Fat embolism syndrome (FES) is a phenomenon usually found in trauma patients. It typically occurs post long bone fracture. These include the femur, pelvis and tibia. Pathophysiologically, fat from the marrow of the long bones may flick off and lodge themselves in smaller vessels distally. Usually, these fat emboli lodge in the pulmonary vasculature. This patient had a ventricular septal defect which facilitated the fat emboli bypassing the pulmonary vasculature and traveling arterially into the brain.

Fat embolism syndrome classically presents as a triad of:

• respiratory failure - pulmonary embolism

• cerebral dysfunction - cerebral embolism

• skin petechiae - skin embolism

The clinical manifestations of FES typically occur 24-72 hours post trauma ¹. Clinical diagnosis of FES can be made using Gurd and Wilson's major and minor criteria ². This requires at least one of the major criteria, and at least four minor criteria. They are:
Major criteria:

• petechial Rash

• respiratory insufficiency

• cerebral involvement

Minor criteria:

• tachycardia

• fever

• retinal changes

• jaundice

• renal signs

• thrombocytopaenia

• anemia

• raised ESR

• fat macroglobinaemia

Management of FES is conservative, by ensuring good arterial oxygenation and maintaining intravascular volume (in order to prevent concurrent shock). Medical therapy has largely been found to be ineffective.

Case contributed by A/Prof. Pramit Phal.