28115731 Visualization

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