Perioperative Pulseless Electrical Activity Following Long Bone Fracture Fixation: Fat Embolism Syndrome by Exclusion

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Fat Embolism Syndrome (FES) is a condition in which fat globules enter the circulatory system. Generally occurring secondary to fractures of the long bones or pelvis, marrow fat enters into circulation, resulting in symptoms of respiratory distress, neurological change, and a petechial rash across the chest within 24 to 72 hours of the initial insult. Multiple minor criteria also support the diagnosis. Fat emboli do not necessarily result in FES, and may resolve spontaneously without noticeable physiological effect. Inpatient mortality rates for FES approach 12% and increase with age. Cardiac arrest is an established, albeit rare complication of FES, generally occurring as a consequence of acute right heart failure due to pulmonary capillary occlusion by fat emboli. Management of FES is supportive as there is no curative treatment.

71 yo man with a ground level fall sustained a comminuted right humerus fracture and minimally displaced fracture of right femoral neck. PMH included COPD, HTN, and smoking. The humerus was repaired with plate and screws and the femur was repaired with a pin during uneventful general anesthesia. Shortly after arriving in the post-anesthesia care unit he became unstable: acute hypoxemia required emergent endotracheal intubation after difficult mask ventilation, hypotension was refractory to pressors, and pulseless electrical activity (PEA) required 3 rounds of CPR. He was then admitted to the surgical intensive care unit (SICU).

PEA arrest precipitated by fat embolism is rare. Hemodynamic compromise from fat embolism is most often a consequence of acute right heart failure secondary to occlusion of pulmonary capillaries, although hypoxic arrest from fat emboli is another feasible etiology. This case offers an opportunity to review FES pathophysiology and diagnostic criteria while providing a humbling reminder of the limited treatment options.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2048

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