Assessment

HISTORY. The patient may have been scuba diving or flying at the onset of symptoms. Usually patients who develop an iatrogenic air embolism are under the care of the healthcare team, who assesses the signs and symptoms of air embolism as a complication of treatment. Some patients have a gasp or cough when the initial infusion of air moves into the pulmonary circulation. Suspect an air embolism immediately when a patient becomes symptomatic following insertion, maintenance, or removal of a central access catheter. Patients suddenly become dyspneic, dizzy, nauseated, confused, and anxious, and they may complain of substernal chest pain. Some patients describe the feeling of "impending doom."

PHYSICAL EXAMINATION. On inspection, the patient may appear in acute distress with cyanosis, jugular neck vein distension, or even seizures and unresponsiveness. Some reports explain that more than 40% of patients with an air embolism have central nervous system effects such as altered mental status or coma. When auscultating the patient's heart, listen for a "mill-wheel murmur" produced by air bubbles in the right ventricle and heard throughout the cardiac cycle. The murmur may be loud enough to be heard without a stethoscope but is only temporarily audible and is usually a late sign. More common than the mill-wheel murmur is a harsh systolic murmur or normal heart sounds. Most patients have a rapid apical pulse and low blood pressure. You may also hear wheezing from acute bronchospasm. The patient may have increased

50 Air Embolism central venous pressure, pulmonary artery pressures, increased systemic vascular resistance, and decreased cardiac output.

PSYCHOSOCIAL. Most patients respond with fear, confusion, and anxiety. The family or significant others are understandably upset as well. Evaluate the patient's and family's ability to cope with the crisis and provide the appropriate support.

Diagnostic Highlights

Abnormality with Test Normal Result Condition

Explanation

Arterial blood Pao2 80-100 mm Hg; Pao2 < 80 mm Hg; Paco2 gases PacO2 35-45 mm Hg; varies; Sao2 < 95% Sao2 > 95%

Poor gas exchange leads to hypoxemia and hypercapnea from dead-space ventilation

Other Tests: Supporting tests include electrocardiogram (ECG), chest x-ray, transthoracic or transesophageal echocardiography, precordial Doppler.

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