Arterial gas embolism: Difference between revisions
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==Background== | ==Background== | ||
*Also known as "air embolism" | *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 | *Dialysis related | ||
**Due to negative intrathoracic pressure from spontaneous breathing | **Due to negative intrathoracic pressure from spontaneous breathing | ||
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==Clinical Features== | ==Clinical Features== | ||
*Asymptomatic | |||
*Mild: dyspnea, cough | |||
*Cardiogenic shock: hypotension, oliguria, altered mental status, chest pain | |||
*Dialysis related | *Dialysis related | ||
**Acute dyspnea, chest tightness, LOC, cardiac arrest | **Acute dyspnea, chest tightness, LOC, cardiac arrest | ||
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{{Scuba diving DDX}} | {{Scuba diving DDX}} | ||
== | ==Evaluation== | ||
*Low ETCO2 in significant venous air embolism | *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== | ==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 | *100% [[O2]] non-rebreather | ||
*Hemodynamic support with positive inotropes | *Hemodynamic support with positive inotropes | ||
*Rapid CPR in large air embolus | *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=== | ===Dialysis Related=== | ||
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==External Links== | ==External Links== | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] | ||
[[Category: | [[Category:Neurology]] | ||
[[Category: | [[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
- 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[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
- ↑ Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013
- ↑ *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.