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Fat embolism syndrome (FES) co-existing with venous thromboembolism is rare entity. It is a serious clinical disorder occurring after trauma, orthopedic procedures and rarely in non-traumatic patients. We report one such case, which posed clinical dilemma in the management. A 20-year-old male patient was admitted to the hospital with bilateral closed fracture of the femur and bilateral both bone leg fractures following a road traffic injury. He was referred to our Center approximately 36 hours after the accident. On admission he was fully awake, obeying commands and hemodynamically stable. Electrocardiogram showed S1Q3T3 pattern, suggestive of pulmonary embolism. He was intubated and shifted for computed tomographic pulmonary angiography (CTPA) that showed small thrombus in segmental branch of right pulmonary artery. He was put on heparin infusion and transferred to Intensive Care Unit (ICU). In ICU, he was placed on Volume Control Ventilation mode with 100% FiO 2. He was hemodynamically stable (BP-140/76 mm Hg) with tachycardia (pulse rate-140 beats/min). Three hours later, the patient became irritable, confused with a drop in sensorium. His oxygen saturation fell to 80% from the baseline value of 98%, increasing to 90% on 100 % FiO 2 with recruitment maneuver. The chest X-ray was normal. Arterial blood gas analysis showed PaO 2 of 62 mmHg on 100% FiO 2. By now the patient developed petechial rash all over his upper trunk including axillae [Fig-ure 1]. Ophthalmic fundoscopy revealed retinal hemorrhages. Fat embolism was suspected based on clinical findings. Low tidal volume with high peep ventilation strategy was continued to maintain SpO 2 within acceptable limits. Two days later, the patient's chest X-ray showed diffuse fluffy infiltrate with PaO 2 /FiO 2 ratio of 70. Blood investigations showed low platelet counts (70 × 10 3 /μL) and hemoglobin (8.1%). CT head indicated features of cerebral edema. These findings further confirmed the diagnosis. Heparin Infusion was stopped. The patient's condition improved remarkably over the next few days. He was tracheostomised early in the course of illness, later decannulated and 25 days later discharged from the ICU in healthy clinical condition. Discussion Fat emboli typically manifest 24-72 h after initial insult. Affected patients presented with the classic triad of hypoxemia, neurological abnormality and petechial rash. Fat embolism could be difficult to diagnose. There is no diagnostic test that is sensitive or specific for confirmation or exclusion. Imaging studies are most useful in diagnosis of FES. X-ray chest radiograph often …

Management of fat embolism co-existing with thromboembolism may be challenging!