Correct!
1. Arterial air embolism
There is air in the proximal ascending aorta and possibly coronary arteries (Figure 2).
Figure 2. CT images showing air in aorta (arrows).
While there was a small pneumothorax in the left apex, this cannot be seen in the CT scan mediastinal windows. Whether there was air in the coronary arteries is not completely clear but clearly the air in the aorta had to traverse the sinus of Valsalva in the aortic root, from whence the left and right coronary arteries arise. Then low BP may have been due to either transient air emboli obstruction in the aortic outflow tract, and/or air emboli causing obstruction in the coronary arteries leading to myocardial ischemia.
The bradycardia and ST changes could be explained by air in the right coronary arteries, but no right sided EKG was obtained. Air may also have entered both left and right coronary circulations. Since the patient had EKG and troponin evidence consistent with an ST elevation MI, it is likely that some air entered one or both of the coronary circulations or at least occluded them long enough to cause ischemia.
Although this was a non-contrasted CT, a pulmonary embolism in the traditional sense is not likely, and there was no pulmonary edema on exam or in the lung windows (not shown). A pneumothorax was present but was too small to explain the shock and did not warrant chest tube placement.
What is or are the possible mechanism(s) of the above pathology post biopsy? (Click on the correct answer to be directed to the third of six pages)