Don't forget cerebral fat embolism syndrome (FES) on the differential for altered trauma patients. FES is typically associated with long bone fractures, but has been reported with other fractures, orthopedic reaming (i.e. aggressive orthopedic procedures), and in rare cases even with non-fracture (soft-tissue) trauma. Typically symptoms occur between 24 and 72 hours after injury, but there have been cases both earlier and later. Diagnosis is clinical, but MRI may be helpful, and will often show multiple cerebral white matter lesions. It is debated whether FES is truly an embolic phenomena (i.e fat molecules traveling to and blocking blood supply of organs), or rather an inflammatory response to free fatty acids in the blood stream (i.e. more of a vasculitis type pathology). Management is supportive care, but give these patients time as there can be favorable outcomes, even after prolonged coma.
