Acute Respiratory Distress

Syndrome, Fat Embolism, &

Thromboembolic Disease in the
Orthopaedic Trauma Patient

Steve Morgan, MD & Scott Adams, MD

Original Authors: Steve Morgan, MD; March 2004;
New Authors: Steve Morgan, MD & Scott Adams, MD;
Revised January 2007 and November 2011
 Objectives
• Define • Understand
– ARDS – Prevention
– FES – Diagnosis
– Thromboembolic Disease – Treatment
– Outcomes
• Understand Etiology &
Physiology of each
Condition
 ARDS
Acute Respiratory Distress Syndrome

• Acute respiratory failure in the post traumatic

period characterized by a decreased PaO2 and
a diffuse and often massive extravasations of
fluid from the pulmonary vasculature to the
interstitial space of the lungs.
 ARDS Clinical Definition
– Acute onset of symptoms

– Ratio of PaO2 to FIO2 of 200 mm Hg or less

– Bilateral infiltrates on CXRs

– Pulmonary arterial wedge pressure of 18 mm Hg or less

or no clinical signs of left atrial hypertension

– American-European Consensus Conference (AECC) on ARDS, 94

 ARDS
• Incidence 5% – 8% after polytrauma
– Much lower in isolated fracture

• Mortality up to 40%

• Uncommon in Children and the Elderly

 ARDS
Common Causes
• Trauma • Pulmonary Edema
• Massive Transfusion • Prolonged LOC
• Embolism • Cardiopulmonary
• Sepsis Bypass
• Aspiration • Pancreatitis
• Abdominal Distension • Major Burns

MULTIFACTORAL
 ARDS Etiology
• ARDS related to MODS

Trauma Inflammatory Organ

Mediators Injury

• Release of inflammatory mediators results

in organ dysfunction
 ARDS
PATHOPHYSIOLOGY
• Systemic • Alveolar Collapse
Inflammatory • Decreased Pulmonary
Mediators Compliance
• Damage to Endothelial • Ventilation Perfusion
Lining Abnormalities
• Increased Capillary • Arteriolar Hypoxemia
Permeability
• Fluid Extravasation
 ARDS

Chest Radiograph Autopsy Specimen

ARDS Chest CT Scan
 ARDS
Prevention
• Limiting Blood Loss
• Decreasing Transfusion
Requirements
• Early Stabilization Of
Unstable Fractures
• Early Prophylactic
Mechanical Ventilation
Temporary Ex-Fix For Stabilization
 ARDS
Treatment
• Ventilator Support
– Acceptable ABG’s
– Avoid further alveolar damage
• Toxic FIO2
• Barotrauma
• General Organ Support
• Research
– Optimal ventilator settings
– Pharmalogical agents
 ARDS
Outcome

• Significant Cause of Mortality

• Major Cause of Death in Patients with the
Lowest ISS scores
• 30% - 40% Mortality Rate
– Mortality Rate Slowly Decreasing with
Changing & Improving Therapy
 Fat Embolism Syndrome
(FES)
• A condition characterized by hypoxia,
confusion and petechiae presenting soon
after long bone fracture and soft tissue
injury.

• Diagnosis of Exclusion
 FES
• Often Placed in the Category of ARDS
– May share common pathological pathways

• R/O other Causes of Hypoxia & Confusion

• Index Patient
– young adult with isolated LE injury seen after long
transfer with no supporting therapy or splintage.
 FES
• Occurs in 0.9 – 8.5% of all fracture patients

• Up to 35% of the multiply injured

• Mortality 2.5%

• Rare in upper limb injury and children

 Etiology
• The likely pathogenetic reaction of lung tissue to
shock, hypercoagulability and lipid metabolism

• Mechanical Theory

• Biochemical Theory
 Mechanical Theory
• Fracture Liberates Fat

• Intravasation - Fat Enters Venous System

• Fat Causes Mechanical Obstruction

 Mechanical Theory
FES To Brain On MRI
• Systemic Fat Embolization

– Patent Foramen Ovale

– Pulmonary Pre-Capillary
Shunts

– Skin petechiae, CNS signs

 Biochemical Theory
• Neutral Fat and Chemical Mediators
Released at Time of Fracture

• Neutral Fat Metabolized by Lipases releases

Free Fatty Acids

• Free Fatty Acids Result in Endothelial Lung

Damage
 FES Diagnosis

• Major Criteria • Minor Criteria

– Hypoxemia – Tachycardia
– CNS Depression – Pyrexia
– Petechial Rash – Retinal Emboli
– Pulmonary Edema – Fat in Urine
– Fat in Sputum
– Thrombocytopenia
– Decreased Hematocrit

Gurd et al
 FES Diagnosis
• Gurd & Wilson Criteria

• At least 1 Major Sign

• 4 Minor Signs

Gurd et al
 FES Prevention

• Appropriate
Splinting

• Early Fracture
Stabilization

• Oxygen Therapy
 FES Prevention
• Therapies
– Fluid Loading
– Hypertonic Fluid
– Alcohol
– Heparin
– Dextran
– Aspirin

• None Shown to be Effective

 FES Treatment
• Supportive

– Oxygen Therapy to maintain PaO2

– Mechanical Ventilation

– Adequate Hydration
 FES Treatment Steroids
• Steroids
– Decrease endothelial damage
– 30mg/kg initial dose repeated @ 4 Hours, 1gm
dose repeated @ 8 Hours: Total 3 Doses

• Complications - Frequent
– Infection
– GI
• Steroid Therapy Avoided Secondary To Poor Risk
Benefit Ratio
 Systemic Effects of Trauma
Second Hit in susceptible patients

ARDS
Post Injury MODS
Inflammatory Threshold
Response in
2 Patients

24 hours 48 hours
Injury (First Hit)

IM Nailing as a Cause of Secondary Systemic Injury

 Fracture Fixation Technique
-Controversial-
• Early Total Care • Damage Control
– Definitive Early – Temporary Stability
Fixation • External Fixator
• Nail or Plate – Limit Further Blood
Loss
– Limit Anesthetic Time
– Delay Definitive
Fracture fixation
 Effect of IM Nailing
• Increased IM Pressure
• Embolic Showers On Echocardiograms
• Caused by
– Canal Opening
– Reaming
– Nail Insertion (both reamed & unreamed)
 Fracture Fixation Technique
-Controversial-
• IM Nail - Reamed vs Un-Reamed
– Decreased with Unreamed Technique
• Pape et al

– No Difference
• Keating et al
• Canadian OTS

• IM Nail Reamed vs Plate Osteosynthesis

– No Difference In Pulmonary Dysfunction
• Bosse et al
 DVT Incidence

• DVT occurrence
60% if ISS >9.
• 35%-60% DVT in
pelvic fracture
• PE-Most common
preventable cause of
death in trauma.
Virchow Triad
 Hypercoaguability
• Tissue Thromboplastin
• Activated Procoagulants
• Decreased Fibrinolytic Activity
• Ineffective Heparin Clearance of Activated
Clotting Factors
• Catecholamine Release
 Endothelial Injury
• Direct Trauma to Vein at time of Injury
• Compression of the Vein Secondary to
Fracture Position
• Vein Manipulation at Time of Fracture
Fixation
 Venous Stasis
• Immobilization
• Hypotension
• Venous Occlusion
– Edema
– Fracture Position
• Tourniquet
 DVT Prevention
Goals
• Clinically significant events
– PE
– Post Thrombotic syndrome
• Low Complication Rate
• High Compliance Rate
• Cost Effective
 DVT Prevention
Mechanical
Non Pharamcologic

Pneumatic Elastic
Compression Stockings
Vena Cava
Filter
 DVT Prevention
Pharamcologic Pentasacharides

Unfractionated Elastic
Heparin Stockings
LMWH Warfarin
Heparin Oral
Anticoagulants
 Prophylaxis
• Elastic Stockings • Pentasaccharide
• Mechanical • Low Molecular
Compression Weight Heparin
Devices • Heparin
• Early Mobilization • Aspirin
• Warfarin
• IVC Filter (PE Prophylaxis)
 Mechanical Methods
• Activity
• Compression
Stockings
• Sequential
Compression Device
• Pedal Pumps
Mechanism of Action
• Decrease Stasis
•  Fibrinolytic Activity
 IVC Filter Indications
• Anticoagulation
Prohibited
• High Risk Patients
• DVT Prior to
Necessary Surgery
• PE Despite
Anticoagulation
 IVC Filter
Advantages Disadvantage
• Prevents Major PE • Expensive
• Low Morbidity • Invasive
– 96% Patent • Does not treat DVT
– 8% Migration • Venous Insufficiency
– 4% PE • Filter Occlusion
• Filter insertion in the
ICU
 ACCP Recommendation on Vena
Cava Filter

• No Recommendation
for Vena Caval Filter
 Pentsaccharide
• Selective Inhibitor of Activated Xa
– Decreased DVT rate with no change in major
bleeding rate compared to LMWH
• Eriksson B I et al N Engl J Med 2001

– Increased risk of minor bleeding

• Delay administration for several hours after surgery
and removal of epidural catheter
 Low Molecular Weight Heparin
(LMWH)
• Potentiates Antithrombin III
• Inhibits Factor Xa & II
• Minimal effects on other Factors
 LMWH
Advantages Disadvantage
• No Monitoring • Parenteral
Administration
• Increased Efficacy
• Cost
• Longer 1/2 life
• Predictable
Response
• Lower risk of
thrombocytopenia
 Heparin
• Heparin Potentiates Anti-Thrombin III
Activity
• Complex Inhibits
– Thrombin (IIa), IXa, Xa
• Heparin effect relative short duration
– Reversed with Protamine Sulfate
• Significant hemorrhage risk
 SQ Heparin
Advantages Disadvantage
• Low Cost • Insufficient
• No Monitoring Efficacy in High
• Convenient Risk Patients
• Relatively Low • Unpredictable
Incidence of Responses
Bleeding • Heparin Induced
Thrombocytopenia
 Aspirin
Advantages Disadvantage
• Oral Administration • ? Efficacy when used
• Tolerated well alone
• In-expensive • GI Intolerance
• No Monitoring • Prolonged anti-platelet
effect
 Aspirin
• Inhibits cyclooxygenase
• Decreases Platelet Adherence

• ? Effectiveness in Musculoskeletal Trauma

– Venous clots not typically found to have
Platelet aggregates
ACCP Recommendation on Aspirin

• No Recommendation
For The Use of
Aspirin

• Recommend Against
The Use of Aspirin
For Any Indication
 Warfarin
• Blocks Vit K conversion in Liver
• Effects Vit K Dependent Factors
• Effects the Extrinsic Clotting System
• Factor VII Effected first, Short Half Life
• Monitored with Pro-Time
– INR 2.0-2.5
• Reversed With Vitamin K or FFP
 Warfarin
Advantages Disadvantage
• Effective • Requires Monitoring
• Oral Administration • Difficult to Reverse
• Inexpensive • Increased Bleeding
Complications in
Elderly
 EAST Guidelines
• Guidelines based on
qualitative review of the
current scientific literature
improve uniformity of
opinion and prescribing
practices
– Watts JBJS B 05
• Risk Factors
• Level I Evidence – Major
Significance
– Spinal Fracture
– Spinal Cord Injury
• Level II – No Major
Significance
– Advanced Age
– ISS Score
– Blood Transfusion
– Long Bone, Pelvis, Head
Injury
 ACCP Guidelines
• Guidelines based on
qualitative review of the
current scientific literature
improve uniformity of
opinion and prescribing
practices
– Watts JBJS B 05
• Risk Factors
• Level I Evidence – Major
Significance
– Spinal Cord Injury
– Major Trauma
– Hip Fractures
– Complex Lower-extremity
Fracture
– Pelvic Fracture
– Prolonged Immobility
– Delay in Commencement Of
Thromboprophylaxis
 ACCP Guidelines on Hip
Fractures

• Recommend Routine
Thromboprophylaxis

• Fondaparinux
• LMWH
• Warfarin (INR 2.5)
• LDUH
 ACCP Guidelines on Spinal
Cord Injury
• Recommend Routine
Thromboprophylaxis

• LMWH Once
Hemostasis Obtained

• IPC and/or GCS

– While Obtaining
Hemostasis
 ACCP Guidelines on Isolated
Injuries Distal To The Knee

• No Routine
Thromboprophylaxis
Duration of Prophylaxis
 ACCP Guidelines Duration of
Therapy Hip Fractures

• 10 to 35 Days

• Agents
– LMWH
– Fondaparinux
– Warfarin
 ACCP Guidelines on Duration of
Therapy for Trauma Patients

• Up to Hospital
Discharge

• Agents
– LMWH
– Fondaparinux
– Warfarin
 ACCP Guidelines Length of
Prophylaxis
Trauma Population
• Exception
– Impaired mobility
who undergo
inpatient
rehabilitation
– Thromboprophylaxis
– LMWH
– Warafarin INR, 2.5
 DVT screening
• Physical Exam
• Ascending venography
• Duplex Ultrasonography
• Magnetic Resonance Venography
 Physical Examination
• Calf Swelling
• Palpable Venous Cords
• Calf Pain
• Homan’s Sign

• All Unreliable
 Ascending Contrast Venography
• Sensitive for detection
• Invasive
• Dye Problems
(allergies, renal)
• Injection Site Irritation
• Poor Pelvic Vein
Evaluation

• Gold Standard
*Invasiveness,expense make ACV a poor screening tool
 Doppler/Duplex Ultrasound
• Comparable to Venogram
• Non Invasive
• No Morbidity
• Poor Axial (i.e Pelvic)
Vein Evaluation
• Operator Dependent
• Good Screening Tool
– Noninvasive, reproducible
 Magnetic Resonance Venography
• Non Invasive
• Good Visualization of
Pelvic Veins
• Difficult in Polytrauma
Patient
• Excellent specificity and
sensitivity for suspected
DVT
• Controversial for screening
 Pulmonary Embolism
Clinical
Shortness of breath, agitation, confusion
Laboratory
 PaO2,  A-a gradient
Diagnostic studies
V/Q scans
Pulmonary Angiogram, CT PA
 Ventilation Perfusion Scan
• Ventilation Perfusion mismatch
• Results
– Low probabiltity
• 15% False Negative
– Medium
• Need Angiogram
– High probability
• 15% False Positive
• Screening Tool
 Pulmonary Angiogram
• Angiographic Evaluation of
pulmonary vascular tree

• Allows Placement of IVC

Filter in same setting if
indicated

• Sensitive - Standard in PE
Detection. Diagnostic
 Treatment PE
• Anticoagulation

• Filter for recurrent

event despite
anticoagulation

• Thrombectomy
– Serious Acute PE
– Patient in extremous
– Large identifiable PE
 Treatment DVT/PE
• Heparin • LMWH / Pentasaccharide
– Bolus 10-15K units – Mass related dose SQ inj
– Continuous Infusion – Single daily dose
• 1000Units/Hr – No monitoring necessary
– Goal  PTT 2x Control – Discontinue when
• Prevent Clot Therapeutic on Warfarin
propagation and
recurrent PE
– Discontinue when
Therapeutic on Warfarin
 Treatment DVT/PE
• Warfarin
– INR 2.0-3.0
– 3-6 Month Duration
– Contraindicated in:
• Pregnancy
• Liver insufficiency
• Poor Compliance
– Prolonged Therapy may decrease recurrence rates
 DVT/PE Outcome
• No Diagnosis and Treatment
– 30% Mortality
• Correct Diagnosis and Therapy
– 11% Mortality in First Hour
– 8% Mortality After First Hour
 DVT/PE Outcome
• Post Thrombotic Syndrome
– Valvular Incompetence
– Venous Stasis
– Edema
– Cutaneous Atrophy

• Recurrent DVT
– 20% of Patients
 Bibliography FES/ARDS

• Gurd AR, Wilson RI Fat-embolism syndrome Lancet. 1972 Jul

29;2(7770):231-2
• Giannoudis PV, Pape HC, Cohen AP, Krettek C, Smith RM. Review: systemic
effects of femoral nailing: from Küntscher to the immune reactivity era. Clin
Orthop Relat Res. 2002 Nov;(404):378-86
• Bosse MJ, MacKenzie EJ, Riemer BL, Brumback RJ, McCarthy ML, Burgess
AR, Gens DR, Yasui Y. Adult respiratory distress syndrome, pneumonia, and
mortality following thoracic injury and a femoral fracture treated either with
intramedullary nailing with reaming or with a plate. A comparative study. J
Bone Joint Surg Am. 1997 Jun;79(6):799-809
• Canadian Orthopaedic Trauma Society.Reamed versus unreamed
intramedullary nailing of the femur: comparison of the rate of ARDS in
multiple injured patients. J Orthop Trauma. 2006 Jul;20(6):384-7
 Bibliography DVT/PE

• Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR,
Colwell CW; American College of Chest Physicians Prevention of venous
thromboembolism: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6
Suppl):381S-453S

• Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA Practice

management guidelines for the prevention of venous thromboembolism in
trauma patients: the EAST practice management guidelines work group. J
Trauma. 2002 Jul;53(1):142-64

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