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Young, postpartum woman transported to emergency room in full cardiorespiratory arrest. PowerPoint Presentation
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Young, postpartum woman transported to emergency room in full cardiorespiratory arrest.

Young, postpartum woman transported to emergency room in full cardiorespiratory arrest.

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Young, postpartum woman transported to emergency room in full cardiorespiratory arrest.

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  1. Young, postpartum woman transported to emergency room in full cardiorespiratory arrest.

  2. Cause of Death • Venous air embolism. • Due to vaginal insufflation. • Other significant conditions: • Postpartum subinvolution of uterus.

  3. Embolism: an obstruction in a blood vessel due to a blood clot or foreign material which occludes the vessel after traveling through the blood stream.

  4. Types of emboli • Thromboemboli • Fat • Air • Tumor • Bullets

  5. Venous Air Embolism

  6. Venous Air Emboli • Air/gas introduced into systemic venous circulation. • Many cases are probably subclinical and resolve without significant consequences.

  7. Required Conditions • Direct communication between the source of air and vasculature. • Pressure gradient favoring the passage of gas into the venous circulation.

  8. Important Factors • Amount of air introduced into the venous circulation. • Rate of accumulation of air in venous circulation. • Position of patient.

  9. Quantity of Gas • Small amounts of air are broken up and reabsorbed in the capillary beds. • 100 to 200 ml have been reported in the literature as potentially fatal. • > 5 ml/kg. • Significant symptoms have been reported with as little as 20 ml of air (length unprimed IV tubing). • 2-3 ml into cerebral circulation can be fatal. • 0.5 ml into the LAD can cause ventricular fibrillation.

  10. Rate of Air Infusion • Rapid infusion of air overwhelms the capacity of the capillaries and leads to right ventricular strain with outflow obstruction, increased pulmonary artery pressure and ultimately cardiovascular failure.

  11. Frequency • True incidence is unknown. • Radiologic literature reports 0.13% during insertion and removal of central venous catheters with optimal technique. • 1/47 to 1/3000 of CVC. • 10-50% of high risk neurosurgical procedures.

  12. Morbidity and Mortality • Dependent on multiple factors: • Amount and rate of air infusion. • Other associated conditions.

  13. Causes • Surgical procedures: • Neurosurgical procedures especially with patient in sitting position or with open dural sinuses. • Trauma surgery with compromised large vessels. • Tumors with high vascularity.

  14. Causes • OB-GYN procedures. • Central venous catheters: • Central lines. pulmonary catheters, hemodialysis catheters, Hickman lines, etc. • Mechanical insufflation: • Orogenital sexual activity. • Inadvertent injection of air with IV contrast or other radiologic studies.

  15. Diagnosis • Must have a high suspicion as clinical symptoms can be non-specific or mimic other conditions.

  16. History • Recent surgical procedures. • Blunt or penetrating trauma of head, neck, chest or abdomen • Central venous catheterization. • Peripostpartum oral genital sexual activity.

  17. Clinical Symptoms • Will be dependent on the amount of air and rate of effusion. • Position of patient (sitting versus recumbent). • Paradoxical arterial embolism.

  18. Presentation • Symptoms include shortness of breath, cough, nausea, chest pain, agitation (impending doom) and disorientation. • Cardiovascular findings: • dysrhythmias, hypotension, pulmonary hypertension, myocardial ischemia, increased central venous pressure, “mill wheel murmur”, nonspecific ECG findings (ST segment and T wave changes), shock.

  19. Presentation • Pulmonary findings: • Abnormal breath sounds (rales and wheezing), tachypnea, hemoptysis, cyanosis, decreased arterial oxygen saturation, elevated CO2, increased pulmonary artery pressures, pulmonary edema.

  20. Presentation • Neurologic: • Altered mental status, seizures, focal deficits, loss of consciousness, coma. • Ophthalmologic: • Air bubbles in retinal vessels • Skin: • Crepitus over superficial vessels.

  21. Differential Diagnosis • Extensive and can include coronary artery syndrome, aortic stenosis, atrial fibrillation, bronchospasm, COPD, CHF, aortic dissection, CVA, metabolic disorders, pulmonary emboli and shock from multiple causes.

  22. Diagnostic Studies • Laboratory: • No specific tests. • Blood gas. • Specific tests may be useful for assessing organ damage.

  23. Diagnostic Studies • Imaging studies: • Transesophageal echocardiography. • High sensitivity for detecting air in right ventricle and outflow tract. • Precordial Doppler ultrasound. • Chest x-ray. • CT scan.

  24. Diagnostic Studies • ECG • Non-specific findings (right ventricular strain, increased heart rate, ST depression). • Pulse oximetry • Central venous catheter aspiration.

  25. Management • Transport patient in left lateral decubitus position. • Stop any procedure immediately. • Can attempt to remove air via catheter. • Provide hemodynamic support. • 100% oxygen/intubation. • Maintain volume. • Vasopressors and mechanical ventilation. • Consider hyperbaric oxygen therapy if neurologic symptoms or cardiac instability

  26. Prevention