Arterial gas embolism: Difference between revisions
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==Background== | ==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) | *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)<ref>Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013</ref> | ||
* | *Dialysis related | ||
**Positive pressure mechanical ventilation reduces positive pressure gradient | **Due to negative intrathoracic pressure from spontaneous breathing | ||
*Diving related | |||
**Results from pulmonary barotrauma (most common) and decompression sickness, most commonly in last 10m of ascent. | |||
**Classically presents as LOC within 2 minutes of surfacing, can lead to stroke-like symptoms. | |||
===Prevention=== | |||
*Positive pressure mechanical ventilation reduces positive pressure gradient | |||
*Trendelenburg for insertion/removal of IJV and subclav lines | |||
*Reverse Trendelenburg for femoral | |||
*Slow and controlled ascent when diving, with special precaution to exhale during ascent in the last 10m so the lungs do not over-pressurize. | |||
==Clinical Features== | ==Clinical Features== | ||
*Acute dyspnea, chest tightness, LOC, cardiac arrest | *Asymptomatic | ||
*Mild: [[dyspnea]], [[cough]] | |||
*[[Cardiogenic shock]]: [[hypotension]], oliguria, [[altered mental status]], [[chest pain]] | |||
*[[dialysis complications|Dialysis]] related | |||
**Acute [[dyspnea]], [[chest pain|chest tightness]], [[syncope|LOC]], [[cardiac arrest]], [[arrhythmia]]<ref>Diving Medicine, Karen B. Van Hoesen and Michael A. Lang, Auerbach's Wilderness Medicine, Chapter 71, 1583-1618.e6</ref> | |||
*Scuba related | |||
**Symptoms develop during ascent or immediately upon surfacing | |||
**Causes variety of [[stroke syndromes]] depending on part of brain affected | |||
***Immediate [[cardiac arrest|death]], [[syncope|loss of consciousness]], [[seizure]], [[vision loss|blindness]], [[weakness|hemiplegia]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Scuba diving DDX}} | |||
{{Dialysis complications DDX}} | {{Dialysis complications DDX}} | ||
== | ==Evaluation== | ||
[[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:PMC3420467 CRIM.PULMONOLOGY2012-416360.002.png|thumb|Arterial air embolism (arrows)]] | |||
*Low ETCO2 in significant venous air embolism | |||
*[[echocardiography|TEE]]: most sensitive, invasive not available in emergencies | |||
*Doppler US: noninvasive; air in chamber = high pitch sound | |||
==Management<ref>*Shaikh N., Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185.</ref><ref>Gordy S and Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013 Jan-Mar; 3(1): 73–76.</ref>== | |||
*Central line aspiration of air from right heart | |||
*100% [[O2]] non-rebreather | |||
**Regardless of SaO2 (to reduce embolism size) | |||
*Hemodynamic support with positive [[vasopressors|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 | *Prevent any further air entry | ||
*Immediately cover puncture site with saline soaked gauze | **Immediately cover puncture site with saline soaked gauze | ||
* | |||
*Rapid | ===Diving Related=== | ||
*[[IVF]] (increases tissue perfusion) | |||
*Rapid recompression, [[Hyperbaric medicine|hyperbaric oxygen therapy]] | |||
==Disposition== | ==Disposition== | ||
* | *Likely admission | ||
==See Also== | ==See Also== | ||
*[[Dialysis complications]] | *[[Dialysis complications]] | ||
*[[Scuba diving emergencies]] | |||
*[[Diving medicine]] | |||
*[[Hyperbaric medicine]] | |||
==External Links== | ==External Links== | ||
*[https://www.merckmanuals.com/professional/injuries-poisoning/injury-during-diving-or-work-in-compressed-air/arterial-gas-embolism Merck Manual - Arterial Gas Embolism] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] | ||
[[Category: | [[Category:Neurology]] | ||
[[Category:Environmental]] |
Latest revision as of 12:13, 17 September 2021
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
- Diving related
- Results from pulmonary barotrauma (most common) and decompression sickness, most commonly in last 10m of ascent.
- Classically presents as LOC within 2 minutes of surfacing, can lead to stroke-like symptoms.
Prevention
- Positive pressure mechanical ventilation reduces positive pressure gradient
- Trendelenburg for insertion/removal of IJV and subclav lines
- Reverse Trendelenburg for femoral
- Slow and controlled ascent when diving, with special precaution to exhale during ascent in the last 10m so the lungs do not over-pressurize.
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
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
Dialysis Complications
- Dialysis-associated hypotension
- Dialysis disequilibrium syndrome
- Air embolism
- Missed dialysis (pulmonary edema)
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
Diving Related
- IVF (increases tissue perfusion)
- Rapid recompression, hyperbaric oxygen therapy
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.