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Major arterial hemorrhage
Crush injury (rhabdomyolysis)
Fat embolism
Open-fracture and joint injury
Vascular injury
Traumatic amputation
Compartment syndrome
Neurologic injuries
Distal femur fracture
Open femur fracture
Tibial plateau fractures
Floating knee (ipsilateral tibia and femur fractures) injury
Knee dislocations
Elbow fracture/dislocation
Ankle fracture/dislocation
Expanding hematoma
Pulsatile hematoma
Cold, pale, and pulseless extremities
Diminished peripheral pulses
Absent Doppler in the artery
Ankle brachial index <0.9 in lower-extremity injuries
Injury in the proximity of a major vessel
Patients with hard signs of vascular injury require emergent surgical exploration and revascularization.
Revascularization must be performed as soon as possible.
Muscle ischemia for >6 hours results in irreversible injury and muscle necrosis.
Unstable fractures should be stabilized with an external fixation before revascularization.
Revascularization procedures
Vascular repair
Vein grafting
Arterial stents
Temporary shunts indicated in the following:
Unstable patients with concomitant life-threatening injuries
>3-4 hours of delay in arterial revascularization
Fasciotomy should be performed in high-risk patients with vascular injury:
Prolonged ischemia time (>3-4 hours)
Significant preoperative hypotension
Associated crush injury
Combined arterial and venous injury
Major venous ligation in the popliteal or femoral area
Direct muscle injury
Muscle ischemia
Myoglobin release
Disruption of the sarcolemma of the muscle cells
Cellular adenosine triphosphate (ATP) depletion
Cellular sodium-potassium pumps failure
Generation of oxidative free radicals
Elevated creatine kinase (CK)
Amber-colored urine, positive for hemoglobin
Myoglobinuria
Renal function test for acute kidney injury (AKI)
Aggressive IV crystalloid solution infusion
0.9% normal saline solution preferred
Infusion rate may range from 200 mL/hr to 1000 mL/hr based on the response.
Renal protection
Use of sodium bicarbonate is controversial.
Sodium bicarbonate may cause hypocalcemia.
Alkalinization of the urine and diuresis are considered renal protective in myoglobinuria because myoglobin is more soluble in alkaline solution.
IV fluid with bicarbonate may be considered in patients with significant myoglobinuria.
May consider mannitol 1 g/kg after resuscitation with crystalloid.
Close monitoring of urine output with a goal of 1–2 mL/kg/hr
Monitor for complications including the following:
Acute renal failure
disseminated intravascular coagulation (DIC)
Hyperkalemia
Hypocalcemia
Compartment syndrome
Long bone fractures
Pelvic fractures
Fat globules release in peripheral circulation.
Interaction of fat globules with platelets and clotting cascades, causing intravascular coagulation.
Leukocyte activation
Intravascular endothelial damage
Increased capillary permeability
Decreased level of functional surfactant leading to pulmonary edema and acute respiratory distress syndrome (ARDS)
Early persistent tachycardia
Acute respiratory failure/ARDS
High temperature
Petechial rash
Over the upper body, especially in the axillae
Usually develops 24–36 hours after the injury
Seen in in 20%–50% of patients
Subconjunctival hemorrhage
Mental status changes
Agitation
Delirium
Seizures
Stupor or coma
Retinal hemorrhages with intraarterial fat globules seen in fundoscopy
High index of suspicion
No specific tests
Lipiduria
Fat globules in alveolar macrophage on bronchoalveolar lavage
Supportive care
Management of respiratory distress, including mechanical ventilation
Corticosteroid: Controversial
Early (<24 hours after injury) fixation of long bone fractures are associated with decreased incidence of fat embolism syndrome.
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