Decompression sickness: Difference between revisions
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*Also known as "the bends" | *Also known as "the bends" | ||
*Dissolved nitrogen (and occasionally helium) comes out of solution and forms bubbles in blood and tissue | *Dissolved nitrogen (and occasionally helium) comes out of solution and forms bubbles in blood and tissue | ||
*Occurs in rapid ascent in diving | *Occurs in rapid ascent in diving, and more rarely in military operations rapid ascent in high altitude aviation or hypobarics training | ||
==Clinical Features== | ==Clinical Features== | ||
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===Type I (Pain only DCS)=== | ===Type I (Pain only DCS)=== | ||
*Involves the joints and extremities, with constitutional symptoms | *Involves the joints and extremities, with constitutional symptoms | ||
*Usually only single joint is involved | *Usually only single joint is involved, most commonly: | ||
**Shoulder | |||
**Elbow | |||
**Knee | |||
*Skin and lymphatics | *Skin and lymphatics | ||
**Pruritis, stinging, paresthesias, hot/cold sensations | **Pruritis, stinging, paresthesias, hot/cold sensations | ||
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==Workup== | ==Workup== | ||
'''Decompression sickness is a clinical diagnosis''' | '''Decompression sickness is a clinical diagnosis''' | ||
*Pain may be reduced by BP cuff inflation over the joint to 150-200 mmHg | |||
*In patients that are ambiguous or decompensated, consider additional workup without delaying definitive treatment | *In patients that are ambiguous or decompensated, consider additional workup without delaying definitive treatment | ||
*Other considerations | *Other considerations | ||
* | **Fingerstick | ||
* | **CBC | ||
* | **Chem10 | ||
* | **Lactate | ||
* | **PT/PTT | ||
* | **VBG (or ABG) | ||
* | **Ethanol level | ||
* | **Consider UDT | ||
==Management== | ==Management== | ||
'''Treatment based almost solely on case reports and series''' | '''Treatment based almost solely on case reports and series''' | ||
*ABCs/BLS/ACLS | *ABCs/BLS/ACLS | ||
*100% NRB regardless of SpO2 | *Denitrogenation with 100% NRB regardless of SpO2, and continue 2 hours after symptom resolution | ||
*Keep supine, Trendelenburg not recommended<ref>Moon RE, ry sl. Guidelines for treatment of decompression illness. Aviat Space Environ Med. 1997; 68:234–243.</ref> | *Keep supine, Trendelenburg not recommended<ref>Moon RE, ry sl. Guidelines for treatment of decompression illness. Aviat Space Environ Med. 1997; 68:234–243.</ref> | ||
*Initiate IV crystalloid fluids, rate of 250 cc/hr for first few hours | |||
*Hyperbaric oxygen | *Hyperbaric oxygen | ||
**Effective even in delayed cases | **Effective even in delayed cases | ||
**Immediate recompression for suspicion of Type 2 DCS, in consultation with hyperbarics specialist | |||
**Do not wait for recompression, but if delayed presentation, may recompress up to 14 days after symptom onset<ref>Marx et al. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th Ed. 2013. Ch 143. Pg. 1925.</ref><ref>Edmonds C et al. Diving and Subaquatic Medicine, Fifth Edition. 2015. Decompression Sickness: Treatments. Pg 173.</ref> | **Do not wait for recompression, but if delayed presentation, may recompress up to 14 days after symptom onset<ref>Marx et al. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th Ed. 2013. Ch 143. Pg. 1925.</ref><ref>Edmonds C et al. Diving and Subaquatic Medicine, Fifth Edition. 2015. Decompression Sickness: Treatments. Pg 173.</ref> | ||
*Contact Divers Alert | *If due to high altitude aviation or hypobarics | ||
**Descend to ground level ASAP | |||
*Contact Divers Alert Network (DAN) Emergency Hotline at 1-919-684-2948<ref>https://www.diversalertnetwork.org/medical/ Accessed 11/15/2018</ref> | |||
**Similar function as to poison control | **Similar function as to poison control | ||
* | *If patient requires transport to another facility, consider ground transport, air transport at max of 1000 ft, or air transport with pressurization capability | ||
**[[Lidocaine]] | **O2 with tight fitting mask during flight | ||
*Consider adjuncts such as [[Lidocaine]], Perfluorocarbon emulsions | |||
==Disposition== | ==Disposition== | ||
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==External Links== | ==External Links== | ||
==References== | ==References== |
Revision as of 21:05, 15 November 2018
Background
- Also known as "the bends"
- Dissolved nitrogen (and occasionally helium) comes out of solution and forms bubbles in blood and tissue
- Occurs in rapid ascent in diving, and more rarely in military operations rapid ascent in high altitude aviation or hypobarics training
Clinical Features
- Symptom typically start soon after surfacing
Type I (Pain only DCS)
- Involves the joints and extremities, with constitutional symptoms
- Usually only single joint is involved, most commonly:
- Shoulder
- Elbow
- Knee
- Skin and lymphatics
- Pruritis, stinging, paresthesias, hot/cold sensations
- Fine scarletiniform rash from nitrogen movement through sweat glands
- Cutis marmorata - marbling rash, purplish-bluish discoloration, otherwise common and normal in infants
- Pitting edema, peripheral swelling from lymphatic blockage
Type II (Serious DCS)
- Some consider multiple joint involvement qualifies as Type II
- Spinal cord involvement
- Ascending paralysis
- Signs often cannot be traced to single location in the cord (may have skip lesions)
- Limb weakness, paresthesias, or paralysis
- Urinary retention, fecal incontinence, or priapism
- Vestibular ("staggers") involvement
- Vertigo, hearing loss, tinnitus
- Differentiated from inner ear barotrauma which usually occurs on descent
- Vertigo, hearing loss, tinnitus
- Pulmonary "chokes"
- Cough, hemoptysis, dyspnea, substernal chest pain
Type III (Type II + gas embolism)
- Variety of stroke symptoms/signs
- May spontaneously resolve
Differential Diagnosis
Diving Emergencies
- Barotrauma of descent
- Otic barotrauma
- Pulmonary barotrauma
- Sinus barotrauma
- Mask squeeze
- Barodentalgia (trapped dental air causing squeeze)
- Barotrauma of ascent
- Pulmonary barotrauma (pulmonary overpressurization syndrome)
- Decompression sickness (DCS)
- Arterial gas embolism
- Alternobaric vertigo
- Facial baroparesis (Bells Palsy)
- At depth injuries
- Oxygen toxicity
- Nitrogen narcosis
- Hypothermia
- Contaminated gas mixture (e.g. CO toxicity)
- Caustic cocktail from rebreathing circuit
Workup
Decompression sickness is a clinical diagnosis
- Pain may be reduced by BP cuff inflation over the joint to 150-200 mmHg
- In patients that are ambiguous or decompensated, consider additional workup without delaying definitive treatment
- Other considerations
- Fingerstick
- CBC
- Chem10
- Lactate
- PT/PTT
- VBG (or ABG)
- Ethanol level
- Consider UDT
Management
Treatment based almost solely on case reports and series
- ABCs/BLS/ACLS
- Denitrogenation with 100% NRB regardless of SpO2, and continue 2 hours after symptom resolution
- Keep supine, Trendelenburg not recommended[4]
- Initiate IV crystalloid fluids, rate of 250 cc/hr for first few hours
- Hyperbaric oxygen
- If due to high altitude aviation or hypobarics
- Descend to ground level ASAP
- Contact Divers Alert Network (DAN) Emergency Hotline at 1-919-684-2948[7]
- Similar function as to poison control
- If patient requires transport to another facility, consider ground transport, air transport at max of 1000 ft, or air transport with pressurization capability
- O2 with tight fitting mask during flight
- Consider adjuncts such as Lidocaine, Perfluorocarbon emulsions
Disposition
- Hyperbaric chamber and admission
Prognosis
- One study showed at an average of 6.1 yrs, almost 50% of patients had impairments[8]
- These include impaired urination, defication, and sexual function
See Also
External Links
References
- ↑ Navy Department. US Navy Diving Manual. Revision 6. Vol 5: Diving Medicine and Recompression Chamber Operations. NAVSEA 0910-LP-106-0957. Washington, DC: Naval Sea Systems Command, 2008.
- ↑ Francis TJ, et al. Central nervous system decompression sickness: latency of 1070 human cases. Undersea Biomed Res. 1988; 15:403–417.
- ↑ Freiberger JJ, et al. The relative risk of decompression sickness during and after air travel following diving. Aviat Space Environ Med. 2002; 73:980–984.
- ↑ Moon RE, ry sl. Guidelines for treatment of decompression illness. Aviat Space Environ Med. 1997; 68:234–243.
- ↑ Marx et al. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th Ed. 2013. Ch 143. Pg. 1925.
- ↑ Edmonds C et al. Diving and Subaquatic Medicine, Fifth Edition. 2015. Decompression Sickness: Treatments. Pg 173.
- ↑ https://www.diversalertnetwork.org/medical/ Accessed 11/15/2018
- ↑ Vann RD, et al. Decompression illness. Lancet. 2011; 377(9760):153-164.