Whether you are a fan of champagne or prosecco, bubbles usually mean a celebratory drink. Bubbles seen during echo however, is not something you want to celebrate. In fact, one might want to identify the source of the bubbles, and the impact it is likely to have on the patient. It is very common to see bubbles when coming off cardiopulmonary bypass after valvular heart surgery. This echo loop however, was taken in a patient who did not have heart surgery but in an emergency situation.
What is the diagnosis?
This patient, in fact had air embolism associated with a central venous catheter removal. CVAD associated air embolism:
- Occurs at the time of insertion, catheter disconnection, removal. Incidence 1 in 47 to 3000.
- negative intrathoracic pressure during inspiration draws air in venous circulation, arterial circulation.
- Risk factors (pressure gradient)- deep inspiration, upright, hypovolaemia, line manipulation, removal.
- Suspected in sudden cardiorespiratory and neurological collapse during central line related procedures.
- Paradoxical embolism can also occur in the presence of PFO, ASD. In its absence, occurs due to incomplete filtering of the air in pulmonary capillaries, pulmonary-arterial venous malformation. Do not need to have an intracardiac shunt to have PDE! It can also occur as a result of retrograde cerebral venous air embolism by overcoming opposing venous blood flow.
Clinical Findings are:
- chest pain, mill wheel murmur (specific but rare), non-specific ST changes, RV strain, tachy/bradyarrythmia.
- dyspnoea, hypoxaemia.
- seizures, focal neurological deficits.
- “hiss” sound- false negative
- Sudden neurological deterioration + hypotension + hypoxia (CVAD) = HIGH INDEX of SUSPICION