Postoperative complications of trauma surgery

A horse rider falls at a jump and sustains a closed head injury without impairment of

consciousness at any stage and a femoral shaft fracture, which is internally fixated with

an intramedullary nail soon after admission. At 48 hours post-injury she becomes

confused, tachypnoeic, hypoxaemic and pyrexial (38.2 °C). An atypical rash is also

noted. Which one of the following statements is MOST APPROPRIATE?

a) Immediately alert the orthopaedic surgeons

b) Based on these features, anticoagulation is indicated

c) Transfusion of packed red cells is indicated

d) A chest X-ray will contribute to resolving the situation

e) An urgent CT head scan is highest priority

Answer: D

Explanation

The question is written to give rise to suspicion of fat embolism syndrome. Remember,

however, that this is rare, and sensible exclusion of common, treatable diagnoses is

required. The characteristic rash is present in less than half of cases of fat embolism

syndrome and this diagnosis is less treatable than other differentials. Although the

patient’s orthopaedic team should be kept up to date, they will have little to contribute

currently. There is no mention as to the presence or absence of blunt chest trauma

during the accident, but at 48 hours a lower respiratory tract infection is a possibility, as

might be a slowly worsening pneumothorax. Immediate introduction of supportive

care and a prompt portable chest X-ray (and other basic investigations) will help work

towards a solution.

Red cell transfusion would be indicated for haemorrhage, or sometimes fat embolism,

but further investigation would be required in advance of this. Pulmonary

embolism is a possibility but again anticoagulation should not be initiated based on

these features. The history and chronology of the head injury prompts a low suspicion

of primary intracranial pathology, but the possibility of a secondary bleed must be

borne in mind. Beware any option that suggests that the ‘highest priority’ is anything

other than applying oxygen and instigating resuscitation measures.

Reference

Gupta A, Reilly C. Fat embolism. Contin Educ Anaesth Crit Care Pain 2007; 7(5): 148–51.