Cerebral fat embolism in a young polytrauma patient: A case report

Subin

Nursing Supervisor, ICU, Kauvery Hospital, Hosur, Tamil Nadu

Abstract

Cerebral Fat Embolism (CFE) is a rare but serious complication following long bone fractures and polytrauma, characterized by fat globules entering the systemic circulation and occluding cerebral microvasculature. This may lead to a spectrum of neurological manifestations such as altered sensorium, seizures, or coma, often occurring within 24–72 hr post-injury. Early recognition and timely intervention significantly influence outcomes.

This case report discusses a 22-year-old male who developed acute neurological deterioration following polytrauma involving a femur fracture, tibia-fibula fracture, and renal laceration. Imaging studies revealed multiple diffusion-restricted foci consistent with cerebral fat embolism. Prompt critical care management, seizure control, orthopedic intervention, and early rehabilitation resulted in a favorable neurological recovery. This case highlights the importance of high clinical suspicion, multidisciplinary care, and early supportive management in patients with suspected CFE.

Introduction

Cerebral Fat Embolism (CFE) is a recognized neurological complication of long bone fractures, orthopedic surgery, and polytrauma. The condition arises when fat droplets from bone marrow enter the bloodstream and lodge in cerebral vessels, triggering ischemia and inflammatory responses. Clinical presentation usually occurs within 12–72 hours of injury and may include confusion, disorientation, seizures, focal deficits, or decreased consciousness.

In polytrauma patients, timely stabilization, imaging, and monitoring are crucial to prevent delayed surgical intervention and complications. In cases where the injury is not immediately life-threatening, orthopedic surgery may safely be deferred for up to 72 hours to allow optimization. This report presents a case of CFE in a young trauma victim, highlighting the diagnostic challenges and importance of multidisciplinary care.

A 22-year-old male was brought to the emergency department after a road traffic accident (RTA). He sustained polytrauma and arrived with hypotension and multiple injuries. Resuscitation and trauma assessment were initiated immediately. Eight hours after admission, he developed altered sensorium and subsequently suffered a seizure, prompting escalation to critical care.

Clinical Findings

On initial evaluation

Hemodynamic status: Hypotensive, stabilized with fluids

Injuries identified

Grade III right renal laceration
Closed displaced right femur fracture
Open Type II both-bone (tibia-fibula) fracture of right leg

Neurological status (8 hours’ post-admission)

Altered sensorium
Single episode of generalized seizure
Decline in GCS prompting emergency intubation

Post-seizure GCS: Persistently low despite antiepileptic therapy

A 22-year-old male was admitted with an alleged history of road traffic accident (RTA) resulting in polytrauma. On arrival, he was hypotensive and was immediately managed with fluid resuscitation and primary trauma assessment. Subsequent evaluation revealed a Grade III laceration of the right kidney, a closed displaced fracture of the right femur, and an open Type II both-bone fracture of the right leg.

Approximately eight hours after admission, the patient developed altered sensorium followed by a single episode of seizure. His Glasgow Coma Scale (GCS) score deteriorated, necessitating emergent endotracheal intubation. Neurology consultation was obtained, and antiepileptic therapy was initiated. Despite treatment, his GCS remained low after six hours, prompting an urgent MRI brain scan.

Investigations	Result
WBC	9,200 cells/mm3
Hb	13.2g/dl
Platelet	2,79,000 Lakhs/ mm3
PCV	36.4%
Sodium	138mmol/L
Potassium	4.4mmo/L
Calcium	1.22mmol/L
Urea	38.5 mg/dl
Creatinine	1.0mg/dl
pH	7.3
pCo2	29.9 mmHg
pO2	87 mmHg
HCO3	18.1mmol/L
Lactate	1.19 mmol/L

Echo – EF 62%

CT Brain – Normal study

MRI Brain

The hippocampi appear normal. Multiple tiny diffusion-restriction foci are noted in the cerebral hemispheres, cerebellar hemispheres, and brainstem.

MR Angiogram (MRA) of the Brain

Major intracranial arteries appear normal, except for a few normal anatomic variants.

MR Venogram (MRV)

The intracranial venous sinuses appear patent.

MRI findings demonstrated multiple tiny diffusion-restriction foci in the bilateral cerebral and cerebellar hemispheres, suggestive of diffuse axonal injury (DAI). Given the persistent low GCS and the need to prevent further complications, informed consent was obtained from his parents, and the patient underwent right femoral nailing, tibial nailing, and tracheostomy.

Postoperatively, comprehensive critical care and early rehabilitation measures were initiated. The patient showed gradual neurological improvement, and decannulation was successfully performed on postoperative day (POD) 4. By POD 14, his GCS improved to E4V5M6, and he was discharged in stable condition with advice for continued follow-up and rehabilitation.

Diagnosis

Cerebral Fat Embolism Syndrome (FES)
Polytrauma
Long bone fractures (femur and tibia-fibula)
Associated renal laceration

Nursing Management

1. Emergency and Critical Care

Rapid assessment of airway, breathing, and circulation
Assisted ventilation and maintenance of oxygenation
Continuous GCS monitoring
Seizure precautions and administration of antiepileptic medications
Hemodynamic monitoring, IV fluids, and strict urine output charting

2. Neurological Monitoring

Hourly neurological checks
Monitoring for seizure recurrence
Prevention of secondary brain injury (maintaining adequate oxygenation and perfusion)

3. Pain and Comfort Measures

Adequate analgesia
Positioning to prevent contractures and pressure injuries

4. Orthopaedic and Postoperative Care

Preoperative stabilization of fractures
Postoperative monitoring after femur and tibia nailing
Care of tracheostomy site
Prevention of infection and DVT

5. Respiratory Care

Chest physiotherapy
Suctioning and tracheostomy care
Prevention of ventilator-associated pneumonia

6. Nutrition and Fluid Balance

Adequate hydration
Enteral feeding once stable
Monitoring electrolytes and metabolic parameters

7. Family Education and Emotional Support

Explanation of condition, prognosis, and rehabilitation needs
Counseling regarding neurological recovery timeline

Outcome

Gradual neurological improvement noted after postoperative care
Decannulation successfully performed on POD 4

By POD 14

GCS improved to E4V5M6
Patient alert, oriented, and hemodynamically stable
Mobilization and physiotherapy initiated, resulting in improved functional status

Discharge Summary

The patient was discharged on Postoperative Day 14 in stable condition.

Discharge Condition

GCS 15
Vitals stable
No recurrent seizures
Surgical wounds healthy
Ambulating with support

Discharge Advice

Continue physiotherapy and rehabilitation
Regular neurology and orthopedics follow-up
Tracheostomy wound care instructions (if applicable)
Avoid strenuous activities until clearance
Follow-up MRI if neurological symptoms recur

Discussion

Medical Aspects

CFE is often underdiagnosed due to nonspecific presentation and frequently normal CT findings. MRI is the diagnostic modality of choice due to its sensitivity in detecting micro embolic lesions. Early supportive care including seizure management, mechanical ventilation, and stabilization of fractures is critical.

This case highlights how changes in neurological status within hours of long bone trauma should raise suspicion for CFE. Early orthopedic intervention after stabilization helps prevent further fat release into circulation.

Nursing Aspects

Nurses played a pivotal role in:

Early recognition of neurological deterioration
Managing airway, ventilation, and hemodynamics
Administering antiepileptic’s and monitoring their effects
Preventing complications like aspiration, infection, and pressure sores
Providing psychosocial support to the family
Facilitating early rehabilitation and patient education

Comprehensive nursing care contributed significantly to the patient’s favorable neurological and functional recovery.

Conclusion

Cerebral Fat Embolism is a rare but potentially life-threatening complication of long bone fractures. Early recognition, prompt neurological evaluation, aggressive supportive management, and timely orthopedic intervention are essential for improving outcomes. Multidisciplinary coordination including emergency physicians, orthopedic surgeons, neurologists, intensivists, and nursing staff played an integral role in this patient’s recovery.
The successful outcome of this case demonstrates that with vigilant monitoring, appropriate imaging, early rehabilitation, and holistic nursing care, patients with CFE can achieve complete neurological recovery.

Cerebral fat embolism in a young polytrauma patient: A case report

Cerebral fat embolism in a young polytrauma patient: A case report

Subin

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