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+A 64-year-old female was found lying down after 10–12 hours of binge drinking.
+She was taken to an outlying emergency department (ED), and subsequently transferred to our hospital with mental status changes and respiratory distress and hypoxia for further management.
+She had a past history of rheumatoid arthritis, congestive heart failure, controlled hypertension, and alcoholism.
+She smoked two packs a day for the past 50 years.
+On presentation, she had a blood pressure of 176/80 mm/Hg, heart rate of 80 bpm, respirations 24 bpm, temperature 98°F (36.7°C).
+Arterial blood gases on room air showed a pH of 7.30, PaCO2 60, PaO2 61 mm/Hg, H−CO3 29 mEq/L, and saturation 92% which improved to 95% with oxygen by a high flow non-rebreather mask.
+On physical examination she was lethargic, disoriented, dysarthritic, but without neurological focalization.
+Scattered expiratory wheezes were noted bilaterally along with normal heart sounds.
+The remaining results of her physical examination and routine laboratory results were unremarkable with the exception of a leukocyte count of 14,000/dL with 88% neutrophils.
+Repeated vitals signs were consistent with a normal blood pressure but evidence of tachycardia in the monitor.
+Repeated ABG’s on the non-rebreather mask showed: pH 7.22, PaCO2 78, PaO2 140 mm Hg, H−CO3 30 mEq/L, and hemoglobin SaO2 97%.
+In the ED she was started on IV steroids and antibiotics for a COPD exacerbation.
+As part of the diagnostic workup, she underwent a chest x ray that did not show any infiltrates or any major abnormal findings.
+The ECG was only significant for sinus tachycardia.
+Given the negative findings on chest x ray, sinus tachycardia on ECG, and an increased A-a gradient, the patient was sent for a spiral chest CT with contrast to rule out a pulmonary embolism.
+During CT about 100–150 mL of air was inadvertently injected through the right antecubital vein using a power contrast injector (estimated by the technician and approximation of volumes on available imaging).
+Concurrent imaging (CT) showed a significant amount of air in the right atrium and right ventricular cavity (Figure 1), and air mixed with contrast in the main pulmonary artery and its proximal branches divisions of the pulmonary circulation (Figure 2).
+Concurrently, a filling defect was noted in the right lower lobe artery consistent with pulmonary thromboembolism (Figures 3, ​,4).4).
+The patient maintained hemodynamic stability with Trendelenburg, and left lateral decubitus positioning (Durant’s maneuver), and supportive care alone and she was transferred to the intensive care unit (ICU) for observation.
+Her respiratory distress worsened, and she was placed temporarily on non-invasive positive pressure ventilation (NIPPV) without improvement and a few hours later she was intubated and placed on mechanical ventilation.
+Intravenous full dose heparin infusion (initial bolus, 80 units/kg, followed by 18 units/kg/hour) was initiated for treatment of concurrent thromboembolism.
+Echocardiography did not show any evidence of right or left ventricular failure.
+Subsequent echocardiography done 24 hours later did not show any evidence of intracardiac air and complete resolution of the air embolism.
+During the next 48 hours, she remained hemodynamically stable with no requirements of vasoactive agents.
+She was finally extubated 48 hours after the initial presentation.
+She was later discharged home on warfarin with subsequent outpatient follow-up.