A BUBBLING HEART

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Air embolism is a rare but devastating event that occurs as a consequence of the entry of air into the vasculature. It mostly results from surgical procedures, barotrauma from mechanical ventilation or scuba diving. It can either be arterial or venous with varied implications. Venous air embolism from a routine blood draw is a rare entity not reported much in the literature. CASE PRESENTATION: 62 years old female with past medical history of congestive heart failure with preserved ejection fraction and Sjogren's syndrome presented with complains of sudden onset midsternal chest pain for 5 hours. She rated her pain 7/10 in intensity, radiating to back and pressure-like in sensation, aggravated by inspiration and coughing with no relieving factors. This was also associated with shortness of breath at rest for the same duration. Review of systems was also positive for one episode of lightheadedness and blurry vision on her way to the hospital. She denied any such symptoms in the past. She was a non-smoker. On presentation, she was found to be hypoxic and hypotensive. Her initial labs including workup for acute coronary syndrome was unremarkable, but her CT chest revealed moderate amount of air within the visualized portion of the right and left internal jugular veins, brachiocephalic veins and the right ventricle. She was subsequently admitted to the intensive care unit. The only triggering factor identified for her venous air embolism was a recent regular blood workup done at her rheumatologist’s office one day prior to the onset of her symptoms. She was placed on high-flow nasal oxygen and was also recommended to stay in a left lateral position. These conservative measures led to complete resolution of her symptoms as well as the air embolism on the repeat CT chest within 24 hours. DISCUSSION: Venous air embolism is a catastrophic entity which if not identified and managed on time can lead to life threatening complications. The spectrum of clinical findings ranges from minimal or no symptoms to dyspnea, chest pain, dizziness, sudden loss of consciousness, hemodynamic instability and cardiac arrest. One of the most dangerous complications is the acute right heart failure leading to obstructive shock due to dislodgement of air bubble from the right ventricle into the pulmonary vasculature. It is therefore, managed conservatively with keeping the patient in left lateral (Durant's maneuver) or trendelenburg position that helps in preventing the air lock. Other supportive measures include adequate hydration, high flow nasal oxygen or hyperbaric oxygen in patients with concerns for end organ damage for 12-24 hours. Use of inhalers or mechanical ventilation is contraindicated to prevent barotrauma. CONCLUSIONS: Venous air embolism if not recognized timely can prove to be fatal. Supportive treatment is the key to resolution in majority of the cases. Reference #1: Black, Michael, James Calvin, Kwan L. Chan, and Virginia M. Walley. "Paradoxic air embolism in the absence of an intracardiac defect." Chest 99, no. 3 (1991): 754-755. Reference #2: Cushman, Mary. "Epidemiology and risk factors for venous thrombosis." In Seminars in hematology, vol. 44, no. 2, pp. 62-69. WB Saunders, 2007. Reference #3: Bhatia, Sameer. "Systemic air embolism following CT-guided lung biopsy." Journal of Vascular and Interventional Radiology 6, no. 20 (2009): 709-711. DISCLOSURES: No relevant relationships by Fatima Ayub, source=Web Response No relevant relationships by Vishesh Paul, source=Web Response