Arterial Gas Embolism

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 Arterial Gas Embolism (AGE) : Gas bubbles
in the systemic arterial system resulting from
pulmonary barotrauma, iatrogenic entry of gas
into the arterial system, or arterialized venous
gas emboli.
 Etiology
Gas emboli may enter the arterial circulation in any
of the following ways:
• From ruptured alveoli after lung barotrauma
• From within the arterial circulation itself in
severe decompression sickness
• Via migration from the venous circulation (venous
gas embolism) either via a right-to-left shunt
(patent foramen ovale, atrial septal defect) or by
overwhelming the filtering capacity of the lungs
 Manifest
Arterial gas embolism  CNS ischemia with rapid loss of
consciousness, other CNS manifestations, or both; it also
may affect other organs.
• Symptoms occur within a few minutes of surfacing and
may include altered mental status, hemiparesis, focal
motor or sensory deficits, seizures, loss of
consciousness, apnea, and shock; death may follow.
Signs of pulmonary barotrauma or type II
decompression sickness may also be present.
Other symptoms may result from arterial gas
embolism in any of the following:
• Coronary arteries (eg, arrhythmias, MI, cardiac
arrest)
• Skin (eg, cyanotic marbling of the skin, focal
pallor of the tongue)
• Kidneys (eg, hematuria, proteinuria, renal failure)
 Diagnosis
Diagnosis is clinical and may be corroborated by imaging tests.
Clinical evaluation:
• Sometimes confirmation by imaging
• Diagnosis is primarily clinical. A high level of suspicion is
necessary when divers lose consciousness during or
immediately after ascent. Confirming the diagnosis is
difficult because air may be reabsorbed from the affected
artery before testing.
However, imaging techniques that may support the diagnosis
(each with limited sensitivity) include the following:
• Echocardiography (showing air in the cardiac
chambers)
• Ventilation-perfusion scan (showing results
consistent with pulmonary emboli)
• Chest CT (showing local lung injury or
hemorrhage)
• Head CT (showing intravascular gas and diffuse
edema)
• Immediate 100% oxygen
• Recompression therapy
• Divers thought to have arterial gas embolism
should be recompressed promptly.
• Transport by air may be justified if it saves
significant time, but exposure to reduced
pressure at altitude must be minimized.
• Before transport, high-flow 100% oxygen enhances
nitrogen washout by widening the nitrogen pressure
gradient between the lungs and the circulation, thus
accelerating reabsorption of embolic bubbles.
• Patients should remain in a supine position to decrease
the risk of brain embolism.
• Mechanical ventilation, vasopressors, and volume
resuscitation are used as needed.
• Placing patients in the left lateral decubitus position
(Durant’s maneuver)
 Referensi
• MSD Manual by Alfred A. Bove, MD, PhD,
Professor (Emeritus) of Medicine, Lewis Katz
School of Medicine, Temple University