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Air Embolism: Pathophysiology, Clinical Presentation & Emergency Management

Air embolism is entry of gas into the vascular system, causing obstruction of blood flow. Venous air embolism (VAE) enters right heart → pulmonary artery; arterial air embolism (AAE) enters systemic circulation (cerebral, coronary) – far more dangerous.

Mechanisms of Entry

  • Iatrogenic: Central line insertion/removal, hemodialysis, surgery (neurosurgery, laparoscopic, C-section), contrast injection
  • Trauma: Chest wall defect, pulmonary vein laceration
  • Diving: Pulmonary barotrauma → AAE
  • Bomb blast: Pressure wave forces air into vessels

Pathophysiology

  • VAE: Air in right ventricle → "mill wheel" murmur, V/Q mismatch, pulmonary hypertension, RV failure
  • AAE: Air in left heart → coronary occlusion (MI), cerebral embolism (stroke), spinal cord infarction
  • Critical volume: 50–100 mL VAE can be fatal; 0.5–1 mL AAE to coronary/cerebral circulation causes ischemia

Clinical Presentation

SystemSigns/Symptoms
RespiratoryDyspnea, hypoxia, cough, pulmonary edema
CardiovascularHypotension, tachycardia, arrhythmias, JVD, mill wheel murmur
NeurologicConfusion, seizures, focal deficits, coma (AAE)
CutaneousMottling, petechiae (diver's)

Emergency Management (VAE Focus)

  1. Prevent further entry: Clamp line, flood field, Trendelenburg + left lateral decubitus (Durant's position) – traps air in RV apex
  2. Support ABCs: 100% O2 (nitrogen washout), fluids, vasopressors
  3. Aspiration: Central line catheter (multi-orifice) into RV – aspirate air
  4. Hyperbaric oxygen (HBO): Definitive for AAE (cerebral, coronary); reduces bubble size, improves oxygenation
  5. Advanced: ECMO if refractory

Prevention

  • Strict line protocols (air-tight connections, priming, trendelenburg for insertion/removal)
  • Surgical: bone wax, flooding field, venous pressure control
  • Diving: controlled ascent, no breath-holding

Air embolism is a time-critical emergency. Early recognition and Durant's position + 100% O2 are lifesaving.

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