Challenge 12

Embolic Events

An embolic event or "embolism" describes a process by which any substance that does not readily dissolve in blood enters the circulation.  Embolic substances can be solid, liquid, or gas.  Examples include blood clots, fat, air, bone marrow, amniotic fluid, and cement used in joint prostheses.  Once they enter the circulation, usually on the venous side, embolisms (or "emboli") have two possible pathways.  Most often, they follow the venous blood flow through the right side of the heart, and then travel through the pulmonary arteries to the lungs.  Here they can do serious or even fatal harm by blocking the blood flow to portions of the lungs.  Many people (30% in one study) have undiagnosed pathways from the pulmonary (right-heart) to the arterial (left-heart) circulation, and in these patients a venous embolism can bypass the lungs to become an arterial embolism.  These "paradoxical emboli" can block the circulation to vital organs, particularly the brain or heart.  Small emboli that would do only minor damage in the lungs can cause fatal harm to the brain or heart by this mechanism.   The most common source of embolism is blood clot (thrombus) from the periphery, usually from the leg veins.  These venous clots can break loose from the walls of the vein in which they were formed (e.g., the saphenous vein) and thus enter the circulation.  This mechanism of "Deep Venous Thrombosis" or "DVT" is the subject of APSS 12A.  Another common embolic mechanism is the admission or air into the venous circulation, which can occur in trauma, during surgery, or by inadvertent injection of air into any type of venous access catheter.  "Air Embolism" is the topic of APSS 12B.  In both of these subAPSS, we discuss the prevention, early detection or diagnosis, and emergency treatment of the embolic event.  Other subAPSS for future development may include fat, marrow, and amniotic fluid embolism.  

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Recent mortality rates due to arterial emboli range from 4 to 15%.1

Lyaker, M. R., Tulman, D. B., Dimitrova, G. T., Pin, R. H., & Papadimos, T. J. (2013). Arterial embolism. International Journal of Critical Illness and Injury Science, 3(1), 77–87.

Aortic atherosclerotic plaque is one of the leading sources of embolic disease.2

Kronzon I., Tunick P.A. Aortic atherosclerotic disease and stroke. Circulation. 2006;114:63–75.

Complications of arterial embolism are a leading cause of disability and death in the United States.3

Lyaker, M. R., Tulman, D. B., Dimitrova, G. T., Pin, R. H., & Papadimos, T. J. (2013). Arterial embolism. International Journal of Critical Illness and Injury Science, 3(1), 77–87.

The cost for each occurrence is an average of $66,007 per air embolism.4

Rowland, Hudson T. (2009) “When Never Happens: Implications of Medicare’s Never-Event Policy,” Marquette Elder’s Advisor: Vol. 10: Iss. 2, Article 7.

The mortality rate of central line related air emboli death ranges from 23% to 50%.5

Feil, M. (2015). Preventing Central Line Air Embolism. AJN, American Journal of Nursing,115(6), 64-69. doi:10.1097/01.naj.0000466327.76934.a0

The incidence of massive air embolism in cardiac bypass procedures is between 0.003% and 0.007% with 50% having adverse outcomes.6

Hammon, J.W., Hines, M.H. Extracorporeal Circulation. In: Cohn LH, editor. Cardiac Surgery in the Adult. 4th ed. New York: McGraw-Hill; 2012.

In Europe, there are 544,000 VTE-related deaths every year.7

Heit, JA. Poster 68 presented at: American Society of Hematology, 47th Annual Meeting, Atlanta, GA, December 10-13, 2005.

In the United States, there are 100,000 – 300,000 VTE-related deaths every year.8

Office of the Surgeon General (US. (2008). The Surgeon General’s call to action to prevent deep vein thrombosis and pulmonary embolism.

Every year, there are approximately 10 million cases of VTE worldwide.9

Jha, A. K., Larizgoitia, I., Audera-Lopez, C., Prasopa-Plaizier, N., Waters, H., & Bates, D. W. (2013). The global burden of unsafe medical care: Analytic modelling of observational studies. BMJ Quality & Safety, 22(10), 809-815.

In the U.S. and Europe, VTE-related events kill more people than AIDS, breast cancer, prostate cancer and motor vehicle crashes combined.10

Cohen AT, Agnelli G, Anderson FA, et al. Venous thromboembolism (VTE) in Europe. Thromb Haemost. 2007;98:756-764.