(P90) Sonographic Findings of Patient with Air Embolism and Pneumothorax

Chief Complaint : Shortness of Breath and Confusion

History of Present Illness : A 64-year-old woman with a history of multiple myeloma was brought to the emergency department by her son who noticed she was confused and short of breath. She was in respiratory distress and had poor peripheral perfusion. She was intubated for airway protection and taken for computed tomography (CT) imaging before returning for central line placement.

Pertinent Physical Exam: Patient was alert and oriented only to her name. She had a normal heart exam. She had decreased breath sounds on her right lung.

Pertinent Laboratory Data: The CT chest image revealed a right-sided pneumothorax. Point-of-care ultrasound was used in an attempt to guide cannulation of the left femoral vein when the sonographer observed what was later termed the “venous curtain sign,” showing intermittent air artifact within the lumen of the vessel with ventilations (Figures 1 and 2). This is the first published use of this term to describe the sonographic appearance of venous air embolism. CT of the abdomen/pelvis confirmed this finding of air within the left femoral vein (Figure 3).

Case Discussion: Barotrauma is a known complication of endotracheal intubation and mechanical ventilation, estimated to occur in 0.5%–38% of patients who are critically ill.1, 2 There may be a higher incidence of venous air emboli associated with barotrauma than previously thought as most remain clinically inconsequential and likely go unnoticed.3 Rapidly formed or large air emboli lead to high morbidity and mortality.4 The recognition of the “venous curtain sign” as a sonographic finding of venous air emboli may lead to rapid diagnosis and management.

References and Acknowledgements (Optional): 1Petersen GW, Baier H. Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med. 1983; 11: 67- 69.
2Ibrahim AE. Pneumothorax and systemic air embolism during positive-pressure ventilation. Anesthesiology. 1999; 90(5): 1479- 1481.
3Azan B, Teran F, Nelson B, Andrus P. Point-of-care ultrasound diagnosis of intravascular air after lower extremity intraosseous access. J Emerg Med. 2016; 51.
4Bessereau J, Genotelle N, Chabbaut C. Long-term outcome of iatrogenic gas embolism. Intensive Care Med. 2010; 36: 1180- 1187.