Fatty embolism – multiple occlusion of blood vessels lipidic globula. It is shown in the form of respiratory insufficiency, damage of the central nervous system, an eye retina. The headache, encephalopathy, floating eyeballs, paralyzes, paresis, pains behind a breast, short wind, tachycardia is among the main symptoms. The diagnosis is made on the basis of a clinical picture, existence of the contributing factors in the anamnesis and identification of large lipidic particles in blood. Specific treatment includes IVL, fat dezemulgator, anticoagulants, glucocorticosteroids, sodium hypochlorite. In addition nonspecific medical events are held.
The Fatty Embolism (FE) – the heavy complication developing mainly at injuries of long tubular bones as a result of obstruction of vascular pools by the lipidic complexes which got to a blood-groove. Frequency of occurrence fluctuates within 0,5-30% of total of traumatologic patients. It is usually diagnosed for patients at the age of 20-60 years. The minimum quantity of embolisms is registered among the people who were traumatized in alcohol intoxication. The lethality makes 30-67%; this indicator directly depends on weight and a type of damages, the speed of delivery of health care.
Reasons of a fatty embolism
Essence of pathological process – an obturation of blood vessels fat drops. It leads to violation of a blood-groove in important structures of an organism – a head and spinal cord, lungs, heart. Treat number of states which can serve as ZhE reason:
- Injuries. The main reason for a lipidic embolism – changes of a diaphysis of femurs, shins, a basin. The risk of development of pathology increases at the volume and multiple injuries which are followed by a razmozzheniye of a bone tissue. It is considered that pathology arises at 90% of people with damages of the musculoskeletal device. However its clinical manifestations develop only in rather small amount of cases. In addition, the dislipidemiya capable to provoke an obturation of vessels occur at patients with burns, damage of large volume of hypodermic fatty cellulose.
- Shocks and post-resuscitation disease. Formation of embol happens at shocks of any origin in 2,6% of cases. The reason – strengthening of catabolic processes, a metabolic storm. The symptomatology develops by the end of 2-3 days after the patient's conclusion from critical condition more often.
- Intravenous administration of oil solutions. Cases of a yatrogenny origin of a disease are single. Fatty occlusion arises at the expense of the exogenous fats which got to a blood-groove at wrong actions of the health worker. Besides, the fatty embolism is sometimes diagnosed for the athletes applying to increase in muscle bulk.
- Gipovolemiya. At the expressed gipovolemiya there is an increase in a gematokrit, the level of fabric perfusion decreases, there are developments of stagnation. All this becomes the reason of formation of large fatty drops in blood system. Dehydration develops at long vomiting, diarrhea, the insufficient use of drinking water in the conditions of hot climate, excessive reception of diuretics.
According to the classical theory, a fatty embolism - result of direct hit of parts of marrow in a blood-groove at the time of getting injured. Further globula with current of blood extend in an organism. At the size of particles> 7 microns they cause obstruction of pulmonary arteries. Small drops of fat pass lungs and get into blood network of a brain. There is a cerebral symptomatology. There are also other assumptions concerning process development mechanisms.
According to statements of supporters of the biochemical theory, directly at getting injured and after it the plasma lipase becomes more active. It becomes an incentive for an exit of fats from places of deposition, the giperlipidemiya develops, there is a formation of rough fatty drops. The colloidal and chemical version is that the dezemulgation of fine emulsions begins because of delay of a blood-groove in the struck zone.
Follows from the hyper coagulative theory that disorder of microcirculation, a gipovolemiya, oxygen starvations is the reason of formation of fatty drops. There is a formation lipidic with a diameter of 6-8 microns which create a basis for disseminirovanny intra vascular folding. Process continuation - a system kapillyaropatiya which leads to a liquid delay in lungs and endointoxication products of lipidic exchange.
The fatty embolism can proceed in the pulmonary, cerebral or mixed option. The respiratory form develops at primary occlusion of branches of a pulmonary artery and is shown in the form of respiratory insufficiency. A cerebral version – result of obstruction of arteries and , providing blood supply of a brain. The mixed form is the most widespread and includes signs of both pulmonary, and cerebral defeat. The period before emergence of the first symptoms varies over a wide range. On time of a latent interval distinguish the following forms of a disease:
- Lightning. Demonstrates directly after a trauma, differs critically in a rapid current. The death of the patient comes within several minutes. Mortality at similar option of an embolism is close to 100% since rendering the specialized help in so short terms is impossible. Meets only at multiple or massive injuries. Emergence frequency – no more than 1% of cases of ZhE.
- Sharp. Arises less than in 12 hours from the moment of receiving damages at 3% of patients. Is a zhizneugrozhayushchy state, however the lethality does not exceed 40-50%. Death comes from hypostasis of lungs, sharp respiratory insufficiency, an extensive ischemic stroke.
- Subsharp. It is shown within 12-24 hours at 10% of patients; in 24-48 hours – at 45%; 48-70 hours later – at 33% of victims. Cases when symptoms of an embolism developed in 10-13 days are known. The current of subsharp forms rather easy, the number of the dead does not exceed 20%. Chances of survival increase if symptoms of a disease develop when finding the patient in a hospital.
Symptoms of a fatty embolism
Pathology is shown by a number of nonspecific symptoms which can arise also at other states. Occlusion of pulmonary vessels leads to emergence of feeling of constraint in a thorax, pains behind a breast, concerns. Objectively at the patient short wind, the cough which is followed by a blood spitting, foam from a mouth, pallor, sticky cold sweat, concern, fear of death, comes to light. There is persistent tachycardia, premature ventricular contraction squeezing heartaches. Development of fibrillation of auricles is possible. Changes from respiratory system occur at 75% of patients and are the first symptoms of pathology.
The neurologic symptomatology turns out to be consequence of a cerebral embolism: spasms, violation of consciousness up to a stupor or a coma, a disorientation, severe headaches. Aphasia, apraxia, an anizokoriya can be noted. The picture reminds that at a craniocereberal trauma that considerably complicates diagnostics. Development of paralyzes, paresis is possible, local loss of sensitivity, a paresteziya, decrease in a muscular tone takes place.
At a half of patients petekhialny rash in axillary hollows, on shoulders, a breast, a back comes to light. Usually it occurs in 12-20 hours since emergence of signs of respiratory insufficiency and testifies to restretching of capillary network of an embolama. At survey of an eye bottom of the patient injury of a retina is found. The hyperthermia at which body temperature reaches 38-40 °C develops. It is caused by irritation of the thermoregulatory centers of a brain fatty acids. Traditional febrifugal medicines at the same time are inefficient.
Help to patients with ZhE has to be given the first minutes from the moment of development of signs of vascular occlusion. Otherwise the fatty embolism leads to development of complications. Respiratory insufficiency terminates in alveolar hypostasis at which pulmonary bubbles are filled with liquid, propotevayushchy of the blood course. At the same time gas exchange is broken, blood oxygenation level decreases, the metabolism products which normal are removed with the exhaled air collect.
Obturation of a pulmonary artery fatty globula leads to development of right ventricular insufficiency. Pressure in pulmonary vessels increases, the right departments of heart are overloaded. At such patients arrhythmia, trembling and blinking of auricles comes to light. Sharp right ventricular insufficiency, as well as lung hypostasis, are zhizneugrozhayushchy states and in many cases lead of the patient to death. It is possible to prevent similar succession of events only at the most bystry assistance.
The intensivist, and also consulting physicians takes part in diagnosis of embolisms of a lipidic origin: cardiologist, pulmonologist, traumatologist, ophthalmologist, radiologist. Considerable value directed by the correct diagnosis is played by data of laboratory researches. ZhE has no patognomichny signs therefore its lifetime identification happens only in 2,2% of cases. For definition of pathology the following methods are used:
- Objective inspection. The clinical picture corresponding to a disease, heart rate more than 90-100 beats per minute, breath frequency – more than 30 times a minute comes to light. Breath is superficial, weakened. In lungs damp krupnopuzyrchaty rattles are listened. The indicator of SpO2 does not exceed 80-92%. A hyperthermia within febrilny values.
- Electrocardiography. On the ECG the deviation of an electric axis of heart to the right, nonspecific changes of a segment of ST is registered. Amplitudes of teeth of P and R increase, the negative tooth of T in certain cases meets. Signs of blockade of the right leg of a bunch of Gis can be found: expansion of a tooth of S, change of a form of the QRS complex.
- X-ray analysis of lungs. In pictures the diffusion infiltrates of pulmonary fabric on both sides prevailing on the periphery are looked through. Transparency of a pulmonary background decreases in process of increase of hypostasis. Emergence of the level of liquid demonstrating existence of a pleural exudate is possible.
- Laboratory diagnostics. A certain diagnostic value has identification in plasma lipidic 7-6 microns in size. It is more preferable to take away biomaterial from the main artery and the central vein. The research of environments from both pools is conducted separately. Identification increases risk of development of occlusion, however does not guarantee its emergence.
Differential diagnostics is carried out with other types of embolisms: air, thrombembolia, obturation of vessels tumor or foreign matter. Distinctive feature of ZhE is existence in blood of microdrops of fat in combination with the corresponding radiological and clinical picture. At other types of vascular occlusion lipidic globula in blood are absent.
Treatment of a fatty embolism
Therapy is performed by conservative medicamentous and non-drug methods. For delivery of health care of the patient place in intensive care unit and intensive therapy. All medical actions divide on specific and nonspecific:
- Specific. Are directed to a dezemulgation of fats, correction of work of the curtailing system, ensuring adequate gas exchange. For the purpose of oxygenation of the patient intubirut and transfer to artificial ventilation. For synchronization with the device introduction of sedatives in a complex with miorelaksant of peripheral action is allowed. Restoration of a normal consistence of lipidic fractions is reached by use of essentsialny phospholipids. For prevention of hyper coagulation heparin is entered.
- Nonspecific. Carry a detoxication by means of infusional therapy to number of nonspecific techniques. Prevention of bacterial and fungal infections is carried out by prescription of antibiotics, nystatin. As antimicrobic and metabolic means sodium hypochlorite is applied. Since 2 days to the patient appoint parenteral food with the subsequent translation on probe enteralny.
Experimental method of treatment use of blood substitutes on the basis of Volga federal district connections is considered. Medicines improve haemo dynamics indicators, restore normal rheological properties of blood, promote reduction of the size of lipidic particles.
Forecast and prevention
At a subsharp current the fatty embolism has the favorable forecast. In due time given help allows to stop the pathological phenomena, to provide necessary perfusion in vitals, to gradually dissolve embola. At sharp option of a disease the forecast worsens to adverse. The lightning current leads to death of the patient practically in 100% of cases.
Prevention during operations consists in application of low-traumatic techniques, in particular the chreskozhny spoke osteosynthesis which is carried out in the delayed order. It is recommended to refuse use of skeletal extension as this method does not provide the situation of stability of otlomk and can lead to development of a late embolization. Before hospitalization the most bystry stop of bleeding at its existence is required, an adequate analgeziya, maintenance of level HELL at the normal physiological level. A specific method is introduction of ethyl alcohol for 5% glucose solution.