Arterial gas embolism: Difference between revisions
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[[File:PMC3829274 IJNL-12-030-g001.png|thumb|Cerebral air embolism with multiple air bubbles.]] | [[File:PMC3829274 IJNL-12-030-g001.png|thumb|Cerebral air embolism with multiple air bubbles.]] | ||
[[File:PMC2772239_IJCCM-13-108-g001.png|thumb|Fatal cerebral arterial gas embolism. (a) CT head showing air bubbles predominantly in the right cerebral hemisphere (b) CT head showing air bubbles predominantly in the right cerebral hemisphere]] | [[File:PMC2772239_IJCCM-13-108-g001.png|thumb|Fatal cerebral arterial gas embolism. (a) CT head showing air bubbles predominantly in the right cerebral hemisphere (b) CT head showing air bubbles predominantly in the right cerebral hemisphere]] | ||
[[File:PMC3420467 CRIM.PULMONOLOGY2012-416360.002.png|thumb|Arterial air embolism (arrows)]] | |||
*Low ETCO2 in significant venous air embolism | *Low ETCO2 in significant venous air embolism | ||
*[[echocardiography|TEE]]: most sensitive, invasive not available in emergencies | *[[echocardiography|TEE]]: most sensitive, invasive not available in emergencies | ||
Revision as of 21:28, 2 March 2020
Background
- Also known as "air embolism"
- May be fatal when air entry reaches 200-300 mL (pressure gradient of 5 mmHg across 14 ga catheter entrains air at 100 mL/sec)[1]
- Dialysis related
- Due to negative intrathoracic pressure from spontaneous breathing
- Scuba related
- Results from pulmonary barotrauma (most common) and decompression sickness
Prevention
- Positive pressure mechanical ventilation reduces positive pressure gradient
- Trendelenburg for insertion/removal of IJV and subclav lines
- Reverse Trendelenburg for femoral
Clinical Features
- Asymptomatic
- Mild: dyspnea, cough
- Cardiogenic shock: hypotension, oliguria, altered mental status, chest pain
- Dialysis related
- Acute dyspnea, chest tightness, LOC, cardiac arrest, arrhythmia[2]
- Scuba related
- Symptoms develop during ascent or immediately upon surfacing
- Causes variety of stroke syndromes depending on part of brain affected
- Immediate death, loss of consciousness, seizure, blindness, hemiplegia
Differential Diagnosis
Dialysis Complications
- Dialysis-associated hypotension
- Dialysis disequilibrium syndrome
- Air embolism
- Missed dialysis (pulmonary edema)
Diving Emergencies
- Barotrauma of descent
- Otic barotrauma
- Pulmonary barotrauma
- Sinus barotrauma
- Mask squeeze
- Barodentalgia (trapped dental air causing squeeze)
- Barotrauma of ascent
- Pulmonary barotrauma (pulmonary overpressurization syndrome)
- Decompression sickness (DCS)
- Arterial gas embolism
- Alternobaric vertigo
- Facial baroparesis (Bells Palsy)
- At depth injuries
- Oxygen toxicity
- Nitrogen narcosis
- Hypothermia
- Contaminated gas mixture (e.g. CO toxicity)
- Caustic cocktail from rebreathing circuit
Evaluation
- Low ETCO2 in significant venous air embolism
- TEE: most sensitive, invasive not available in emergencies
- Doppler US: noninvasive; air in chamber = high pitch sound
Management[3][4]
- Central line aspiration of air from right heart
- 100% O2 non-rebreather
- Regardless of SaO2 (to reduce embolism size)
- Hemodynamic support with positive inotropes
- CPR in large air embolus
- Positioning
- Durant's maneuver - left lateral decubitus and Trendelenburg
- Traps air in apex of RV, relieves obstruction of pulmonary outflow tract
- May require open surgical or angiography for recovery of residual intracardiac or intrapulmonary air
Dialysis Related
- Prevent any further air entry
- Immediately cover puncture site with saline soaked gauze
Scuba Related
- IVF (increases tissue perfusion)
- Rapid recompression
Disposition
- Likely admission
See Also
External Links
References
- ↑ Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013
- ↑ Diving Medicine, Karen B. Van Hoesen and Michael A. Lang, Auerbach's Wilderness Medicine, Chapter 71, 1583-1618.e6
- ↑ *Shaikh N., Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185.
- ↑ Gordy S and Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013 Jan-Mar; 3(1): 73–76.