Abstract Bubble Trouble: Air Embolus After CT ContrastIntroductionAir embolism, a rare and life-threatening condition, occurs when gas enters the vascular system. Swift detection, diagnosis, and intervention are imperative due to its high morbidity and mortality. We present a case of venous air embolism (VAE) identified on a chest CT angiogram (CTA).Case PresentationA 45-year-old Caucasian male with a history of tobacco use, hypertension, diabetes, morbid obesity, neurogenic bladder, hydronephrosis, and congenital adrenal hyperplasia presented to the emergency department via EMS with hypotension, nausea, and vomiting. He reported bilateral flank pain, chest wall pain, and diffuse abdominal discomfort. Initial vitals showed hypotension (MAP 60 mmHg), tachycardia, and tachypnea, with physical exam notable for bilateral costovertebral angle tenderness. Labs revealed leukocytosis (19,000 WBCs), hyponatremia (124 mmol/L), creatinine (2.7 mg/dL), anion gap (15 mmol/L), glucose (530 mg/dL), hyperbilirubinemia (2.34 mg/dL), and lactic acidosis (4.6 mmol/L). Arriving just an hour prior, his undifferentiated shock prompted a broad differential, including aortic dissection, acute coronary syndrome, obstructive uropathy, and pyelonephritis. A stat CTA of the chest, abdomen, and pelvis was ordered, revealing a significant VAE in the main pulmonary artery post-contrast injection, alongside urothelial thickening, a distended left renal collecting system, and perinephric edema suggestive of pyelonephritis. Post-imaging, his blood pressure dropped to 67/40 mmHg. He was emergently placed in Durant’s position (left lateral decubitus with Trendelenburg), started on high-flow nasal cannula with high FiO2, broad-spectrum antibiotics for presumed septic shock, and vasopressors for hemodynamic support. Once stabilized, he was transferred to the medical ICU.DiscussionMajority of cases of air emboli are iatrogenic, tied to invasive procedures. A fatal dose is estimated at 200-300 cc, though smaller volumes may be lethal if shunted to the arterial circulation via a right-to-left shunt such. Despite its rarity, VAE carries a 21% mortality rate, per a 25-year single-center retrospective study. Symptoms are nonspecific, making prevention and early detection critical. Upon diagnosing VAE, placing the patient into Durant’s position helps trap air in the right ventricle, as the right ventricular outflow tract becomes positioned inferiorly to the right ventricular cavity. Volume expansion with intravenous fluids helps elevate central venous pressure to limit gas entry into the venous system, and applying supplemental oxygen via high-flow nasal cannula with a high FiO2 setting may aid in the resorption of the VAE. ConclusionMaintaining a high index of suspicion is necessary to promptly recognize and treat venous air embolism. This abstract is funded by: None
Cedeno et al. (Fri,) studied this question.