Arterial gas embolism: Difference between revisions

No edit summary
(Text replacement - "AMS" to "altered mental status")
(22 intermediate revisions by 5 users not shown)
Line 1: Line 1:
==Background==
==Background==
*Due to negative intrathoracic pressure from spontaneous breathing
*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>
*Prevention is most important
*Dialysis related
**Positive pressure mechanical ventilation reduces positive pressure gradient
**Due to negative intrathoracic pressure from spontaneous breathing
**Trendelenburg for insertion/removal of IJV and subclav lines
*Scuba related
**Reverse Trendelenburg for femoral
**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==
==Clinical Features==
*Acute dyspnea, chest tightness, LOC, cardiac arrest
*Asymptomatic
*Decompression syndrome - see [http://wikem.org/wiki/SCUBA_Diving_Emergencies SCUBA Diving Emergencies]
*Mild: dyspnea, cough
*Cardiogenic shock: hypotension, oliguria, altered mental status, chest pain
*Dialysis related
**Acute dyspnea, chest tightness, LOC, cardiac arrest
*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==
==Differential Diagnosis==
{{Dialysis complications DDX}}
{{Dialysis complications DDX}}


==Workup==
{{Scuba diving DDX}}
 
==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<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
*Hemodynamic support with positive inotropes
*Rapid [[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


==Management==
===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
*Treat w/ 100% NRB
 
*Hemodynamic support with positive inotropes
===Scuba Related===
*Rapid CPR in large air embolus
*IVF (increases tissue perfusion)
*Rapid recompression


==See Also==
==See Also==
*[[Dialysis complications]]
*[[Dialysis complications]]
*[[Scuba diving emergencies]]


==External Links==
==External Links==


==Sources==
==References==
<references/>
<references/>
*The ICU book, 4th edition
*Shaikh N., Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185.


[[Category:Pulm]]
[[Category:Pulmonary]]
[[Category:Neuro]]
[[Category:Neurology]]
[[Category:Environmental]]

Revision as of 13:57, 31 July 2016

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
  • 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

Diving Emergencies

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[2][3]

  • Central line aspiration of air from right heart
  • 100% O2 non-rebreather
  • Hemodynamic support with positive inotropes
  • Rapid 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

See Also

External Links

References

  1. ↑ Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013
  2. ↑ *Shaikh N., Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185.
  3. ↑ Gordy S and Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013 Jan-Mar; 3(1): 73–76.
Retrieved from "https://www.wikem.org/w/index.php?title=Arterial_gas_embolism&oldid=91620"