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Arterial Gas Embolism

(Air Embolism)

By

Richard E. Moon

, MD, Duke University Medical Center

Last full review/revision Jun 2021| Content last modified Jun 2021
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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 Recompression Therapy Recompression therapy is administration of 100% oxygen for several hours in a sealed chamber pressurized to > 1 atmosphere, gradually lowered to atmospheric pressure. In divers, this therapy... read more .

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

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

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

Pearls & Pitfalls

  • Any diver who loses consciousness shortly after surfacing 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

  • Abdominal CT (showing gas within mesenteric vessels or the portal vein)

Table
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Treatment

  • Immediate 100% oxygen

  • Recompression therapy

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 the nitrogen-containing 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, if tracheal intubation is not feasible, unconscious patients with impaired airway reflexes should be kept in the lateral decubitus position. Mechanical ventilation, vasopressors, and volume resuscitation are used as needed. Routine placement of all 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 routinely recommended.

Treatment reference

  • 1. Moon RE: Hyperbaric treatment of air or gas embolism: current recommendations. Undersea Hyperb Med, 46(5):673-683, 2019. PMID: 31683367.

Key Points

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

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

  • Routine imaging to look for intravascular air is not indicated.

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

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

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