Fat Embolism Syndrome and ARDS

Fat Embolism Syndrome and ARDS, histopathology of a pulmonary artery containing fat emboli
Histopathology of a pulmonary artery containing fat emboli. Image by Mikael Häggström, M.D. Author info – Reusing images- Conflicts of interest: None Mikael Häggström, M.D.Consent note: Consent from the patient or patient’s relatives is regarded as redundant, because of absence of identifiable features (List of HIPAA identifiers) in the media and case information (See also HIPAA case reports guidance)., Wikimedia Commons, CC0.

Fat Embolism Syndrome

  • Follows long bone and pelvic fractures, onset 24 to 72 hours after injury
  • Triad of hypoxia, confusion and petechial rash
  • Petechiae in the axillae, conjunctivae and oral mucosa
  • Diagnosis is clinical (Gurd criteria)
  • Subclinical fat embolism is common after long bone fracture
  • Mechanical and biochemical theories explain the syndrome

Gurd Criteria

MajorMinor
Respiratory insufficiencyTachycardia and fever
Cerebral involvementRetinal fat emboli and jaundice
Petechial rashAnaemia, thrombocytopenia, raised ESR and fat macroglobulinaemia
  • One major and four minor criteria with fat macroglobulinaemia

ARDS

  • Berlin definition is onset within one week, bilateral opacities and hypoxia not explained by cardiac failure
  • Severity by PaO2 to FiO2 ratio, mild 200 to 300, moderate 100 to 200, severe 100 or less
  • Lung protective ventilation with low tidal volumes
  • Prone positioning in severe cases
  • Conservative fluid strategy
  • Causes include sepsis, aspiration, massive transfusion and trauma

Management

  • Supportive care with oxygen and ventilation
  • Early stabilisation of long bone fractures lowers pulmonary complications (Bone, JBJS 1989)
  • Damage control orthopaedics for borderline and unstable patients
  • Reaming increases embolic load
  • Avoid excessive reaming pressure and vent the canal
  • Steroids are not routinely recommended
  • Damage control orthopaedics in unstable patients

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.