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A 19-year-old man suffered from progressive dyspnea
and deteriorated consciousness in one day.
Brief History
The 19-years-old man
experienced a traffic accident on the night of the 6th of
October. He was sent to a local hospital where compound
fracture of right femoral bone and multiple abrasion wounds
over bilateral lower extremities were noticed without any
evidence of chest or head trauma. ORIF (open reduction with
internal fixation) was performed without blood transfusion on
the next morning.
However, an episode of chills with
spiking fever developed two days after the traffic accident.
There was no obvious infection focus except mild local heat
and swelling were found over the operating wound. An event of
vomiting occurred on the morning of October 8 after narcotics
injection for pain relief. Dyspnea with productive cough and
consciousness disturbance developed gradually at that night.
Chest radiograph revealed multiple patchy infiltrates over
bilateral lung fields (Figure 1
). Arterial blood gas showed severe
hypoxemia. Under the impression of acute hypoxemic respiratory
failure, he was transferred to MICU in a university hospital
for further management on Oct. 9.
On arrival, his consciousness was clear with intact JOMAC.
The blood pressure was 162/97 mmHg and pulse rate 102 per
minute. Body temperature was 38.5℃. Respiratory distress was
noted with a respiratory rate of 32 per minute, The oxygen
saturation was kept around 90% under non-rebreathing mask.
Conjunctiva was pale and sclera unicteric. Coarse crackles
were auscultated over both lung fields. The surgical wound was
clear with no evidence of local infection. No petechiae or
skin rash could be detected over the trunk. The remaining
physical and neurological examinations were unremarkable.
Laboratory Data
1. CBC/DC
| |
WBC
(K/μL)
|
RBC
(M/μL)
|
HB
(g/dL)
|
MCV
(fL) |
PLT
(K/μL)
|
Seg
(%) |
Lym
(%) |
Eos
(%)
|
| 10/9 |
5.16 |
3.48 |
10.3 |
87.6 |
105.0 |
84.1 |
7.2 |
1.9 |
| 10/11 |
3.86 |
3.21 |
10.0 |
90.3 |
28.0 |
71.6 |
12.7 |
6.9 |
| 10/13 |
7.90 |
3.92 |
11.5 |
89.9 |
167.0 |
69.7 |
16.1 |
4.1 |
2.
ABG
| |
pH |
PaCO2
(mmHg) |
PaO2
(mmHg) |
HCO3-
(mEq/L) |
B.E(mEq/L) |
FiO2
(PEEP) |
VentilatorMode |
| 10/9 |
7.42 |
33.9 |
58.8 |
21.5 |
-2.0 |
0.8 |
Non-rebreath |
| 10/11 |
7.39 |
39.8 |
61.0 |
23.7 |
-0.6 |
0.5 (10) |
CMV |
| 10/16 |
7.44 |
39.9 |
76.7 |
26.5 |
2.7 |
0.35 (5) |
SIMV |
3. BCS
| |
Albumin
(g/dL) |
T-Bil
(mg/dL) |
AST
(U/L) |
ALT
(U/L) |
BUN
(mg/dL) |
Cre
(mg/dL) |
CK
(U/L) |
| 10/9 |
2.3 |
0.7 |
112 |
40 |
13 |
0.9 |
720 |
| 10/12 |
|
0.8 |
88 |
36 |
14 |
0.8 |
210 |
| 10/15 |
2.9 |
1.3 |
57 |
47 |
17 |
0.9 |
41 |
| |
Na
(mmole/L) |
K
(mmole/L) |
Cl
(mmole/L) |
Mg
(mmole/L) |
CRP
(mg/dL) |
LDH
(U/L) |
Lactic acid
(mmole/L) |
| 10/9 |
140 |
4.5 |
109 |
0.7 |
>12 |
1213 |
1.1 |
| 10/12 |
142 |
3.7 |
106 |
1.0 |
|
|
|
| 10/15 |
137 |
4.0 |
107 |
1.2 |
|
|
|
4. Coagulation profile
| |
PT |
PTT |
Fibrinogen
(mg/dL) |
3P |
FDP
(μg/mL) |
D-Dimer
(μg/mL)
|
| 10/9 |
16.4/12.4 |
48.6/37.1 |
160 |
1+ |
20-40 |
2.47 |
| 10/12 |
14.4/12.1 |
40.5/38.7 |
|
|
|
|
5. Urinalysis
| |
pH |
Protein
(mg/dL)
|
Ket |
O.B |
Uro.bil
(IU/dL)
|
RBC
(/HFL)
|
WBC
(/HFL)
|
Epi |
Cast |
Bact |
| 10/9 |
7.5 |
100 |
- |
+ |
1.0 |
10-15 |
1-3 |
0-2 |
- |
+ |
Clinical Course & Treatment
After admission, endotracheal
intubation with mechanical ventilation was performed. Chest
computed tomography (CT) revealed multiple alveolar
infiltrates and consolidations over bilateral lung fields (Figure 2).
Since sepsis with lung
involvement can not be excluded by clinical features,
empirical antibiotics with ticarcillin/clavulaniate and
gentamicin were prescribed. Component therapy was also given
for his coagulation dysfunction. Under the impression of fat
embolism syndrome with acute lung injury, ventilator setting
was adjusted to high PEEP and low tidal volume. The patient
experienced an episode of vomiting with elevated blood
pressure and relative bradycardia on Oct. 10. Emergent cranial
CT disclosed mild brain swelling. The condition was
ameliorated after infusion with osmotic agent. All the
microbiologic studies yielded negative results. Gas exchange
was improving without any specific pulmonary pharmacotherapy.
The bleeding tendency recovered. Ventilator weaning was
performed smoothly and he was extubated on Oct. 17. The
patient was discharged without any sequelae.
 案例分析
本案例是一個典型脂肪栓塞症候群的病程，通常於外傷後24-48小時發生，病人常有皮膚紫斑、呼吸急促及意識障礙的情形。若病人進行到急性呼吸窘迫症候群的程度，通常需要給予氣管插管及機械通氣的協助，此時肺部所呈現的病徵必須與 (1)敗血症引起的急性肺損傷
(2)胃酸吸入引起的肺炎
(3)神經性肺水腫 (4)輸血反應等作鑑別診斷。本案例雖有呼吸急促、發燒、但病程中並無休克、白血球增加及明顯感染源情形，之所以會給予經驗性抗生素治療是因為無法從臨床表徵中絕對區分是嚴重感染症或是脂肪栓塞症候群，因為兩者皆會出現血小板減少及有瀰漫性血管內凝血症之情形。脂肪栓塞症候群好發於外傷長腿骨折的病人，也可發生於非外傷病人，其治療一般建議是
(1)給予外傷長骨骨折病人儘早外科固定
(2)維持適當水分電解質平衡 (3)適當的機械通氣及氧氣治療，類固醇的使用目前仍然沒有定論，肺部通常在經過7-12
天後可以得到完全的恢復。
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Case Discussion
繼續教育考題