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The use of steroids in fat embolism: A case report
218
INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY
Injury Jan. 1971
THE USE OF STEROIDS IN FAT EMBOLISM: A CASE REPORT J. K. W A L S H
The Fracture Service, The Royal Devon and Exeter Hospital
A case o f severe fat e m b o l i s m is presented in w h i c h t h e use o f steroids a p p e a r e d to play a vital p a r t in recovery. T h e i m p o r t a n c e o f h y p o x i a in fat e m b o l i s m is again stressed. CASE REPORT A 19-year-old female, involved in a car accident, was admitted to hospital on 12 Oct., 1969, at 12.30 a.m., with head injuries, multiple lacerations, and a fractured shaft of her left femur. She was conscious
Fig. 1.--Chest
oxyg.en, but she only improved slightly and did not regain consciousness. Thirty-four hours after admission, her condition had worsened. A widespread petechial rash was observed and her platelet count was 66,000. Fat
radiograph showing diffuse changes consistent with massive fat embolism.
Fig. 2.--Chest radiograph 58 hours after
and co-operative, but was moderately shocked and was resuscitated with 3 pints of blood. Six hours after admission she was anaesthetized, the lacerations sutured, and a Steinmann pin inserted in the left tibia for traction to be applied to the femur. She did not recover fully from the anaesthetic, becoming cyanosed in spite of oxygen by mask. Numerous r~.les were heard on auscultation of her chest, and a radiograph showed diffuse changes consistent with massive fat embolism (Fig. 1). She was re-intubated and placed on intermittent positivepressure respiration (I.P.P.R.) with 100 per cent
globules were seen in her urine. Her arterial Po2 was 31 mm. Hg on I00 per cent oxygen, and Pco~ 31.5 mm. Hg. Two hundred ml. of 20 per cent mannitol were given intravenously without significant change in her condition. Fifty-eight hours after admission her arterial Po2 was 46 ram. Hg, and her chest radiograph still showed diffuse infiltration (Fig. 2). She was developing multiple ectopic beats indicating myocardial hypoxia, and a lignocaine drip was set up to give 1 mg. per minute for 4 hours to try to correct the cardiac arrhythmia.
admission.
Volume 2 Number 3
W A L S H : STEROIDS IN FAT EMBOLISM
In view of her parlous condition, 10 mg. of dexamethasone were given intravenously and 8 mg. intramuscularly 8-hourly for 24 hours, tailing off with two further doses of 4 rag. and one of 2 rag. at 8-hourly intervals before stopping. Four hours after starting steroids, her Po~ was 68 ram. Hg; 24 hours after, her colour became pink
219
Whatever the mode of production, the result is disseminated and confluent haemorrhages in the lungs with pulmonary oedema, impaired oxygen uptake, and hypoxia. Peltier (1967) states that fat embolism is essentially a pulmonary disease. Ross (1970) supports this view and suggests that the cerebral symptoms may be due to hypoxia. The breakdown of fat emboli to free fatty acids may be responsible for a chemical pneumonitis.
Clinical Features Severe cases of fat embolism are uncommonly diagnosed, but produce a clinical picture of delirium leading to coma, dyspnoea, and cyanosis, and a petechial rash, coming on usually within 48 hours after major trauma. Linscheid and Dines (1969) have reported a mortality of 45 per cent. The petechial rash may be due to thrombocytopenia, and Wertzberger and Peltier (1968) and Ross (1970)have also reported cases with a low platelet count, though this may occur in severely injured and burned patients without fat embolism (Innes and Sevitt, 1964).
Treatment
Fig. 3.--Chest radiograph 24 hours after starting steroid therapy. for the first time in 3 days, with a Po2 of 315 mm. Hg. Her chest radiograph had cleared dramatically (Fig. 3). It was decided to continue with I.P.P.R. and a tracheostomy was done to facilitate this. Her condition steadily improved over the next 5 days and she was taken off the respirator. Nine days after admission she was conscious and responded to commands. Her Po2 on air alone was 180 ram. Hg. Her platelet count had risen to 236,000 and the petechial rash had largely faded. The tracheostomy tube was removed 3 days later and the wound healed by second intention. The femur was treated conservatively and went on to sound bony fusion. There was no evidence of brain damage and the patient returned to her job as a bank clerk. DISCUSSION Pathogeaesis There are two main theories as to the cause of fat embolism. It may derive from the marrow, and the majority favour this view, which is well expressed by Sevitt (1962). Most recent emphasis is on the coalescence of chylomicrons, especially in shock, as explained by Tedeschi, Walter, and Tedeschi (1968); and this has been produced experimentally by Gurd (1969). Rennie (1970) feels that the two views are not incompatible.
Estimation of the arterial oxygen pressure and adequate treatment with oxygen, using I.P.P.R., is the most important measure in combating hypoxia in severe cases. Other therapy has been described, such as heparin, to stimulate the release of lipoprotein lipases (Derian, 1965), low molecular weight dextran, to improve capillary blood-flow (Evarts, 1970), and steroids, to block the inflammation of a chemical pneumonitis (Ashbaugh and Petty, 1966). Of these ancillary measures, Ashbaugh and Petty have described cases who have improved dramatically with steroids, and this case is presented to corroborate their evidence. It is suggested that if hypoxia is not improved using I.P.P.R. then the use of steroids should be considered.
Acknowledgements I wish to thank Mr. C. C. Jeffery, the consultant in charge of this case, for permission to publish, and Dr. Powell, Dr. Clarkson, Dr. Tomlinson, and the other anaesthetists involved in her care, as well as the staff of the Intensive Care Unit of the Royal Devon and Exeter Hospital, for their invaluable help. REFERENCES ASHBAUGH,D. G., and PETTY,T. L. (1966), ' The Use of Corticosteroids in the Treatment of Respiratory Failure associated with Massive Fat Embolism ', Surgery Gynec. Obstet., 123, 493.
220
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
DERIAN, P. S. (1965), ' F a t Embolization--Current Status ', J. Trauma, 5, 580. EVARTS, C. M. (1970), ' The Fat Embolism Syndrome - - A Review ', Surg. Clins N. Am., 50, 493. GURD, A. R. (1969), ' The Origin of Fat Embolism after Injury ', Br. J. Surg., 56, 614 (Abstract). INNES, D., and SEvrrr, S. (1964), 'Coagulation and Fibrinolysis in Injured Patients', J. clin. Path., 17, 1. LINSCHEXD, R. L., and DINES, D. E. (1969), ' T h e Fat Embolism Syndrome', Surg. Clins N. Am., 49, 1137. PELTIER, L. F. (1967), ' Fat Embolism: A Pulmonary Disease ', Surgery, St Louis, 62, 756.
Injury Jan. 1971
RENNIE, A. M. (1970), ' Fat Embolism ', Can. J. Surg., 13, 41. Ross, A. P. J. (1970), ' The Fat Embolism Syndrome: with Special Reference to the Importance of Hypoxia in the Syndrome ', Ann. R. Coll. Surg., 46, 159. SEVITr, S. (1962), Fat Embolism. London: Butterworths. TEDESCHI, C. G., WALTER, C. E., and TEDESCHI, L. G. (1968), ' Shock and Fat Embolism: An Appraisal ', Surg. Clins N. Am., 48, 431. WERTZBERGER, J. J., and PELTIER, L. F. (1968), ' Fat Embolism--The Importance of Arterial Hypoxia ', Surgery, St Louis, 63, 626.
Requestsfor reprints shouMbe addressed to:--J. K. Walsh, Esq., F.R.C.S. (Edin.), 41 Holmes St., Turramurra, Sydney, N.S.W., Australia.
ABSTRACTS ORGANIZATION
TOPICS
Hospital Bed Usage Any mention of hospital statistics and bed-usage factors is liable to make most surgeons react like Goering, who used to reach for his revolver whenever he heard the word ' Culture '. Yet if for no other reason this paper is important for its suggested solution of a problem that faces every specialty in arty large general hospital every day: must beds be kept empty in a ward to deal with emergency admissions ? If enough beds are kept empty to cope with peak emergency demands they will usually not be occupied, since daily demands fluctuate wildly. If too few are kept empty, then wards are overcrowded and emergencies may have to be refused admission. T h e ' lodgingout ' of patients in other wards is a possibility but has many disadvantages. The solution described in this paper is the provision of a discharge ward available for the last few days of their stay to patients of either sex and any specialty. It is not a self-care unit but a ward designed to take patients for the last few days of the care which only a hospital cart provide. With the discharge ward as a safety-valve, the specialty wards can plan to fill their beds with waiting-list cases as appropriate but not keep any beds empty for emergency admissions. They can do this safe in the knowledge that the discharge ward can accept one or more of their patients nearing discharge whenever an emergency patient is admitted to their ward. In the discharge ward patients remain under the care of their original consultant, but one particular consultant is given administrative charge of the ward. Should the discharge ward itself become full, it contains a pool of the fittest patients in the hospital from whom the consultant-in-charge can select cases who can be discharged home. This approach to the problem has been tried out at Dryburn Hospital, Durham, with a 22-bed discharge ward in a general hospital of 300 beds, and this paper describes the great success of this scheme over the first 3--4 years. NEWELL, D. J. (1970), ' H o s p i t a l Bed Usage ', Br. J. hosp. Med., 3, 915.
Car Crashes in Ontario The death-rate and permanent disability rate for victims of road traffic accidents in Canada are much worse than in Great Britain. Four doctors and a lawyer report in depth on 31 serious accidents during the summer of 1967 and 1968. There were 23 deaths and 88 injuries. Investigations conformed to a 40-page manual and covered all aspects of the accident, i.e., type and cause of accident including standard photographs, cause of death and injury, and previous relevant history of the driver. The team was impressed with the fact that three-quarters of the accidents occurred during periods when the barometric pressure was falling, confirming Swiss views on this aetiological factor. They also confirm the widely held opinion in this country that alcohol was a factor in over half the incidents and that one-third of the deaths could have been avoided by the use of lap diagonal seat belts. The authors' detailed manual would be of great help to others who are willing to study this modern and tragic epidemic. GHENT, W. R., GOOD, B. E., MCCRANK, M. N., PRITCHARD, B., and TODD, T. (1970), ' Car Crashes in Ontario ', Can. J. Surg., 13, 236. Resuscitation Room This reports the work of a room in the Edinburgh Royal Infirmary which acts as both resuscitation room and emergency radiograph room. During 129 days 100 patients were admitted and 3378 patients radiographed; the latter included 62 of the resuscitation admissions, some ward patients requiring radiogr~iphs at night from various parts of the hospital but most of the 3000 were other accident cases. During the same time 22,000 patients attended the Accident and Emergency Department. The commonest diagnosis in patients admitted to the resuscitation room was trauma (62 per cent), of which two-thirds were multiple and more than two-thirds had head injuries. Poisoning was the next commonest diagnosis (21 per cent). As a result over half the admitted patients were unconscious. Most patients were moved within 1 ],our and all within 2 hours and they went to the N~.,~-osurgical or Poisons Unit or to other departments in the hospital. Three patients died in the room and 13 after transfer. JENKINS, A. McL., McQUILLAN, W. M., and McNAIR, T. J. (1969), ' Resuscitation Room Survey ', Scott. med. J., 14, 29.
INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY
Injury Jan. 1971
THE USE OF STEROIDS IN FAT EMBOLISM: A CASE REPORT J. K. W A L S H
The Fracture Service, The Royal Devon and Exeter Hospital
A case o f severe fat e m b o l i s m is presented in w h i c h t h e use o f steroids a p p e a r e d to play a vital p a r t in recovery. T h e i m p o r t a n c e o f h y p o x i a in fat e m b o l i s m is again stressed. CASE REPORT A 19-year-old female, involved in a car accident, was admitted to hospital on 12 Oct., 1969, at 12.30 a.m., with head injuries, multiple lacerations, and a fractured shaft of her left femur. She was conscious
Fig. 1.--Chest
oxyg.en, but she only improved slightly and did not regain consciousness. Thirty-four hours after admission, her condition had worsened. A widespread petechial rash was observed and her platelet count was 66,000. Fat
radiograph showing diffuse changes consistent with massive fat embolism.
Fig. 2.--Chest radiograph 58 hours after
and co-operative, but was moderately shocked and was resuscitated with 3 pints of blood. Six hours after admission she was anaesthetized, the lacerations sutured, and a Steinmann pin inserted in the left tibia for traction to be applied to the femur. She did not recover fully from the anaesthetic, becoming cyanosed in spite of oxygen by mask. Numerous r~.les were heard on auscultation of her chest, and a radiograph showed diffuse changes consistent with massive fat embolism (Fig. 1). She was re-intubated and placed on intermittent positivepressure respiration (I.P.P.R.) with 100 per cent
globules were seen in her urine. Her arterial Po2 was 31 mm. Hg on I00 per cent oxygen, and Pco~ 31.5 mm. Hg. Two hundred ml. of 20 per cent mannitol were given intravenously without significant change in her condition. Fifty-eight hours after admission her arterial Po2 was 46 ram. Hg, and her chest radiograph still showed diffuse infiltration (Fig. 2). She was developing multiple ectopic beats indicating myocardial hypoxia, and a lignocaine drip was set up to give 1 mg. per minute for 4 hours to try to correct the cardiac arrhythmia.
admission.
Volume 2 Number 3
W A L S H : STEROIDS IN FAT EMBOLISM
In view of her parlous condition, 10 mg. of dexamethasone were given intravenously and 8 mg. intramuscularly 8-hourly for 24 hours, tailing off with two further doses of 4 rag. and one of 2 rag. at 8-hourly intervals before stopping. Four hours after starting steroids, her Po~ was 68 ram. Hg; 24 hours after, her colour became pink
219
Whatever the mode of production, the result is disseminated and confluent haemorrhages in the lungs with pulmonary oedema, impaired oxygen uptake, and hypoxia. Peltier (1967) states that fat embolism is essentially a pulmonary disease. Ross (1970) supports this view and suggests that the cerebral symptoms may be due to hypoxia. The breakdown of fat emboli to free fatty acids may be responsible for a chemical pneumonitis.
Clinical Features Severe cases of fat embolism are uncommonly diagnosed, but produce a clinical picture of delirium leading to coma, dyspnoea, and cyanosis, and a petechial rash, coming on usually within 48 hours after major trauma. Linscheid and Dines (1969) have reported a mortality of 45 per cent. The petechial rash may be due to thrombocytopenia, and Wertzberger and Peltier (1968) and Ross (1970)have also reported cases with a low platelet count, though this may occur in severely injured and burned patients without fat embolism (Innes and Sevitt, 1964).
Treatment
Fig. 3.--Chest radiograph 24 hours after starting steroid therapy. for the first time in 3 days, with a Po2 of 315 mm. Hg. Her chest radiograph had cleared dramatically (Fig. 3). It was decided to continue with I.P.P.R. and a tracheostomy was done to facilitate this. Her condition steadily improved over the next 5 days and she was taken off the respirator. Nine days after admission she was conscious and responded to commands. Her Po2 on air alone was 180 ram. Hg. Her platelet count had risen to 236,000 and the petechial rash had largely faded. The tracheostomy tube was removed 3 days later and the wound healed by second intention. The femur was treated conservatively and went on to sound bony fusion. There was no evidence of brain damage and the patient returned to her job as a bank clerk. DISCUSSION Pathogeaesis There are two main theories as to the cause of fat embolism. It may derive from the marrow, and the majority favour this view, which is well expressed by Sevitt (1962). Most recent emphasis is on the coalescence of chylomicrons, especially in shock, as explained by Tedeschi, Walter, and Tedeschi (1968); and this has been produced experimentally by Gurd (1969). Rennie (1970) feels that the two views are not incompatible.
Estimation of the arterial oxygen pressure and adequate treatment with oxygen, using I.P.P.R., is the most important measure in combating hypoxia in severe cases. Other therapy has been described, such as heparin, to stimulate the release of lipoprotein lipases (Derian, 1965), low molecular weight dextran, to improve capillary blood-flow (Evarts, 1970), and steroids, to block the inflammation of a chemical pneumonitis (Ashbaugh and Petty, 1966). Of these ancillary measures, Ashbaugh and Petty have described cases who have improved dramatically with steroids, and this case is presented to corroborate their evidence. It is suggested that if hypoxia is not improved using I.P.P.R. then the use of steroids should be considered.
Acknowledgements I wish to thank Mr. C. C. Jeffery, the consultant in charge of this case, for permission to publish, and Dr. Powell, Dr. Clarkson, Dr. Tomlinson, and the other anaesthetists involved in her care, as well as the staff of the Intensive Care Unit of the Royal Devon and Exeter Hospital, for their invaluable help. REFERENCES ASHBAUGH,D. G., and PETTY,T. L. (1966), ' The Use of Corticosteroids in the Treatment of Respiratory Failure associated with Massive Fat Embolism ', Surgery Gynec. Obstet., 123, 493.
220
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
DERIAN, P. S. (1965), ' F a t Embolization--Current Status ', J. Trauma, 5, 580. EVARTS, C. M. (1970), ' The Fat Embolism Syndrome - - A Review ', Surg. Clins N. Am., 50, 493. GURD, A. R. (1969), ' The Origin of Fat Embolism after Injury ', Br. J. Surg., 56, 614 (Abstract). INNES, D., and SEvrrr, S. (1964), 'Coagulation and Fibrinolysis in Injured Patients', J. clin. Path., 17, 1. LINSCHEXD, R. L., and DINES, D. E. (1969), ' T h e Fat Embolism Syndrome', Surg. Clins N. Am., 49, 1137. PELTIER, L. F. (1967), ' Fat Embolism: A Pulmonary Disease ', Surgery, St Louis, 62, 756.
Injury Jan. 1971
RENNIE, A. M. (1970), ' Fat Embolism ', Can. J. Surg., 13, 41. Ross, A. P. J. (1970), ' The Fat Embolism Syndrome: with Special Reference to the Importance of Hypoxia in the Syndrome ', Ann. R. Coll. Surg., 46, 159. SEVITr, S. (1962), Fat Embolism. London: Butterworths. TEDESCHI, C. G., WALTER, C. E., and TEDESCHI, L. G. (1968), ' Shock and Fat Embolism: An Appraisal ', Surg. Clins N. Am., 48, 431. WERTZBERGER, J. J., and PELTIER, L. F. (1968), ' Fat Embolism--The Importance of Arterial Hypoxia ', Surgery, St Louis, 63, 626.
Requestsfor reprints shouMbe addressed to:--J. K. Walsh, Esq., F.R.C.S. (Edin.), 41 Holmes St., Turramurra, Sydney, N.S.W., Australia.
ABSTRACTS ORGANIZATION
TOPICS
Hospital Bed Usage Any mention of hospital statistics and bed-usage factors is liable to make most surgeons react like Goering, who used to reach for his revolver whenever he heard the word ' Culture '. Yet if for no other reason this paper is important for its suggested solution of a problem that faces every specialty in arty large general hospital every day: must beds be kept empty in a ward to deal with emergency admissions ? If enough beds are kept empty to cope with peak emergency demands they will usually not be occupied, since daily demands fluctuate wildly. If too few are kept empty, then wards are overcrowded and emergencies may have to be refused admission. T h e ' lodgingout ' of patients in other wards is a possibility but has many disadvantages. The solution described in this paper is the provision of a discharge ward available for the last few days of their stay to patients of either sex and any specialty. It is not a self-care unit but a ward designed to take patients for the last few days of the care which only a hospital cart provide. With the discharge ward as a safety-valve, the specialty wards can plan to fill their beds with waiting-list cases as appropriate but not keep any beds empty for emergency admissions. They can do this safe in the knowledge that the discharge ward can accept one or more of their patients nearing discharge whenever an emergency patient is admitted to their ward. In the discharge ward patients remain under the care of their original consultant, but one particular consultant is given administrative charge of the ward. Should the discharge ward itself become full, it contains a pool of the fittest patients in the hospital from whom the consultant-in-charge can select cases who can be discharged home. This approach to the problem has been tried out at Dryburn Hospital, Durham, with a 22-bed discharge ward in a general hospital of 300 beds, and this paper describes the great success of this scheme over the first 3--4 years. NEWELL, D. J. (1970), ' H o s p i t a l Bed Usage ', Br. J. hosp. Med., 3, 915.
Car Crashes in Ontario The death-rate and permanent disability rate for victims of road traffic accidents in Canada are much worse than in Great Britain. Four doctors and a lawyer report in depth on 31 serious accidents during the summer of 1967 and 1968. There were 23 deaths and 88 injuries. Investigations conformed to a 40-page manual and covered all aspects of the accident, i.e., type and cause of accident including standard photographs, cause of death and injury, and previous relevant history of the driver. The team was impressed with the fact that three-quarters of the accidents occurred during periods when the barometric pressure was falling, confirming Swiss views on this aetiological factor. They also confirm the widely held opinion in this country that alcohol was a factor in over half the incidents and that one-third of the deaths could have been avoided by the use of lap diagonal seat belts. The authors' detailed manual would be of great help to others who are willing to study this modern and tragic epidemic. GHENT, W. R., GOOD, B. E., MCCRANK, M. N., PRITCHARD, B., and TODD, T. (1970), ' Car Crashes in Ontario ', Can. J. Surg., 13, 236. Resuscitation Room This reports the work of a room in the Edinburgh Royal Infirmary which acts as both resuscitation room and emergency radiograph room. During 129 days 100 patients were admitted and 3378 patients radiographed; the latter included 62 of the resuscitation admissions, some ward patients requiring radiogr~iphs at night from various parts of the hospital but most of the 3000 were other accident cases. During the same time 22,000 patients attended the Accident and Emergency Department. The commonest diagnosis in patients admitted to the resuscitation room was trauma (62 per cent), of which two-thirds were multiple and more than two-thirds had head injuries. Poisoning was the next commonest diagnosis (21 per cent). As a result over half the admitted patients were unconscious. Most patients were moved within 1 ],our and all within 2 hours and they went to the N~.,~-osurgical or Poisons Unit or to other departments in the hospital. Three patients died in the room and 13 after transfer. JENKINS, A. McL., McQUILLAN, W. M., and McNAIR, T. J. (1969), ' Resuscitation Room Survey ', Scott. med. J., 14, 29.