How is venous air embolism (VAE) treated in the emergency department (ED)?

Updated: Dec 30, 2017
  • Author: Brenda L Natal, MD, MPH; Chief Editor: Erik D Schraga, MD  more...
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If venous air embolism (VAE) is known about before presentation to the emergency department (ED), affected patients should be transported in the left lateral decubitus position. [7]

Management of VAE, once it is suspected, includes identification of the source of air, prevention of further air entry (by clamping or disconnecting the circuit), reduction of the volume of air entrained, and hemodynamic support. 

Administer 100% O2 and perform endotracheal intubation for severe respiratory distress or refractory hypoxemia or in a somnolent or comatose patient in order to maintain adequate oxygenation and ventilation. Institution of high-flow (100%) O2 will help reduce the bubble's nitrogen content and therefore size. [1, 4, 7, 10, 11, 15, 23, 30]

Immediately place the patient in the left lateral decubitus (Durant maneuver) and Trendelenburg position. This helps to prevent air from traveling through the right side of the heart into the pulmonary arteries, leading to right ventricular outflow obstruction (air lock). If cardiopulmonary resuscitation (CPR) is required, place the patient in a supine and head-down position. [1, 7, 11, 15, 23]

Direct removal of air from the venous circulation by aspiration from a central venous catheter in the right atrium may be attempted. However, no current data support emergency catheter placement for air aspiration during an acute setting of VAE-induced hemodynamic instability. [1, 4, 11, 15]

If necessary, initiate CPR. Besides maintaining cardiac output, CPR may also serve to break large air bubbles into smaller ones and force air out of the right ventricle into the pulmonary vessels, thus improving cardiac output. Even without the need for CPR, this rationale holds for closed-chest massage. Animal studies have shown that the benefit of cardiac massage equals that of left lateral recumbency, as well as intracardiac aspiration of air. [1, 4, 11, 15]

Admit patients to the intensive care unit (ICU), as they may develop cardiopulmonary distress/failure following VAE.

Consider transfer to a hyperbaric oxygen therapy (HBOT) facility. Indications for HBOT include neurologic manifestations and cardiovascular instability. Potential benefits include compression of existing bubbles, establishing a high diffusion gradient to speed resolution of existing bubbles, improved oxygenation of ischemic tissues, and lowered intracranial pressure.

Immediate HBOT, once VAE is diagnosed, is recommended; however, prognosis may still be good if therapy is initiated beyond 6 hours of event. Prompt transfer to an HBOT center has been reported to decrease mortality in patients with cerebral air embolism. If transfer is necessary, ground transportation is preferred. If air transportation cannot be avoided, the lowest altitude should be sought. [1, 4, 7, 11, 14, 15, 18, 42]

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