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Introduction   

When hearing the phrase fat embolism syndrome (FES), what comes to mind? If you’re a nurse, you’ve heard of emboli before. What happens during FES? What constitutes a fat embolism? Especially considering that many instances of FES can go undetected and unrecognized, the nurses’ role in FES education and awareness is essential.  

Presently, patients seek guidance and information on various health topics from nurses, including medication education and symptom awareness. The information in this course will serve as a valuable resource for nurses of all specialties, education levels, and backgrounds to learn more about the management of FES.  

Defining FES 

What Is FES? 

Fat embolism syndrome (FES) is a medical condition in which a fat embolism, similar to a blood clot, is found in the body’s systemic blood circulation. FES is a rare condition given that fat is rarely found floating in the body’s blood circulation naturally. That said, when FES occurs, the dissolution of a fat embolism in blood circulation will cause systemic effects in the body, such as inflammatory immune responses, changes in vital signs, changes in physical appearance, and changes in blood flow (1,2).  

FES is typically caused by orthopedic trauma, such as orthopedic surgery, motor vehicle accident, or extreme bodily trauma. FES can also be caused by medical procedures, such as liposuction, bone marrow transplant, or pancreatic surgery. Common risk factors for FES include younger age, multiple fractures, closed fractures, severe burns, and long bone fractures. Chronic health conditions that can increase the risk of FES include a history of fatty liver disease, sickle cell disease, and blood disorders (1,2). 

There are two main theories regarding the pathophysiology of FES. The mechanical theory focuses on the mechanisms of fat droplets into the bloodstream as a result of increased pulmonary arterial pressure and dysregulated oxygen exchanges. As a result of imbalanced pressure changes and oxygen exchanges, blood perfusion from a fat embolism affects organ health and leads to systemic failure. The biochemical theory focuses on bodily responses to trauma, which leads to hormonal shifts and possible releases of free fatty acids (FFA) (1,2).  

While these are the two main theories for FES, it is important to note that FES is still viewed as a rare complication in the orthopedic world and even more rare of complication outside of orthopedic settings. That said, the earlier the detection of FES, the more likely it is for a patient to survive, as FES can be fatal when left untreated. Because of the lack of earlier detection of FES, there are several conflicting studies and statistics regarding its prevalence in the United States (1,2). 

How and Where Is FES Diagnosed? 

FES can be diagnosed in outpatient and inpatient settings. FES is typically diagnosed in inpatient settings post-surgery, often within 24 to 72 hours after the possible fat embolism into the bloodstream. Rarely are FES cases diagnosed in outpatient settings, but it is a possibility. Cases of FES, whether they are located in inpatient or outpatient settings, require prompt assessment and management to avoid organ failure and future health complications (1,2). 

FES is often diagnosed by clinical symptoms and patient assessment. Depending on the patient’s symptoms, a chest X-ray, CAT scan, MRI, and blood work can be ordered. Some common tools for assessing the risk for FES include the Schoenfield Criteria, the Guard Criteria, the Lindeque Criteria, and a bronchoalveolar lavage (BAL) (1,2).  

What are the Clinical Criteria for Diagnosing FES? 

Clinical criteria for diagnosing FES are wide and complex given the varying clinical presentations of patients with FES. When considering if a patient has FES, it is important to consider the tools used to assess FES, such as the Schoenfield Criteria, the Guard Criteria, the Lindeque Criteria, and a bronchoalveolar lavage (BAL).  

The Schoenfield Criteria ranges from 1-5, where a score of 5 or more is required for an FES diagnosis and involves clinical presentations of hypoxemia, diffuse infiltration on imaging, fever, and petechiae rash. The Guard Criteria asserts that an FES diagnosis should require clinical symptoms from two major criteria or at least one major criterion along with four minor criteria (1,2). 

Per the Guard Criteria, major criteria for FES include (1) petechial rash, (2) respiratory complications, and (3) cerebral involvement in patients without a head injury. Per the Guard Criteria, minor criteria for FES include (1) fever, (2) tachycardia, especially >110bpm, (3) jaundice, (4) retinal complications, (5) anemia, (6) renal complications, (7) changes in platelet count, especially thrombocytopenia, (8) elevated erythrocyte sedimentation rate (ESR), and (9) fat macroglobulinemia (1,2). 

The Lindeque Criteria is not as widely used as the Guard Criteria, but it is still a possible clinical criteria tool for FES. The Lindeque Criteria involves monitoring respiratory symptoms, such as changes in arterial blood volume gases, tachypnea, or dyspnea. A BAL is a diagnostic tool for FES which possibly helps locate a fat embolism. That said, a BAL is not specific and is not guaranteed to locate a fat embolism. Like with all health complications, it is also important to recognize possible symptoms associated with FES (1,2).  

What Are the Common Symptoms of FES? 

Common symptoms of FES can include (1) bone fracture pain, (2) dyspnea, (3) headache, (4) GI upset, (5) tachycardia, (6) diaphoresis, (7) seizures, (8) nervous system disturbances, (9) retinal complications, and (10) rash. While symptoms of FES can be similar to symptoms of other health conditions, assessment and monitoring are essential for an accurate FES diagnosis for prompt treatment and management. It is important to note that FES requires prompt intervention, as this is an acute condition, not a chronic condition, so that is important to recognize for identifying symptoms and management (1,2).  

What Is the Average Cost for FES Treatment? 

The cost of FES treatment can significantly vary depending on the type of treatment needed, insurance, dosage, frequency, and other factors (1,2). Cost is among a leading reason why many patients cannot maintain their medication and treatment regime (3). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost-effective solutions for your patients.  

Managing FES  

Obtaining a Relevant Patient History 

As a nurse, one of the most important things you can do for your patients is obtain a relevant patient history. Especially in the case of FES, given that many things can cause FES and that many conditions have similar clinical presentations of FES, your role as a nurse in obtaining a relevant patient history can truly be lifesaving and essential for the patient and healthcare team in addressing FES.  

Specific questions to consider when assessing for FES include: 

• A detailed symptom onset history 
  • What symptoms are you experiencing?  
  • Do you have any trouble breathing, seeing, standing, or moving?  
  • When did the symptoms begin? 
  • Has anything improved your symptoms over the past 72 hours? 
  • Have you had any surgeries in the past 72 hours?  
  • Have you had any traumatic injuries, such as a motor vehicle accident or fall, in the past 72 hours?  
  • Have you had a fever in the past 72 hours?  
  • Have you ever felt like this before?  
• Medication and medical history 
  • What medications are you currently taking, including supplements? 
  • What health conditions do you currently have, such as anemia, blood disorders, or fatty liver disease? 
  • What surgeries have you experienced (including in the last 72 hours and prior)? 
  • When was the last time you were hospitalized?  
  • Do you consume any alcohol?  
  • Do you smoke, such as marijuana, cigarettes, or vape? 
  • Do you use any other recreational drugs? 
• General assessment questions 
  • Rate your pain on a scale of 1 to 10. Please tell me exactly where it is hurting you. 
  • Do you have any trouble peeing or pooping? 
  • Do you have any changes in sleep patterns?  
  • Do you have any vision changes or headaches? 

Additional important questions to consider as well include:  

• Are you willing to receive a blood transfusion? 

• Are you willing to have medical intervention done on your bones? 

• Are you willing to undergo anesthesia?  

As always, you should obtain vital signs and possibly prep the patient for bloodwork, a detailed exam, and imaging depending on the clinical presentation and health care provider discretion (1,2).  

Evaluating FES 

FES evaluation can truly vary from person to person. One woman might present to the emergency room with blood on her pants stating that she was in a car accident two days ago, and now she can’t feel her legs and is having trouble breathing. Another person might present to the primary care clinic a few days after a bone marrow transplant complaining of trouble breathing, changes in vision, and trouble standing (1,2).  

Knowing the wide range of clinical presentations, it is also important to be aware of several possible options for evaluating FES. FES evaluation can consist of a physical examination, and bloodwork, including a complete blood count (CBC), arterial blood gas (ABG), a comprehensive metabolic panel (CMP), MRI, and other radiographic imaging (1,2). 

As part of a good evaluation, knowing the source of the pain and the fat embolism’s location is critical. Most importantly, early intervention and proper diagnosis for FES is lifesaving, as untreated FES can lead to severe bodily function impairment, organ damage, and death (1,2).  

Pharmacological Methods to Manage FES 

There is no specified pharmacological treatment for the management or prevention of FES. Some studies have examined the role of medications, such as heparin, corticosteroids, or ethanol, but the results from those studies were inconclusive. Pain medication options, such as NSAIDs or opioids, can be offered depending on the patient’s health history and clinical presentation (1,2).  

Non-Pharmacological Methods to Manage FES 

Non-pharmacological interventions to manage FES include an inferior vena cava filter, surgery, and palliative care. An inferior vena cava filter is often recommended as a prophylactic option for FES and is not well-reviewed in evidence-based literature. Surgery is often the first-line option for early FES management and intervention, as it is the most evidence-based and recommended option. Depending on the location of the fat embolism, patient clinical presentation, and other factors, orthopedic surgery can be performed. That said, surgery is not a guarantee for treatment for FES (1,2).  

Because there is no 100% effective method for FES, palliative support is a main source of management for patients with FES. The goals of palliative, supportive care include blood transfusions, oxygen exchanges, adequate caloric intake, pain medication administration, and use of compression devices (1,2).  

Nursing Considerations 

What Is the Nurses’ Role in FES Patient Education and Management? 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several healthcare settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in FES education and management, here are some suggestions to provide quality care for patients who are experiencing or are suspected to be experiencing FES. 

• Take a detailed health history. Oftentimes, pain, headache, and GI upset can be dismissed in health care settings, even in post-operative settings. If a patient is complaining of symptoms that could be related to FES, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms are getting worse, if new symptoms emerge, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other healthcare professionals, advocate for that patient to the best of your abilities.  

• Review medication history at every encounter. Oftentimes, in busy clinical settings, reviewing health records can be overwhelming. While millions of people take medications, many people take medications that are no longer benefiting from the medication. Ask patients how they are feeling on the medication if their symptoms are improving, and if there are any changes to medication history.  

• Be willing to answer questions about FES. FES is a possible outcome of orthopedic surgical procedures, and it is important to raise awareness of possible outcomes from medical procedures. While FES can also emerge outside of surgical settings, FES is not well-known to the general public, so education about this complication is essential, especially for people with health conditions that can increase their risk for FES. Be willing to be honest with yourself about your comfort level discussing topics and providing education on FES. 

• Communicate the care plan to other staff involved for continuity of care. For several patients, FES management often involves a team of surgeons, specialists, nurses, palliative care specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 

• Stay up to date on continuing education related to FES and orthopedic health conditions, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other healthcare professionals and educate your patients with the latest information. You can learn more about the latest research on FES by following updates from evidence-based organizations (1,2).  

How can nurses identify if someone has FES?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have FES. Because of the varied clinical presentation and risk factors, FES can vary from person to person. Nurses can suspect if someone has FES by taking a complete health history, listening to the patient’s concerns, and communicating any concerns to other healthcare professionals (1, 2). 

What should patients know about FES?  

Patients should know that anyone who experiences physical trauma or has certain health conditions has the possibility of experiencing FES. Patients should be aware that if they notice any changes in their vision, experience any sharp pains or feel like something is a concern, they should seek medical care.  

Nurses should also teach patients to advocate for their health to avoid the progression of FES and possible FES complications.  

Here are important tips for patient education in the inpatient or outpatient setting (1,2).  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 

• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, and menstrual cycle changes (need to identify lifestyle factors that can influence FES) 

• Tell the health care provider if you notice any changes in your behavior, sleep, or skin (possible changes that could hint at early stages of FES) 

• Tell the health care provider if you have any changes in urinary or bowel habits, such as increased or decreased urination or defecation (potential risk for FES and other health concerns) 

• Tell the nurse or health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life. 

• Keep track of your medication use and health concerns via an app, diary, or journal (self-monitoring for any changes) 

• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries. 

Research Findings 

What Research on FES Exists Presently? 

There is extensive publicly available literature on FES via the National Institutes of Health and other evidence-based journals.  

What are some ways for people who have FES to become a part of research? 

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and healthcare organizations. 

Case Study #1 

Emily is a 20-year-old woman working as a writing assistant. There was a major fire in her office building caused by an electrical problem in the staff kitchen, and she arrived at the local emergency room. After assessment and treatment, Emily suffered from severe burns on her right arm, mostly on her upper arm and near her right shoulder. Emily also fractured her right humerus as a result of tripping on a wire trying to escape the fire.  

She is being observed in the inpatient orthopedic setting for her severe burns and fractured humerus. You see Emily about 12 hours after the burn and fracture incident, and she states she is in pain in her arm. 

Case Study #1 Continued 

She mentions that she has fatty liver disease and sickle cell disease. Emily mentions that she is trying to work on her diet and exercise to help with the cholesterol, but it hasn’t been going too well lately. You leave her room to see another patient, and her CBC and CMP from the lab appear unremarkable. The night shift nurse assesses Emily, and she notices that Emily has a slight fever. Emily also states that she’s been feeling really tired after the surgeon “fixed my arm,” and she’s still in a lot of pain.  

You see Emily the next day, approximately 36 hours after her fracture and burn incident at work. She’s in her patient room, and you take her temperature and see her fever is much higher. Emily is stating that the pain in her arm is getting much worse, and she requests more pain medication. Emily also states that she’s having some trouble seeing, even with her glasses on. She asks if this is a possible side effect of the pain medication and because of the fever.  

Conclusion

Fat embolism syndrome (FES) is a complex, acute health concern that can be fatal if left untreated and without early intervention. While symptoms of FES can look similar to several other health complaints and post-surgical complications, it is important to perform a thorough patient assessment and take patient’s complaints seriously. Education and awareness of FES can influence the lives of many people.  

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