2017
Pulmonary,Air,Fat,Gas
Embolism
DR. Roman Al
Mamun
Forensic Science,Autopsy
surgeon and Forensic Death
Investigator.
12/2/2017
Pulmonary,Air,Fat,Gas Embolism
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pulmonary infarcts:
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Autopsy Diagnosis:
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definite and not the segmental break up of blood in the vessels with
collapsed segments in between.
2. Avoid pulling the sternum and ribs to avoid creating negative pressure in
the tissues, which may result in aspiration of air into vessels.
3. Before handling thoracic organs, the pericardium is opened, heart is
lifted upwards and the apex is cut with a knife.
4. The left ventricle is filled with frothy blood, if air is in sufficient quantity to
cause death.
5. If the right ventricle contains air, the heart will float in water.
6. Air embolism can also be demonstrated by cutting the pericardium
anteriorly and grasping the edges with hemostat on each side.
7. The pericardial sac is filled with water and heart is punctured with the
scalpel and twisted a few times. Bubbles of air will escape if air is present.
8. The amount of air can be measured by placing inverted water filled
graduated glass cylinder, with the mouth of cylinder in pericardial sac.
9. Oxygen in heart indicates air embolism because it is not present in
appreciable quantity if gases were those of decomposition.Frothy blood
resembling air embolism can be found especially in right ventricle due to
handling of heart before it is opened at autopsy, putrefaction, as a
postmortem event and artificial respiration in dying or recently dead.
10. Skull vault be removed without puncturing the meninges.
11. Internal carotid and basilar arteries are ligated before the brain is
removed.
12. Meningeal vessels should be examined for visible air bubbles. In acute
cases, gas bubbles will be visible within the cerebral arteries but not in the
cortical veins.
13. Brain should be submerged in water and ligature should be released.
Then the vessels are cut and slightly compressed to watch for air bubbles.
14. An air tight, water filled glass syringe with a needle can be used to
collect gas from blood vessels, heart or cavities.
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For dating an embolus, veins along with the thrombi and the muscles
around it are excised as a sample for routine Histopathological
examination.
Fat Embolism:
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1.Fixation of walls of veins e.g. in clavicular and pelvic regions, the upper
dorsal spine and dural membranes.
2. The suction effect of the respiratory movements and heart’s actions on
such veins as the jugular, subclavian and vertebral has a tendency to
create a negative pressure in the vessels during phase of inspiration.
Presence of fat droplets in the blood stream indicates that the injury was
produced during life, except in case of burning, advanced putrefaction and
charring after death. Large amounts of liquefied fat are derived from fat
cells.
When cardiac massage is done, fat enters the blood vessels even if the
circulation has stopped. If during resuscitation, the sternum or ribs are
fractured bone marrow embolism is seen in the lungs.
Clinically:
The phenomenon presents as sudden loss of consciousness usually after
a period following the traumatic accident, which need not in itself be serious
such as a fractured tibia and fibula.
Autopsy diagnosis:
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The second theory is that free fatty acids, released from either the marrow
directly or from fat lodged in the lungs, cause direct toxic injury to the
pneumocytes and endothelium, with resultant abnormalities in gas exchange.
Microscopically, there are fat emboli in the pulmonary vasculature, with
edema, transudate, and exudate in the alveoli.
Visualization of fat emboli within the pulmonary vasculature requires the
use of frozen sections and fat stains.
If the individual survives a few days, the brain will show small perivascular
hemorrhages in the white matter around vessels containing fat emboli.
In the early stages, the brain may appear grossly normal.
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While early studies reported an 86% mortality, more recent work indicates
that the mortality has decreased to 61%.
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Etiology:
The syndrome of amniotic fluid embolism has been attributed to the acute
embolization of amniotic fluid and debris of fetal origin into the maternal
venous circulation, with resultant pulmonary microvascular obstruction.
On reaching the lung, this material is presumed to produce severe transient
vasospasm of the pulmonary vasculature, pulmonary hypertension, right
heart failure, and hypoxia.
No matter how small the amount of amniotic fluid involved, simple
exposure of the maternal circulation to amniotic fluid triggers a
pathophysiologic cascade similar to anaphylactic or septic shock generating
the physiological derangements characterizing these syndromes.
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This would explain the observation that fetal debris is not seen at autopsy in
all cases where there is no doubt, clinically, that the patient had “amniotic
fluid emboli.
Autopsy Findings:
The detection of squamous cells alone in the pulmonary arterial blood would
not be sufficient for the diagnosis of amniotic fluid embolism.
Just as the presence of squamous cells is not pathegnomonic of amniotic
fluid embolus, neither is the presence of trophoblastic cells.
Trophoblastic cells can be found in the blood and lungs of women who do
not have amniotic fluid emboli.
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Gas Embolism
Gas emboli may involve either or both the venous and arterial systems.
In most instances, the gas is air, though, in some diagnostic situations, it
could be carbon dioxide, nitrous oxide or nitrogen.
In the venous system, death from air embolism depends on the size of the
bolus and the rate of delivery.
In arterial embolism, these factors are not as important, because only a small
number of air bubbles occluding a coronary artery or a cerebral vessel can
result in death. In venous air embolism, between 75 and 250 cm of air
delivered rapidly is necessary to cause death.
Venous air embolism may occur during therapeutic or diagnostic procedures
secondary to trauma, during childbirth or abortion, and during oralgenital
sex in a pregnant woman when her partner blows air into the vagina.
Arterial air embolism occurs secondary to cardiopulmonary bypass, arterial
catherization, surgical procedures involving arteries, or injury to the
pulmonary veins after chest trauma.
One might also incur a paradoxical air embolism, that is, air crossing from
the venous to the arterial circulation.
Air entering the venous system is carried to the heart and pulmonary arteries,
with resultant mechanical occlusion of the pulmonary arterial vasculature by
air bubbles.
This is followed by a transient vasoconstriction.
Obstruction of the pulmonary blood flow results in churning of the blood
and air, producing the frothy appearance of the blood seen at autopsy.
This churning can result in the development of complexes of air bubbles,
fibrin, platelet aggregates, erythrocytes, and fat globules, thus further
occluding the vasculature.
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bolus of air, the obstruction occurs not only in the pulmonary vasculature but
also in the right ventricle.
occur when air or gas that has entered the venous system crosses over to the
arterial system.
Typically, these have been described in association with septal defects of the
heart. These permit air to go from the right side of the heart to the left
without passing through the pulmonary vasculature.
If a large air embolism is carried to the heart, the sudden rise in the right-
sided heart pressure may result in a right-to-left shunt through a probe
patent, but physiologically closed, foramen ovale. Increased right-sided heart
pressure also causes air to be forced into the epicardial veins on the surface
of the heart.
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Thus, in individuals incurring stab or incised wounds of the neck with injury
to the veins, the prosector may want to explore the possibilities of air
embolism at the time of autopsy.
The true incidence of venous air embolism during surgical and diagnostic
procedures is unknown, with one exception — craniotomy in the sitting
position.
Here, air emboli occur in 21 to 29% of all craniotomies and 40% of all
occipital craniotomies.
Air emboli have also been reported in a host of other therapeutic and
diagnostic procedures.
Any surgical procedure that causes a negative pressure gradient between the
right side of the heart and a vein is a potential risk for venous air embolism.
Individuals have been seated or prone, supine, in the lithotomy position, and
in the lateral knee-chest position at the time they incurred air emboli.
Air emboli were more common when blood and other fluids were delivered
in glass bottles rather than the present collapsible plastic bags.
Even with plastic bags, there is the possibility, though rare, of an air
embolus.
Air emboli have also occurred following cesarean section, placenta previa,
and
subclavian venipuncture.
With a large-bore channel to a vein, a fatal amount of air can pass quickly
into a vessel.
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Theoretically, 100 cm of air per second can enter through a 14-gauge needle
with a 5-cm water pressure drop across it.
Fortunately for people with subclavian lines, this is more theoretical than
actual.
When abortions were, for the most part, illegal, occasional deaths caused by
air emboli were encountered.
This occurred following dilatation of the cervical os, with resultant tears of
the margins of the placenta or the cervical veins.
Thus, in one case, after having an illegal abortion, the woman left the
premises, only to collapse and die 2 h later.
At autopsy, air could be seen in the inferior vena cava, right atrium, and
right ventricle.
Death caused by air embolism in association with pregnancy may also occur
secondary to cesarean section and placenta previa.
Just as in an abortion, there can be a time delay prior to the onset of the fatal
air embolus.
In deaths of pregnant females during sexual intercourse, one should always
suspect air emboli.
This occurs during oral–genital intercourse, with the partner blowing air into
the vagina during cunnilingus.
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The second case involved an obese 40-year-old man who was prone in the
semi knee-chest position for a lumbar laminectomy.
Five hours into the procedure, he developed bradycardia and an agonal
rhythm. The autopsy revealed air in the right ventricle, with beading of the
epicardial veins by air bubbles.
The third case was a 39-year-old woman who went into premature labor.
She presented with vaginal bleeding.
On admission to the hospital, she had a complete central placenta previa and
a breech presentation.
The child was delivered by cesarean section at 8:51 in the evening.
The operation was over at 9:30 p.m. She then was returned to the recovery
room. At midnight, she was taken to her room.
As she was being placed into bed, she had a grandma seizure and went into
cardiopulmonary arrest.
Attempts at resuscitation were unsuccessful.
At autopsy, there was air in the right atrium and ventricle with beading of
the epicardial veins by massive numbers of air bubbles.
In a living patient, the diagnosis of venous air embolism to the heart can
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In the deceased individual, to make the diagnosis of air embolism, one must
consider the diagnosis prior to the autopsy.
The first step may be a chest X-ray to look for air in the heart.
A Y-shaped incision can then be made into the skin and musculature of the
chest and the skin and muscle retracted.
Instead of then removing the chest plate in the ordinary way, a “window”
should be cut in the sternum and ribs overlying the heart.
The bony plate should then be retracted very carefully, so as not to introduce
air into the venous system.
The pericardial sac can then be cut open and the heart visualized.
The epicardial veins should be examined for the presence of air.
One or two bubbles in an epicardial vein do not make a diagnosis of air
embolism.
Massive air embolus with air in the right atrium and ventricle.
Note outline of right ventricular wall.
With air embolism, the epicardial veins usually have a beaded appearance,
with numerous air bubbles the length of these vessels.
The pericardial sac should then be flooded, the plunger removed from a 50-
cc syringe, a large-bore needle attached, and the syringe filled with water.
The tip of the needle can then be pushed into the right ventricle.
If there is air in this chamber, it will be seen to bubble up through the water
in the syringe.
The water should then be removed and the right side of the heart opened.
The blood typically has a frothy appearance.
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Following this, the incision can be extended through the anterior abdominal
wall to the pubic area.
If the air entered in the pelvic region, the inferior vena cava is examined for
air bubbles.
One should be careful about interpreting one or two bubbles in this vessel as
evidence of air embolism.
If the deceased has been vigorously resuscitated with a thoracotomy and
internal cardiac massage, it is usually impossible to make the diagnosis of air
embolus based on the autopsy, because the air observed in vessels could be
caused by resuscitation.
The technique described to demonstrate air in the heart using a 50-cc syringe
is very basic and very crude.
A much better and more sophisticated method is to use an aspirometer.
This device not only demonstrates the presence of air but measures the
amount and stores it for subsequent analysis by gas chromatography.
Embolized air differs from atmospheric air in that CO2 is less than 15%; N2
is higher than 70% and O2 is reduced, usually measuring between 8 and
15%.
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