Background FES is a rare complication of long bone fracture in children and adolescents. Mortality ranges from 1%-15%. Typical presentation: hypoxemia, neurological abnormality and petechial rash. FES and thoracic trauma are known causes of ARDS. NIMV is being increasingly used in respiratory failure.

Aim To report the intensive care management of a previously healthy 16-year-old male who developed severe ARDS.

Methods The patient was transferred to our Paediatric Intensive Care Unit, because of respiratory distress, 2 h after being submitted to intra medullary nailing of left femur, for a closed diaphyseal fracture post motorcycle accident. Upon admission, patient was oriented, hemodynamically stable and manifested hemoptysis and hypoxemic respiratory failure –pO₂/FiO₂ = 88,6 mmHg, Alveolar-arterial gradient (AaG)= 572 mmHg (normal= 5,9 mmHg)- not responding to supplemental O₂ through a nonrebreathing face mask with reservoir. Chest X-ray: diffuse bilateral infiltrates. ECG and transthoracic echocardiogram : normal. Blood analysis: anaemia, thrombocytopenia, hypoalbouminemia, hypocalcaemia hypophosphatemia, CPK total 6870 IU/L (CK-MB normal) and d-Dimers 12450 (normal <500 ng/ml). Lower extremity ultrasound: normal. Spiral CT excluded pulmonary embolism, but was suggestive of fat embolism and inferior posterior segments contusions bilaterally. He responded to the use of NIMV (Pressure Support, PIP 22 cm H₂O, Peep 10 cm H₂O, FiO₂ 0.7) Petechial rash on trunk appeared later, confirming FES diagnosis. Additional treatment: RBC transfusion, methylprednisolone 60 mg/day, stress-ulcer prophylaxis, sbc LMWH, antibiotic and nutritional support.

Results Patient improved and was gradually weaned from NIMV 7 days later.

Conclusion NIMV has fewer complications and may be effective even in severe ARDS.