A 62-year-old woman has had atrial fibrillation since experiencing a myocardial infarction (MI) 7 months prior. Two weeks ago she was hospitalized following a car accident in which she suffered a compound fracture of her left femur and several severe contusions. She now returns to the emergency room with right flank pain, hematuria, and left-sided paralysis. These newly developing problems are most likely the result of which of the following?
(A) air embolism from the compound fracture
(B) bone marrow embolus from the fractured femur
(C) fat embolism from the fractured femur
(D) systemic thromboemboli from the left atrium
(E) venous thromboemboli from the deep leg veins
ANSWER:
D:
(A) air embolism from the compound fracture
(B) bone marrow embolus from the fractured femur
(C) fat embolism from the fractured femur
(D) systemic thromboemboli from the left atrium
(E) venous thromboemboli from the deep leg veins
ANSWER:
D:
Atrial fibrillation produces turbulence that is conducive to the formation of thrombi which can then embolize throughout the systemic circulation. In this patient the right flank pain and hematuria and left-sided paralysis suggest that thromboemboli traveled to the right kidney and the brain, respectively.Embolism of air (choice A) has variable effects, although small amounts are typically inconsequential. Larger volumes (~ >100 mL) can obstruct arteries and lead to ischemia and necrosis; an air embolism that lodges in the right heart may lead to sudden death.However, air embolism is rare and is not the most likely event in this patient. Bone marrow embolism (choice B) can occur following a broken bone or cardiac resuscitation, but typically will have no clinical consequences.However, fat embolism (choice C) from a broken long bone or traumatized areas of adipose tissue can, when severe, produce clinical manifestations.
These follow the trauma by about 1–3 days and usually include dyspnea,skin rash, and acute neurologic changes. In a few cases this has been fatal. Venous thromboemboli from deep leg veins (choice E) could not get past the lungs (with the unusual exception of paradoxical embolism in a person with a septal defect) so could not reach the kidneys or brain to cause the effects reported for this patient.
These follow the trauma by about 1–3 days and usually include dyspnea,skin rash, and acute neurologic changes. In a few cases this has been fatal. Venous thromboemboli from deep leg veins (choice E) could not get past the lungs (with the unusual exception of paradoxical embolism in a person with a septal defect) so could not reach the kidneys or brain to cause the effects reported for this patient.
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