Friday, January 9, 2009

On Call

At around 3 in the morning, you get called by the nurse with a question about a trauma patient. You're covering for that service and groggily, you flip through the list of patients. It is a middle age man status post motorcycle accident 2 days ago with bilateral femoral fractures. The nurse says the patient has dyspnea, tachypnea, and hypoxemia. He has also been confused and has a new rash on the head, neck, and anterior thorax. His platelets are fine.

Challenge: You stumble into the elevator and on your way up, you make the diagnosis. What is it?

Note: I tried really hard to find a picture of the rash, but simply could not get one. Sorry!


shabnam said...

Post traumatic Fat embolism...this one's a classic picture fulfilling 3 out of the 4 major Gurd's criteria.

CodeDog said...

Acute respiratory distress syndrome (ARDS) caused by the trauma two days earlier.
The time line for trauma related ARDS is 24-48 hours which fits this case.
The breathing problems, low O2 levels and confusion are all consistent with ARDS.
The rash is a little puzzling. It could be petechiae associated with the ARDS but I would expect to see it more in the underarm area than in the head and neck.
It's possible this could be an adverse drug reaction or an opportunistic infection acquired in the hospital.
Since this was a motorcycle accident polytrauma is most likely.

In any case. He needs ICU, O2 and mechanical ventilation immediately.

Chest X-ray to check for pulmonary contusion.

Alex said...

fat embolism?

Stephanie said...

lipid pulmonary embolism from the broken femurs.

Craig Chen said...

Yes, this notoriously elusive diagnosis is a fat embolism.
On Call

This is fat embolism syndrome, associated with long bone and pelvic fractures. The triad is hypoxemia, neurologic abnormalities, and petechial rash. About half of patients may require mechanical ventilation, and mortality is 5-15%. Supportive care is the mainstay of therapy.

Source: UpToDate.