ICU · Trauma

Fat Embolism Syndrome — The 12–72h Triad, Gurd's Criteria & Lung-Protective Support

Also known as Fat embolism syndrome · FES · Fat embolism · Petechial rash · Triad fat embolism · Gurd's criteria · Cerebral fat embolism · Fat emboli · Post-fracture respiratory failure · Intramedullary nailing embolism

Fat embolism syndrome (FES) is a clinical diagnosis defined by the triad of respiratory insufficiency, neurological dysfunction and a petechial rash arising 12 to 72 hours after a major injury — classically a long bone (femur, tibia) or pelvic fracture, but also orthopaedic procedures (intramedullary nailing, joint replacement), liposuction, pancreatitis, sickle-cell crisis and bone-marrow transplant. The pathophysiology is dual — a MECHANICAL phase in which marrow fat globules embolise to the pulmonary and cerebral microvasculature, and a BIOCHEMICAL phase in which lipase hydrolyses the embolic triglyceride to free fatty acids that ignite an inflammatory cascade, injure the endothelium and produce an ARDS-like lung. The diagnosis rests on Gurd's criteria (major: respiratory insufficiency, cerebral involvement, petechial rash; minor: fever, tachycardia, retinal changes, jaundice, renal changes, thrombocytopenia). Management is SUPPORTIVE: oxygen, lung-protective ventilation (6 mL/kg, plateau <30 cmH₂O) for the ARDS-like lung, cautious fluids, vasopressors; early surgical stabilisation of the fracture (within 24 h) is the single most effective preventive measure; corticosteroid prophylaxis reduces incidence in meta-analysis but remains controversial and is not routine. FES is largely self-limiting with supportive care, but severe instances cause significant respiratory failure, neurological damage and even mortality.