughing with frothy or bloody sputum.
Cerebral (cerebral)	Impaired consciousness, attacks of severe headache, delirium, hallucinations, twitching of the pupils, "floating" pupils, paralysis, muscle cramps, CNS depression up to coma, heat body (39-40 degrees), which is not confused by medications.
mixed	All of the above symptoms. Plus signs of damage to the capillaries of the skin, mucous membranes: dotted red rashes (small hemorrhages) on the skin of the whole body (more on the upper half), in the eyeballs, in the mouth. Symptoms of damage to the renal capillaries also appear: a sharp decrease in the amount of urine formed, a change in the composition of the urine.

Diagnostics

The well-known physician Pashchuk A. Yu. developed such a scale of symptoms, using which physicians can suspect fat embolism in patients with injuries and shock conditions:

With a score of more than 10, even in the absence of symptoms, a latent form of fat embolism can be suspected. With a score of more than 20, doctors are dealing with severe fat embolism.

Accurately confirm the diagnosis of such criteria:

Often there is no time for such detailed studies as an examination of the fundus, X-ray of the lungs, so a fat embolism is diagnosed using a scale of symptoms, urine and blood tests.

What is dangerous pathology

The main danger posed by a fat embolism is the possibility of death.

Death occurs for the following reasons:

If more than 2/3 of the capillaries of the lungs are affected, acute respiratory failure develops, which leads to hypoxia of all body tissues and death.
With the defeat of a large number of cerebral vessels, multiple small hemorrhages occur in the brain, which can also provoke irreversible changes and death.

Treatment Methods

It is carried out urgently and immediately.

If consciousness and breathing are disturbed, even in the absence of a confirmed diagnosis, the patient is connected to a ventilator to prevent further changes in the lungs and death due to respiratory arrest.

After confirming the diagnosis, drug therapy is used.

Patients are given drugs that break down large fat droplets in the blood and turn them into the same small particles that should be normal. Such medicines include Lipostabil, Essentiale, Decholin. To thin the blood, anticoagulants are used: for example, Heparin.

Also, to eliminate the state of shock, strengthen body cells and improve metabolism in tissues, glucocorticosteroids (Prednisolone, Dexamethasone), protease inhibitors (Kontrykal), antioxidants (vitamin C, vitamin E) are used.

All this allows you to stabilize the composition of the blood, improve blood circulation, prevent irreversible changes in the cells of the body.

Non-specific treatment is also used to improve the general condition of the patient and eliminate the risk of other complications of injuries. To maintain vital functions, a glucose solution is infused with insulin, electrolytes (potassium, magnesium), amino acids. Timalin, T-activin, gamma globulin are used to prevent infectious complications in injuries. To prevent purulent-septic complications, doctors prescribe Nystatin, Polymyxin, aminoglycosides.

Forecast

It is unfavorable in most cases. About 10% of patients die from the fat embolism itself. However, the unfavorable prognosis lies in the fact that fat embolism occurs against the background of very serious conditions, which in themselves can provoke the death of the patient.

Etymology of the disease

What is a fat embolism? The disease is a pathology associated with the penetration of fats into blood cells. The main cause of the development of the disease is considered to be trauma. bone tissue especially in patients with increased blood loss or excessive body weight.

Medical specialists distinguish several varieties of this disease, and each form occurs depending on the course of the pathology:

fulminant - characterized by rapid development, and the process itself takes about several minutes, resulting in a fatal outcome;
acute - spread occurs within a few hours after injury;
subacute - more than one day is spent on development.

There is also a conditional division of the disease into groups, while the patient can be diagnosed with pulmonary, cerebral or mixed fat embolism. In most cases, fats have a negative effect on the area of the brain, lungs and liver. On other internal organs, the impact of the disease is much less common.

Origin factors

Fat embolism syndrome can develop due to the influence of certain kinds of factors. Medical professionals tend to hold two theories as to what the causes might be.

The first theory implies that the formation of the disease is associated with an increase in pressure in the bone marrow after injury or as a result of surgery. After the penetration of fat cells into the blood, the formation of the so-called microthrombus occurs, which subsequently moves throughout the entire body area. The second is biochemical. What it is? She says that a violation at the cellular level is directly related to a negative change in the hormonal background of the human body.

Simultaneously with this factor, sepsis can occur, which provokes a violation of the proper movement of blood.

Additional factors affecting the development of the disease include:

a surgical procedure to remove excess fat;
closed bone fractures;
prosthetics of the hip joint;
receiving severe burns of a large area of \u200b\u200bthe skin;
bone marrow biopsy;
diagnosing concomitant diseases, for example, osteomyelitis or acute pancreatitis.

In some and very rare cases, factors that are not associated with injury to individual parts of the body can affect the fat embolism syndrome.

Symptomatic manifestations

Thromboembolism is a rather serious disease, not only because it develops relatively actively and can be fatal in a minimum period of time, but also because it does not show any visible symptomatic signs at the initial stages of its development. The primary symptom of the disease is the occurrence of pain, but patients attribute this to the consequences of injury or surgical treatment. After the development of the disease reaches the optimal point, symptoms begin to appear.

The most common include:

cardiopalmus;
active respiratory process;
the formation of redness of a small size in those places where bleeding of small vessels occurs;
disturbance of consciousness;
the appearance of fever.

The patient may experience a constant feeling of fatigue, accompanied by headaches, dizziness, or pain in the sternum.

If the disease is formed due to the influence of the above factors, then the symptomatic signs have a slightly different nature of manifestation. In this case, the patient has a violation of the central nervous system, headaches have the nature of attacks in relation to their manifestation, the patient loses the ability to adequately respond to the surrounding reality. Often, the patient may be tormented by a cough, and when sputum is separated, blood blotches may be observed in it. In the process of all symptomatic manifestations, the respiratory process begins to noticeably weaken, which provokes the formation of the so-called fine bubbling rales. In almost all cases, the patient's body temperature actively rises almost to the maximum mark, while taking antipyretic drugs does not give positive results.

Diagnostic measures and methods of treatment

First of all, when diagnosing this disease, a thorough study of the patient's sting regarding the manifestation of symptomatic signs is carried out. After that, the patient is sent to conduct a certain series of studies in order to confirm or refute the alleged diagnosis. These activities include:

a laboratory study of a general blood and urine test in order to study the general condition of the patient's body and the presence of concomitant diseases;
a biochemical blood test to detect an indirect cause of the disease;
computed tomography of the skull to examine and identify possible negative violations;
radiography.

Magnetic resonance therapy is considered the most functional and effective, since it can be used to identify main reason occurrence of the disease.

Once the diagnosis is confirmed, the treatment of a fat embolism first begins with the supply of necessary quantity oxygen region of the brain. The following therapeutic measures are divided into:

Therapeutic. They include treatment with oxygen, but over time, this method has lost its increased effectiveness, since the disease is not always detected on time. After that, the patient requires respiratory therapy.
Medical. The standard form of treatment for the disease involves the use of sedatives simultaneously with artificial ventilation of the lungs (used, as a rule, when severe cerebral disorders are detected). This also adds the intake of analgesic drugs to normalize body temperature and broad-spectrum antibiotics. Some medical specialists argue that at the moment it is necessary to use methylprednisolone or prednisolone, as they help to stop the development of the disease. If necessary, diuretics can be included in the use in order to reduce the accumulation of fluid in the lungs.

Carrying out therapeutic measures should be timely, since the disease is capable of leading the patient to death in a minimum time period.

Preventive actions

Preventive measures undoubtedly play an important role, especially for those patients who are prone to the occurrence of this kind of disease and are in the so-called risk group. These include patients who have relatively recently undergone surgical treatment or severely injured. All existing preventive measures regarding this problem imply that the patient receives appropriate and competent medical care in case of injury, normalizes the process of blood circulation and stops bleeding if it occurs, the correct transportation of the patient to the medical facility after injury, and, if necessary, the timely provision and conduct of initial therapeutic measures, the use of appropriate drugs and the implementation of constant monitoring of the general condition of the patient.

The duration of preventive measures, as a rule, is of the order of several days after the surgical treatment has been carried out or the injury has been received.

Without fail, the patient must be aware of possible subsequent complications. Thromboembolism associated with blockage in itself is a complication process, for this reason it is considered a rather dangerous pathology. Even if the patient is provided with highly qualified medical care, and at the same time timely, this does not at all mean that the blood supply remains normal. All these consequences negatively affect the functionality of the body as a whole, as it provokes the active emergence and impact on the body of numerous and diverse diseases of a chronic nature. Of course, death is considered the most serious and most common complication.

Thus, this disease is a serious threat to the life of the patient. The prognosis for the patient's future life depends on the quality and timeliness of treatment. Modern medicine has become a much improvement, as evidenced by the decrease in the number of cases when the disease ends in death. However, this factor is not always confirmed, since some forms of the disease can be difficult to diagnose.

24.09.2017

An embolism is a pathological condition of the blood vessels, when they are clogged with substances that are not normally found in the vascular bed. In particular, blockage of blood vessels by fat particles is what a fat embolism is. In most clinical cases, the cause of the pathology is trauma to the tubular bones, but there are other factors that cause embolism.

Fat embolism is a disease that needs to be treated on time

The similarity of the clinical manifestations of blockage of blood vessels with fat with signs of TBI, pneumonia, leads to errors in diagnosis, often to death due to untimely assistance. The disease is more often diagnosed in young men because of their vigorous activity, which often leads to fractures.

Why does a fat embolism occur?

There should be no fat particles in the blood vessels, but it can enter the bloodstream due to various factors. This can include amputation surgery, a fracture in obese people, excessive bone marrow pressure, and diabetes. In many identified cases, fat embolism occurred with large blood loss in case of extensive damage or during surgery. People with hypotension are at risk.

Not every fracture is fraught, statistics say that a complication occurs in about 10% of all cases of injury. Data on mortality in pathology is disappointing - about 50% of patients die.

Fat embolism most often occurs with large blood loss

Other causes of fat embolism syndrome are burns to large areas of the body, liver injury, and severe tissue damage. In very rare cases, the pathology provokes a closed massage of the heart muscle.

Scientists give different mechanisms for the onset and further course of pathology. The main factor is the increase in bone marrow pressure, which leads to the ingress of fat particles into the venous circulation. According to another opinion, thickening of the blood in case of severe bleeding activates lipase, and with it the number of fat cells. The third (and not the last) theory points to a change in the size of fats in plasma.

Classification of fat embolism

Doctors distinguish 3 types of fat embolism - it is pulmonary, mixed and cerebral. Classification is carried out on the basis of the localization of fatty particles - in the lungs, kidneys and brain tissues, and other organs.

There are three types of fat embolism

Taking into account the rate of development of pathology, embolism is divided into fulminant, when a fatal outcome occurs within a couple of minutes, as well as acute and subacute. The acute form is detected a couple of hours after the injury, subacute - within 12-72 hours. In the last two forms, the mortality rate is lower, because doctors have time to dissolve fats in the vessels, restore blood flow without harm to the state of vital organs.

Clinical picture

The period of manifestation of the first symptoms, as mentioned above, lasts from a couple of minutes to 3 days from the moment of the event that provoked the entry of fats into the bloodstream. The initial course is characterized by small hemorrhages on the neck and shoulders, in the armpits and chest area.

Sometimes such small hemorrhages cannot be noticed without a magnifying glass. Such signs stay on the skin from a couple of hours to a couple of days. This suggests that there is a blockage of the capillaries and there is a traumatic injury. Sometimes hemorrhage is detected in the conjunctiva and in the fundus. An ophthalmologist may notice blood clots from fat cells in the vessels during the assessment of the fundus.

Doctors divide the main signals of fat embolism into 4 syndromes:

Disorders in the work of the central nervous system. These are paresis, paralysis, confusion, severe headache, delirium, convulsions and coma.
Hypothermic fat embolism syndrome. Raised febrile temperature cannot be reduced with antipyretic drugs. Heat appears due to the fact that fatty acids irritate the brain structures responsible for thermoregulation.
Violation of the activity of the heart, respiratory system. Shortness of breath appears, breathing can completely stop. In the sternum - pain, there is a cough with blood in the sputum, tachycardia. Listening to the heart, the doctor detects a strong second tone, and fine bubbling rales in the lungs.
Small on the skin, which were mentioned above.

Separately, it should be considered that accompanies pulmonary embolism. This form of pathology is detected more often than others - it accounts for about 60% of all cases. The condition can be recognized by the following symptoms: dry cough, shortness of breath, frothy sputum with blood inclusions, cyanosis. Urgent diagnosis and treatment is required.

In the case of brain damage, the signs of the first syndrome predominate. If a person has tissues of several organs affected, the clinical picture is mixed. If thromboembolism causes respiratory failure, it is necessary to ventilate the lungs, insert a breathing tube - only such measures can save a life.

Diagnostic measures

Pathology is confirmed not only by the presence of symptoms, but also by diagnostic measures. To do this, there are laboratory and instrumental methods that detect fatty compounds with dimensions of 6 microns in the blood. During the research, doctors discover:

increased fat in alveolar macrophages;
diffuse infiltration in the lungs;
swelling of the retina, the presence of silver spots, signaling impaired blood circulation in the eye vessels;
breakdown of red blood cells leading to anemia;
increase in ESR;
the leukocyte formula shifts to the left, leukocytosis develops;
protein and blood in the urine;
fat cells in the urine (lipuria);
microscopic hemorrhages in the brain;
swelling of the brain and the death of its tissues, myelin degeneration, perivascular infarction.

X-ray is one of the methods for diagnosing this disease.

The listed results are obtained using x-rays, laboratory blood and urine tests, magnetic resonance imaging and other types of diagnostic measures. Based on the results and the symptoms listed above, the doctor establishes the final diagnosis and prescribes treatment.

In most cases, embolism is manifested by symptoms, the spectrum of which depends on the localization of inflammation - with blockage of the blood vessels of the kidneys and spleen, liver, myocardium and adrenal glands, the pathology picture characterizes the inflammatory process in the organ.

How is a fat embolism treated?

Before hospital treatment for a fat embolism is started, the doctor can take steps to manage the complications. During extensive injuries, there is a high risk of blockage of blood vessels by fatty particles. Physicians must take measures to prevent a dangerous condition.

It is important to react in such situations:

decrease in blood pressure for a long time;
traumatic shock;
crushed thighs, shins and pelvic bones;
delay in hospitalization of the victim;
illiterate immobilization.

Fat embolism must be treated in a hospital setting

First aid to the victim in case of injuries - immobilization of the injured limbs, preventing rupture of the tissues surrounding the broken bone. To prevent traumatic shock put painkillers. After the first aid is competently provided, the victim is transported to the traumatology. If necessary, in the ambulance, respiratory support is provided, corticosteroids are administered, and deep vein thrombus prophylaxis is carried out.

When a fat embolism is diagnosed, treatment is carried out in intensive care or in a hospital - it all depends on the severity of the damage, the presence of concomitant diseases and complications. Doctors have at their disposal a number of medicines and procedures designed to improve the blood supply to tissues in the injured area of the body and stabilize the condition of the victim:

ventilation of the lungs is carried out when identifying mental abnormalities, confusion. The procedure is carried out until consciousness is restored, and the patient's condition stabilizes. Even if a person does not have a symptom of respiratory failure, a disturbed acid-base balance indicates the need for lung ventilation;
introduction of demulsifiers. These substances dissolve fats in the blood, transforming large particles into small ones. This will prevent clogging of blood vessels with fats. Thanks to the drugs Decholin, Essentiale, the lipid composition in the blood is normalized;
heparin therapy, the introduction of frozen plasma and fibrinolysin inhibits the development of DIC;
plasmapheresis;
diuresis with sodium hypochlorite;
surgical intervention;
the use of corticosteroid hormones is designed to protect tissues from the effects of harmful substances and enzymes, improve the stability of the blood-brain barrier, and restore membranes. To prevent pneumonia, Prednisolone, Dexamethasone are prescribed;
antioxidants reduce the effect of toxins on organ cells;
antibiotics are prescribed to prevent complications, inflammatory processes;
therapeutic nutrition with amino acids, microelements, vitamins, glucose, insulin is aimed at improving the condition of the victim, accelerating rehabilitation after injury.

Not to be missed possible development For a fat embolism, health workers monitor the patient for 24 hours, monitoring pressure and other indicators of the condition. All medical manipulations are carried out carefully.

Prevention

In case of damage as a result of accidents and industrial injuries, other situations, it is necessary to immediately provide competent assistance to the victim. It is important not to miss the time, since the risk of fat embolism occurs in the first three days, you can not be afraid of such a complication. Transportation of the victim to the intensive care unit is carried out after it is possible to bring him out of a state of shock. A prerequisite is the immobilization bandage. The collection and movement of bone fragments is carried out after removal of the hematoma.

For complex fractures of tubular bones, the method of open osteosynthesis is recommended. If you can not do without surgery, it is carried out as soon as possible, trying to reduce injuries. Medicinal liquids are injected into the vein only through a dropper.

With TBI, the diagnosis of embolism is difficult, so the victim is under the control of a neurologist, who notes the slightest changes in the condition.

Summing up, it can be noted that fat embolism is a dangerous pathology that occurs when the body is damaged - burns, fractures and other injuries. To avoid the problem, you need to take possible measures to reduce the risk of injury.