O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.
FAT EMBOLISM SYNDROME(FES)
DR AFTAB HUSSAIN
History
First diagnosed in 1873 by Dr Von Bergmann
In 1879 Fenger and Salisbury published description of
Fat embolism sy...
Fat Emboli: Fat particles or droplets that
travel through the circulation
Fat Embolism: A process by which fat
emboli pass...
FE vs. FES
Fat embolization is a well-known complication of
skeletal trauma and surgery involving
instrumentation of the ...
Fat Embolism Syndrome
Mortality: 10-20%
Clinical diagnosis, No specific laboratory test is
diagnostic.
Mostly associate...
Causes of fat embolism
TRAUMA RELATED:
Blunt trauma: Long bone (Femur, tibia, pelvic) factures
orthopedic procedures
Sof...
NON TRAUMA RELATED
Pancreatitis
Diabetes mellitus
Osteomyelitis and panniculitis
Bone tumor lysis
Steroid therapy
Si...
Most common cause of FES is blunt trauma.
90 % occursafter blunt trauma complicated by long-
bone fractures
Closed frac...
Non-traumatic fat embolism
It occurs due to the process of fat or marrow necrosis
or by the increased concentration of li...
Drug-related causes of FES
 Infusion of lipids at rates greater than the normal
clearance capacity of lipids.
 Agglutina...
FES can occur in SC
crisis.
Bone marrow necrosis
as a result of hypoxia
may release fat.
Risk factors
Pathophysiology of FES
Exact mechanism unknown, but two main hypothesis
1. Mechanical Hypothesis
2.Biochemical Hypothesis
Mechanical Hypothesis
Obstruction of vessels and capillaries
Increase in inter medullary pressure forces fat and
marrow i...
Smaller fat droplets travel through the pulmonary
capillaries into the systemiccirculation: Embolization to
cerebral vess...
Biochemical Hypothesis
Toxicity of free fatty acids
Circulating free fatty acids directly affectthe
pneumocytes, producin...
 Hormonal changes caused by trauma or sepsis
induce systemic release of free fatty acids as
chylomicrons.
Acute-phase re...
FE in ARDS
Fat emboli obstructs
lung vessel (20microns),
platelets and fibrin
adhere to it
Lipase increases FFA
Inflamm...
CLINICAL FEATURES
Asymptomatic for the first 12-48 hours
Pulmonary Dysfunction
Neurological (nonspecific)
Dermatological S...
Pulmonary
Hypoxia, rales, pleural friction rub
ARDS may develop.
CXR usually normal early on, later may show
‘snowstorm...
Neurological findings
Usually occur after respiratory symptoms
Incidence- 80% patients with FES
Minor global dysfunctio...
Dermatological findings
Petechie
Usually on conjunctiva, neck, axilla, upper limbs.
Results from occlusion of dermal ca...
Early Signs
Dyspnea
Tachypnea
Hypoxemia
Triad of FES
Hypoxemia
Neurological abnormalities
Petechial rash
Other findings
Retinopathy (exudates, cotton wool spots,
hemorrhage)
Lipiduria
Fever
DIC
Myocardial depression (Right...
Diagnostic Criteria
Gurd criteria most
commonly used.
Other indexes are
Schonfeld Index
Lindeque Index
Gurd & Wilson Criteria
Schonfeld Fat Embolism Syndrome
Index
It ranks signs and symptoms of FES in relation to
their incidence of presentation.
...
Schonfeld FES Index
sign score
Petechial rash 5
Diffuse alveolar infiltrate 4
Hypoxemia pao2<70 mm Hg, FIO2-100% 3
confusi...
Lindeque's criteria
Acc. to Lindeque FES can be diagnosed on the basis
of respiratory system involvement alone.
Laboratory Studies
 Arterial Blood Gases (ABGs)
Urine and sputum examination
Haemotological Tests
Biochemical tests
Imaging
• Chest x-ray
– shows multiple flocculent shadows (snow storm
appearance). picture may be complicated by infection...
Imaging contd.
MRI Brain
- Image showing minimal hypodense changes
in periventricular region, which are more evident in
D...
Treatment and management
Prophylaxis
Immobilization and early internal fixation of
fracture.
Fixation within 24 hours ha...
Supportive Medical Care
Maintenance of adequate oxygenation and ventilation
Maintenance of hemodynamic stability.
Admin...
Treatment and management contd.
Oxygenation and ventilation
 High flow rate oxygen is given to maintain the
arterial oxyg...
Treatment and management contd.
Hemodynamic stability
Maintenance of intravascular volume is important,
because shock can...
Steroids
Steroid prophylaxis is controversial to prevent FES.
It causes blunting of inflammatory response and
complement...
Results of Randomized, Controlled Trials of Corticosteroids for Prevention of Fat
Embolism Syndrome
Dose Model Timing Dura...
Heparin
Heparin has also been proposed for treatment as it
"clears" lipemic plasma in vivo by causing the release
of lipo...
Prognosis
The fulminant form presents as acute cor pulmonale,
respiratory failure or embolic phenomena, leading to
death ...
The incidence of FES ranges from < 1 to 29% in
different studies.
 Actual incidence of FES is not known, as mild cases
o...
Refrences
Altaf Hussain: “A Fatal Fat Embolism.” The Internet Journal of Anesthesiology,
2004. Volume 8 Number 2.
Fabian T...
THANK YOU
Próximos SlideShares
Carregando em…5
×

Fat embolism syndrome

19.717 visualizações

Publicada em

Fat embolism syndrome, management, prevention

Publicada em: Saúde e medicina
  • Check out your Transcript here  http://t.cn/AirVsfPx
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • Hear The Angels Sing: Listen to this free musical composition to clear away all the negativity in your life and welcome in miracles! Download your complimentary "Angel Soundscape" now. ●●● https://tinyurl.com/y6pnne55
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy &amp; Proven Way to Build Good Habits &amp; Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy &amp; Proven Way to Build Good Habits &amp; Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download Full doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download PDF EBOOK here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download EPUB Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... Download doc Ebook here { http://bit.ly/2m6jJ5M } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy &amp; Proven Way to Build Good Habits &amp; Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui

Fat embolism syndrome

  1. 1. FAT EMBOLISM SYNDROME(FES) DR AFTAB HUSSAIN
  2. 2. History First diagnosed in 1873 by Dr Von Bergmann In 1879 Fenger and Salisbury published description of Fat embolism syndrome
  3. 3. Fat Emboli: Fat particles or droplets that travel through the circulation Fat Embolism: A process by which fat emboli passes into the bloodstream and lodges within a blood vessel. Fat Embolism Syndrome (FES): serious manifestation of fat embolism occasionally causes multi system dysfunction, the lungs are always involved and next is brain
  4. 4. FE vs. FES Fat embolization is a well-known complication of skeletal trauma and surgery involving instrumentation of the femoral medullary canal.  Fat embolism syndrome (FES) is a physiological response to fat within the systemic circulation. Fat embolization and FES are not synonymus. The embolization of fat can be detected in almost all patients who sustain a pelvic or femoral fracture, but the incidence of FES is less than 1%.
  5. 5. Fat Embolism Syndrome Mortality: 10-20% Clinical diagnosis, No specific laboratory test is diagnostic. Mostly associated with long bone and pelvic fractures, and more frequent in closed fractures. Single long bone fracture has 1-3% chance of developing FES, and increases with number of fractures. Onset is 24-72 hours from initial insult.
  6. 6. Causes of fat embolism TRAUMA RELATED: Blunt trauma: Long bone (Femur, tibia, pelvic) factures orthopedic procedures Soft tissue injury(chest compression with or without rib fracture) Burn Liposuction Bone marrow harvesting and transplant.
  7. 7. NON TRAUMA RELATED Pancreatitis Diabetes mellitus Osteomyelitis and panniculitis Bone tumor lysis Steroid therapy Sickle cell hemoglobinopathy Alcoholic liver disease Fat infusion
  8. 8. Most common cause of FES is blunt trauma. 90 % occursafter blunt trauma complicated by long- bone fractures Closed fractures had higher incidence compared to open fractures. The intramedullary bone pressure is lower in case of open fractures, which reduces the bulk of fat emboli propelled into the blood stream.
  9. 9. Non-traumatic fat embolism It occurs due to the process of fat or marrow necrosis or by the increased concentration of lipids in the blood. It may be caused by agglutination of chylomicrons and VLDL by high levels of plasma CRP. As in Acute pancreatitis in patients with types I, IV, and V hyperlipidaemia and avascular necrosis of bone in patients with corticosteroid-induced hyperlipidaemia.
  10. 10. Drug-related causes of FES  Infusion of lipids at rates greater than the normal clearance capacity of lipids.  Agglutination of lipid emulsion particles with fibrin. Agglutination of endogenous or infused exogenous fat such as Intra lipid.
  11. 11. FES can occur in SC crisis. Bone marrow necrosis as a result of hypoxia may release fat.
  12. 12. Risk factors
  13. 13. Pathophysiology of FES Exact mechanism unknown, but two main hypothesis 1. Mechanical Hypothesis 2.Biochemical Hypothesis
  14. 14. Mechanical Hypothesis Obstruction of vessels and capillaries Increase in inter medullary pressure forces fat and marrow into bloodstream. Bone marrow contents enter the venous system and lodge in thelungs as emboli.
  15. 15. Smaller fat droplets travel through the pulmonary capillaries into the systemiccirculation: Embolization to cerebral vessels or renal vessels also leads to central nervous system and renal dysfunction
  16. 16. Biochemical Hypothesis Toxicity of free fatty acids Circulating free fatty acids directly affectthe pneumocytes, producing abnormalities in gas exchange. Coexisting shock, hypovolemia and sepsis impair liver function and augment toxic effects of free fatty acids.
  17. 17.  Hormonal changes caused by trauma or sepsis induce systemic release of free fatty acids as chylomicrons. Acute-phase reactants( C-reactive proteins) cause chylomicrons to coalesce.  It explains non traumatic forms of fat embolism syndrome and why symptoms take 12 hours to develop.
  18. 18. FE in ARDS Fat emboli obstructs lung vessel (20microns), platelets and fibrin adhere to it Lipase increases FFA Inflammatory changes- >endothelial damage- >ARDS
  19. 19. CLINICAL FEATURES Asymptomatic for the first 12-48 hours Pulmonary Dysfunction Neurological (nonspecific) Dermatological Signs
  20. 20. Pulmonary Hypoxia, rales, pleural friction rub ARDS may develop. CXR usually normal early on, later may show ‘snowstorm’ pattern- diffuse bilateral infiltrates CT chest: ground glass opacification with interlobular septal thickening.
  21. 21. Neurological findings Usually occur after respiratory symptoms Incidence- 80% patients with FES Minor global dysfunction is most common-ranges from mild delirium to coma. Seizures/focal deficits Transient and reversible in most cases. CT Head: general edema, usually nonspecific MRI brain: Low density on T1, and high intensity T2 signal, correlates to degree of impairment.
  22. 22. Dermatological findings Petechie Usually on conjunctiva, neck, axilla, upper limbs. Results from occlusion of dermal capillaries by fat globules and then extravasations of RBC. Resolves in 5-7 days. Usually fast resolving. Pathognomic, but only present in 20-50% of patients.
  23. 23. Early Signs Dyspnea Tachypnea Hypoxemia
  24. 24. Triad of FES Hypoxemia Neurological abnormalities Petechial rash
  25. 25. Other findings Retinopathy (exudates, cotton wool spots, hemorrhage) Lipiduria Fever DIC Myocardial depression (Right heart strain) Thrombocytopenia/Anemia Hypocalcemia.
  26. 26. Diagnostic Criteria Gurd criteria most commonly used. Other indexes are Schonfeld Index Lindeque Index
  27. 27. Gurd & Wilson Criteria
  28. 28. Schonfeld Fat Embolism Syndrome Index It ranks signs and symptoms of FES in relation to their incidence of presentation. Score >5 required for diagnosis of fat embolism syndrome
  29. 29. Schonfeld FES Index sign score Petechial rash 5 Diffuse alveolar infiltrate 4 Hypoxemia pao2<70 mm Hg, FIO2-100% 3 confusion 1 Fever ( >100.4 F) 1 Heart rate >120 beats/min 1 Respiratory rate >30/min 1
  30. 30. Lindeque's criteria Acc. to Lindeque FES can be diagnosed on the basis of respiratory system involvement alone.
  31. 31. Laboratory Studies  Arterial Blood Gases (ABGs) Urine and sputum examination Haemotological Tests Biochemical tests
  32. 32. Imaging • Chest x-ray – shows multiple flocculent shadows (snow storm appearance). picture may be complicated by infection or pulmonary edema.
  33. 33. Imaging contd. MRI Brain - Image showing minimal hypodense changes in periventricular region, which are more evident in DWI and T2WI as areas of high signals.
  34. 34. Treatment and management Prophylaxis Immobilization and early internal fixation of fracture. Fixation within 24 hours has been shown to yield a 5 fold reduction in the incidence of ARDS. Continuous pulse oximeter monitoring in high- risk patients may help in detecting desaturation early, allowing early institution of oxygen and possibly steroid therapy. High doses of corticosteroids.
  35. 35. Supportive Medical Care Maintenance of adequate oxygenation and ventilation Maintenance of hemodynamic stability. Administration of blood products as clinically indicated. Hydration Prophylaxis of deep venous thrombosis . Nutrition. Treatment and management contd.
  36. 36. Treatment and management contd. Oxygenation and ventilation  High flow rate oxygen is given to maintain the arterial oxygen tension in the normal range.  Mechanical ventilation and PEEP may be required to maintain arterial oxygenation.
  37. 37. Treatment and management contd. Hemodynamic stability Maintenance of intravascular volume is important, because shock can exacerbate the lung injury caused by FES. Albumin has been recommended for volume resuscitation in addition to balanced electrolyte solution, because it not only restores blood volume but also binds with the fatty acids and may decrease extent of lung injury
  38. 38. Steroids Steroid prophylaxis is controversial to prevent FES. It causes blunting of inflammatory response and complement activation Prospective studies suggests prophylactic steroids benefit in high risk patients. Preoperative use of methylprednisolone may prevent the occurrence of FES Once FES established, steroids have not shown improved outcomes.
  39. 39. Results of Randomized, Controlled Trials of Corticosteroids for Prevention of Fat Embolism Syndrome Dose Model Timing Duration of study Effect on disease incidence 30mg/kg Dog Before event 60min None 10mg/kg q8h for 24 hrs Human trauma At admission No data Declining 7.5mg/kg q6h for 12hrs or placebo Human Trauma Within 12hrs 2 days Declining
  40. 40. Heparin Heparin has also been proposed for treatment as it "clears" lipemic plasma in vivo by causing the release of lipoprotein lipase into the circulation, but no evidence exists for its use in FES.
  41. 41. Prognosis The fulminant form presents as acute cor pulmonale, respiratory failure or embolic phenomena, leading to death within a few hours of injury. Most death contributed to pulmonary dysfunction Hard to determine exact mortality rate Estimated less than 10%
  42. 42. The incidence of FES ranges from < 1 to 29% in different studies.  Actual incidence of FES is not known, as mild cases often go unnoticed. A high index of suspicion is needed to diagnose FES. A combination of clinical criteria and MRI brain will enable early and accurate diagnosis of FES.
  43. 43. Refrences Altaf Hussain: “A Fatal Fat Embolism.” The Internet Journal of Anesthesiology, 2004. Volume 8 Number 2. Fabian T. “Unraveling the fat embolism syndrome”. N Engl J Med 1993;329:961– 63 U. Galway, J. E. Tetzlaff & R. Helfand : “Acute Fatal Fat Embolism Syndrome In Bilateral Total Knee Arthroplasty – A Review Of The Fat Embolism Syndrome”. The Internet Journal of Anesthesiology. 2009 Volume 19 Number 2 Latif, A., Bashir, A., Aurangzeb. "Fat Embolism and Fat Embolism Syndrome; Management Trends." Professional Med J 15.4 (2008): 407-413. Harrisons principles of Internal medicine 18th edition. Nissar Shaikh, Emergency management of fat embolism syndrome.” J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 29–33
  44. 44. THANK YOU

×