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Air Embolism: Pathophysiology, Clinical Presentation, and Emergency Management

What Is Air Embolism?

Entry of gas (usually air) 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 (via pulmonary venous return, cardiac shunt, or direct arterial injection)—more dangerous.

Mechanisms of Entry

  • IV therapy (central lines, pumps, disconnected tubing)
  • Surgery (neurosurgery sitting position, laparoscopic gas insufflation, open heart)
  • Trauma (chest/neck wounds, lung biopsy)
  • Obstetrics (uterine vein entry during delivery/C-section)
  • Diving (pulmonary barotrauma → arterial gas embolism)
  • Hemodialysis, angiography, mechanical ventilation

Pathophysiology

  • VAE: Air in right ventricle → "air lock" obstructs pulmonary outflow → ↓ cardiac output, ↑ RV pressure, V/Q mismatch, hypoxia. Large volumes (>50–100 mL in adults) cause cardiovascular collapse.
  • AAE: Air in left heart → coronary/cerebral embolism → MI, stroke, seizures, death. As little as 0.5–1 mL in coronary/cerebral circulation can be fatal.

Clinical Presentation

  • Sudden hypotension, tachycardia, arrhythmias
  • Dyspnea, hypoxia, "mill wheel" murmur (VAE)
  • Neurologic: confusion, seizures, focal deficits, coma (AAE)
  • Chest pain, ST changes (coronary air embolism)
  • Cutaneous: petechiae, mottling (decompression sickness)

Emergency Management

  1. Prevent further entry: Clamp lines, lower surgical field, flood field with saline.
  2. Positioning: Left lateral decubitus (Durant's) + Trendelenburg for VAE—traps air in RV apex.
  3. 100% O₂: Accelerates nitrogen washout, reduces bubble size.
  4. Hemodynamic support: Fluids, vasopressors, inotropes.
  5. Aspiration: Central line (multi-orifice catheter) to aspirate air from RA.
  6. Hyperbaric oxygen (HBO): Definitive for AAE/diving embolism; reduces bubble volume, improves oxygenation.
  7. CPR if cardiac arrest: Prolonged resuscitation may be warranted.

Prevention

  • Meticulous line priming, air-eliminating filters, secure connections.
  • Surgical: avoid sitting position if possible; precordial Doppler/TEE monitoring.
  • Diving: controlled ascent, safety stops.

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