Pulmonary fat embolism refers to pulmonary embolism by fat, most commonly due to major trauma. This can rarely progress to life-threatening fat embolization syndrome.
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Pathology
It usually occurs in the context of a long bone fracture and may occur in 1-3% of patients with simple tibial or femoral fractures and up to 20-33% of individuals with more severe trauma.
Other less common causes include:
soft tissue trauma
major burns
overwhelming infection
blood transfusion
The exact pathophysiology is not entirely clear but presumably occurs by one of two mechanisms or a combination thereof:
production of free fatty acids, which initiates a toxic reaction in the endothelium. This process is further complicated by the accumulation of neutrophils and other inflammatory cells, which cause damage to the vasculature.
mechanical obstruction of the pulmonary vasculature by fat globules, aggregates of red blood cells, and platelets.
Markers
Urinalysis for fat globules may be useful in the setting of large pulmonary fat embolism.
Radiographic features
Imaging findings typically become evident at around 24-48 hours after the traumatic insult.
Plain radiograph
Non-specific but can resemble those in acute respiratory distress syndrome from any cause, and shows widespread homogeneous and heterogeneous areas of increased opacity. Normal heart size and the absence of other features of cardiogenic edema (septal lines, pleural effusion, and pulmonary venous hypertension) may aid in the differentiation from noncardiogenic pulmonary edema.
CT
Commonly reported findings include:
may show areas of consolidation
ground-glass opacities: with or without interlobular septal thickening, occasionally appearing as a geographic pattern 7
small (<1 cm) nodules (can sometimes be ground glass-like) of various sizes: presumed to represent alveolar edema, inflamed intrapulmonary lymph nodes or hemorrhage secondary to the fat embolism syndrome 5,6,12
fat attenuating filling defects in pulmonary arteries: rarely described in non-fulminant fat embolism syndrome
Treatment and prognosis
Prophylactic treatment consists of prompt treatment of the causative factor, e.g. fracture fixation. Treatment is largely supportive and involves fluid resuscitation, maintaining good arterial oxygenation and sufficient intravascular volume. Adding albumin to the electrolyte solution used for volume resuscitation can help bind the free fatty acids 8. Mechanical ventilation and PEEP may be required in certain cases. Symptoms are often transient with a good prognosis.
Differential diagnosis
some imaging features can resemble those of acute respiratory distress syndrome 11
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other considerations for multifocal ground glass changes include
multifocal infective inflammatory changes
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