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Arterial Gas Embolism

(Air Embolism)

By

Richard E. Moon

, MD, Duke University Medical Center

Last full review/revision Jul 2019| Content last modified Jul 2019
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Arterial gas embolism is a potentially catastrophic event that occurs when gas bubbles enter or form in the arterial vasculature and occlude blood flow, causing organ ischemia. Arterial gas embolism can cause central nervous system (CNS) ischemia with rapid loss of consciousness, other CNS manifestations, or both; it also may affect other organs. Diagnosis is clinical and may be corroborated by imaging tests. Treatment is 100% oxygen and immediate recompression.

Gas emboli may enter the arterial circulation in any of the following ways:

  • From ruptured alveoli after lung barotrauma

  • From within the arterial circulation itself in severe decompression sickness

  • Via migration from the venous circulation (venous gas embolism) either via a right-to-left shunt (patent foramen ovale, atrial septal defect) or by overwhelming the filtering capacity of the lungs

Even an otherwise asymptomatic venous gas embolism can cause serious manifestations (eg, stroke) in the presence of a right-to-left shunt. Venous gas embolism that does not enter the arterial circulation is less serious.

Although cerebral embolism is considered the most serious manifestation, arterial gas embolism can cause significant ischemia in other organs (eg, spinal cord, heart, skin, kidneys, spleen, gastrointestinal tract).

Symptoms and Signs

Symptoms occur within a few minutes of surfacing and may include altered mental status, hemiparesis, focal motor or sensory deficits, seizures, loss of consciousness, apnea, and shock; death may follow. Signs of pulmonary barotrauma or type II decompression sickness may also be present.

Other symptoms may result from arterial gas embolism in any of the following:

Pearls & Pitfalls

  • Any unconscious diver should be assumed to have arterial gas embolism and should be recompressed promptly.

Diagnosis

  • Clinical evaluation

  • Sometimes confirmation by imaging

Diagnosis is primarily clinical. A high level of suspicion is necessary when divers lose consciousness during or immediately after ascent. Confirming the diagnosis is difficult because air may be reabsorbed from the affected artery before testing. Also, imaging should be used only if the diagnosis is not clear, because imaging can delay treatment. However, imaging techniques that may support the diagnosis (each with limited sensitivity and thus should not be used to exclude the diagnosis) include the following:

  • Echocardiography (showing air in the cardiac chambers)

  • Chest CT (showing local lung injury or hemorrhage)

  • Head CT (showing intravascular gas and diffuse edema), although visible arterial gas is inconsistently present and its absence does not rule out arterial gas embolism

Sometimes decompression sickness can cause similar symptoms and signs (for a comparison of features, see table Comparison of Gas Embolism and Decompression Sickness ).

Table
icon

Comparison of Gas Embolism and Decompression Sickness

Feature

Gas Embolism

Decompression Sickness

Symptoms and signs

Common: Unconsciousness, often with seizures (any unconscious diver should be assumed to have gas embolism and should be recompressed promptly)

Less common: Milder cerebral manifestations, signs of pulmonary barotrauma (eg, mediastinal or subcutaneous emphysema, pneumothorax)

Extremely variable—the bends (pain, most often in or near a joint), neurologic manifestations of almost any type or degree, and the chokes (respiratory distress followed by circulatory collapse—an extreme emergency), occurring alone or with other symptoms

Onset

Sudden, usually during or within a few minutes after surfacing

Gradual or sudden, with symptoms developing 1 hour after surfacing in about 50%; onset up to 24 hours after dives* of > 10 m (> 33 ft) or hyperbaric exposures of > 2 atm abs

Proximate cause

Usual: Breath holding or airway obstruction during ascent (even from a few feet of depth, particularly when ascent is rapid); air trapped in the lungs expands during ascent and causes lung tissue injury

Occasional: Severe decompression sickness

Usual: Diving or hyperbaric exposure, especially beyond no-stop limits

Occasional: Diving or hyperbaric exposure to shallow depths (40 ft or shallower); low-pressure exposure (eg, flying after diving)

Mechanism

Usual: Overinflation of lungs causing entry of free gas into pulmonary vessels followed by embolization of cerebral vessels

Occasional: Coronary, renal, or cutaneous circulatory obstruction by free gas from any source

Formation of bubbles from excess dissolved gas in blood or tissue when external pressure decreases

Emergency treatment

Essential emergency care as needed (eg, airway patency, hemostasis, CPR or mechanical ventilation)

Prompt transport to nearest recompression chamber

Horizontal or lateral decubitus position

100% oxygen by close-fitting mask

Fluids orally if patient is conscious; otherwise, IV

Essential emergency care as needed (eg, airway patency, CPR or mechanical ventilation)

Prompt transport to nearest recompression chamber

Horizontal or lateral decubitus position for unstable patients

100% oxygen by close-fitting mask

Fluids orally if patient is conscious; otherwise, IV

* Repeat dives are frequently involved.

atm abs = atmospheres absolute; CPR = cardiopulmonary resuscitation.

Treatment

  • Immediate 100% oxygen

  • Recompression therapy

Divers thought to have arterial gas embolism should be recompressed promptly. Transport to a recompression chamber takes precedence over nonessential procedures. Transport by air may be justified if it saves significant time, but exposure to reduced pressure at altitude must be minimized.

Before transport, high-flow 100% oxygen enhances nitrogen washout by widening the nitrogen pressure gradient between the lungs and the circulation, thus accelerating reabsorption of embolic bubbles. Hemodynamically unstable patients should remain in a supine position to facilitate maintenance of stable blood pressure and cardiac output; to help prevent aspiration, unconscious patients with impaired airway reflexes should be kept in the lateral decubitus position. Mechanical ventilation, vasopressors, and volume resuscitation are used as needed. Placing patients in the left lateral decubitus position (Durant’s maneuver) or Trendelenburg position is no longer recommended.

Pearls & Pitfalls

  • Place unconscious patients with impaired airway reflexes in the lateral decubitus position until the airway can be protected with an endotracheal tube, after which the patient can be placed supine to facilitate care. Left lateral decubitus position (Durant’s maneuver) or Trendelenburg position are no longer recommended.

Key Points

  • Strongly consider arterial gas embolism if patients have neurologic symptoms within minutes after surfacing or manifestations of ischemia in another organ.

  • Do not exclude arterial gas embolism based on negative imaging results.

  • Start high-flow 100% oxygen and initiate transport to a recompression chamber if gas embolism is suspected.

More Information

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