(433) Fatal Venous Air Embolism in the Setting of Pulmonary Hypertension: A POCUS Diagnosis.

Introduction: Air emboli are rare and often difficult to diagnose. Transesophageal echocardiography remains the most definitive method of diagnosis, but this is not feasible in emergencies.
We present a case of fatal venous air embolism in the setting of hemodialysis with recent evidence of pulmonary hypertension. The diagnosis was made by visualizing air in the right ventricle using bedside point of care ultrasound (POCUS).

Description: An 82-year-old woman with a history of heart failure, atrial fibrillation, end-stage renal disease on hemodialysis, COPD, and type 2 diabetes was admitted to the ICU for acute on chronic hypoxic respiratory failure following an outpatient endoscopic evaluation. She developed respiratory failure from anesthesia, was intubated, and experienced asystole, achieving ROSC after one round of CPR. POCUS showed severe RV dysfunction and dilation, and no initial evidence of venous air embolism. During routine dialysis the next day, she became hypotensive and unresponsive, with air noted in the dialysis line. POCUS revealed RV strain and air bubbles in the RV outflow tract. Despite resuscitative efforts, the patient expired.

Discussion: While POCUS is not routinely used for the diagnosis of air embolism, its accessibility makes it a powerful yet practical emerging tool for the diagnosis of respiratory and cardiovascular emergencies. POCUS offers clinicians immediate visualization while avoiding additional wait time associated with other formal imaging studies.