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Case Report *Corresponding author Sophie Rym Hamada, Department of Anesthesia and Critical Care, Bicêtre University Hospital, 78 rue Cardiac Arrest as an Uncommon du Général Leclerc, 94275 Le Kremlin Bicêtre, France, Tel : 331-452-134-41; Fax : 331-452-120-13; Email:

Presentation of Fat Submitted: 27 September 2016 Accepted: 07 November 2016 1 2 Sophie Rym Hamada *, Dominique Cazal Hatem , Nora Ait Published: 09 November 2016 Hamou3 and Jean Mantz4 Copyright © 2016 Hamada et al. 1Department of Anesthesia and Critical Care, Bicêtre University Hospital, France 2Departement of Anatomopathology, Beaujon University Hospital, France OPEN ACCESS 3Departement of Anesthesia and Critical Care, Pitié Salpetriere Hospital, France 4Departement of Anesthesia and Critical Care, Georges Pompidou European Hospital, Keywords • Fat embolism France • Engraftment • Cardiac arrest Abstract • Fractures Fat Embolism Syndrome has been recognized for over 100 years but considerable controversy remains as to its incidence and clinical significance. We report here the case of a 38 years old female patient with several risk factors of fat embolism including fractured ribs, complex fracture of the humerus, morbid obesity, osteopenia and rough transportation. She presented a cardiac arrest with post mortem examination showing intra-cardiac fixation of fatty hematopoietic tissue. This is the first case report of such a presentation of fat embolism syndrome.

CASE PRESENTATION A 38 year-old woman was admitted to emergency department echogenicity but the intensivist who performed the examination did not notice any abnormality. Rapid hemodynamic recovery enabled to discontinue sedation on day 15. After a week, the in Tunisia following a road traffic accident. She was diagnosed patient remained comatose (Glasgow Scale 3) and EEG four rib fractures and a distal complex closed fracture of the recordings were flat. The dosage of benzodiazepine, barbiturics left humerus (Figure 1A,B).2 She had a history of morbid obesity and morphine were negative. This clinical exam was compatible (Body Mass Index 42 kg/m ), fibromyalgia and osteopenia since with brain death (secondary to cardiac arrest). Nevertheless, her last pregnancy. Operative treatment was indicated. Whilst in the meantime the patient presented a ventilation-acquired intramedullary nailing of the humerus was being performed, and a progressive refractory hypoxemia leading to she demonstrated sudden severe hypotension requiring her death on day 24 because of withholding of life sustaining vasopressive support. Surgery was immediately stopped. The therapies. patient was admitted with unfixed fracture to (ICU). On day 9, the patient was transferred to our ICU in Post-mortem examination was performed on day 26. It France. She was still under but she was off showed no thrombotic but a 4 cm wide vasopressive support. Completion of surgical repair was delayed yellow engraftment of embolised marrow to the right auricular because of local septic condition. On day 13, the patient was fully wall and tricuspid valve (Figure 1C). Microscopic examination alert and ready to be extubated. She suddenly presented extreme showed blood coagulation material mixed with multiple nests bradycardia immediately followed by asystole. Mechanical cause of haematopoietic cells from the three lineages (Figure 1D). The of hypoxemia (accidental extubation, ventilation circuit, tube post-mortem examination did not mention any other evidence obstruction…) and electrolytic disorders were rapidly ruled out. for fat or marrow deposition in other area. After 25 minutes of unsuccessful cardio-pulmonary , Fat Embolism Syndrome (FES) has been recognized for pulmonary embolism was suspected and a 50 mg intravenous over 100 years but considerable controversy remains as to bolus of alteplase was administrated. Five minutes later, she its incidence and clinical significance. It has been reported demonstrated return of spontaneous circulation. Post-cardiac as a clinical, biological and radiological syndrome due to Fat arrest required continuous adrenalin infusion. Neither Embolism (FE) characterised by the release of fat into systemic the electrocardiogram nor the Computed Tomography (CT) circulation [1]. FE is found in approximately 90% of post-mortem pulmonary angiogram showed any evidence of primary cardio- examination in trauma patients [2], whereas only 5% of trauma pulmonary cause of asystole. Cerebral CT scan ruled out cerebral patients demonstrate FES [1]. cause and bacteriological investigations remained negative. Transthoracic echocardiography was difficult because of poor FE is mostly observed after trauma to the fat-containing bony Cite this article: Hamada SR, azal Hatem D, Hamou NA, Mantz J (2016) Cardiac Arrest as an Uncommon Presentation of Fat Embolism. Arch Emerg Med Crit Care 1(3): 1014. Hamada et al. (2016) Email:

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derived conglomerate was hypothesised to be secondary to multiple fat and bone marrow embolism from ribs and humerus andfractures leading and to resulting cardiac arrest coagulation. activation [6]. The formed auricular was potentially blocking the tricuspid valve Our hypothesis is supported by the fact that spontaneous circulation was restored shortly after thrombolytic therapy. We cannot exclude that FE may have been caused by chest compressions of fractured ribs, but in that case, inaugural cardiac arrest would remain unexplained. We also think that early intraoperative severe hypotension observed in the OR operating room might have been the first symptom of FE. We did not find any skin rash or conjonctival signs of FES. Nevertheless, the pulmonary CT scan performed after the cardiac arrest showed bilateral pleural effusion with posterior passive consolidations associated to ground glass opacities predominantly on the right lung. This could be correlated to the clinical course of FES. So far there are no specific treatments for FES. Heparin and corticosteroids have been proposed as treatments but have not reliably demonstrated improved morbidity or mortality. In case of unexplained cardiac arrest during the management of trauma patients, the hypothesis of FE has to be considered. As the between FE and fibrino-cruoric embolism Figure 1 is clinically impossible, the treatment would be thrombolysis A. Complex fracture of the left humerus. CONCLUSIONwith the balance of all the underlying hemorrhagic risks. B. Chest Xray showing 4 rib fractures C. Post mortem examination showed a 4 cm solid fatty mural thrombus attached to the auricular wall and tricuspid valve and potentially occlusive at that location (arrows) We report here the first intra-cardiac fixation of fatty D. Microscopic examination found blood coagulation material mixed with fat hematopoietic tissue with fatal outcome. Early fixation of and multiple nests of bone marrow cells characterized by hematopoitic cells fractures remains probably the best prevention for such life- . from the three lineages (megakaryocyte, granulocyte, and erythroid island (H&E threateningREFERENCES condition. stains : D1 x25 and D2 x350)

1. Talbot M, Schemitsch EH. Fat embolism syndrome: history, definition, or soft tissues. Proper splinting and fixation of fractures should epidemiology. . 2006; 37: S3-7. not be delayed. So far, no other preventive measure can be 2. Riska EB, Myllynen P. Fat embolism in patients with multiple . recommended. Our patient had several risk factors of FE including J Trauma. 1982; 22: 891-894. fractured ribs, complex fracture of the humerus, morbid obesity, osteopenia and rough transportation (ground and air) [3]. 3. Tachakra SC, Potts D, Idowu A. Early operative fracture management of patients with multiple injuries. Br J Surg. 1990;77:1194. Engraftment of embolised marrow at ectopic or pulmonary 4. Bazargan A, Longano A, Moshinsky R, Opat S. Bone marrow sites is extremely rare in FE. Only one case of a patient with engraftment in pulmonary vessels. Br J Haematol. 2009;146: 2. isolated fracture of the humerus has been reported [4]. In our case, alternative aetiologies, such as myxoma, myeloproliferative 5. Wenda K, Ritter G, Ahlers J, von Issendorff WD. [Detection and effects of bone marrow intravasations in operations in the area of the femoral disorder or hematopoietic tumor (angiomyelolipoma), were ruled marrow cavity]. Unfallchirurg. 1990; 93: 56-61. out by histological analysis. Extramedullary hematopoiesis has been reported within myocardial tissue in patients with a history 6. Newbigin K, Souza CA, Armstrong M, Pena E, Inacio J, Gupta A, et al. Fat embolism syndrome: Do the CT findings correlate with clinical course of myocardial infarction [5], nevertheless this hypothesis would and severity of symptoms? A clinical-radiological study. Eur J Radiol. not explain the observations of our patient. The bone marrow- 2016; 85: 422-427.

Cite this article Hamada SR, azal Hatem D, Hamou NA, Mantz J (2016) Cardiac Arrest as an Uncommon Presentation of Fat Embolism. Arch Emerg Med Crit Care 1(3): 1014.

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