Decompression sickness: Difference between revisions
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===Type I (Pain only DCS)=== | ===Type I (Pain only DCS)=== | ||
*Involves the joints and extremities, with constitutional symptoms | *Involves the [[arthralgia|joints]] and extremities, with constitutional symptoms | ||
*Usually only single joint is involved, most commonly: | *Usually only single joint is involved, most commonly: | ||
**Shoulder | **Shoulder | ||
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**Knee | **Knee | ||
*Skin and lymphatics | *Skin and lymphatics | ||
** | **[[Pruritus]], stinging, [[paresthesias]], hot/cold sensations | ||
**Fine scarletiniform rash from nitrogen movement through sweat glands | **Fine scarletiniform [[rash]] from nitrogen movement through sweat glands | ||
**Cutis marmorata - marbling rash, purplish-bluish discoloration, otherwise common and normal in infants | **Cutis marmorata - marbling rash, purplish-bluish discoloration, otherwise common and normal in infants | ||
**Pitting edema, peripheral swelling from lymphatic blockage | **Pitting edema, peripheral swelling from lymphatic blockage | ||
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*Some consider multiple joint involvement qualifies as Type II | *Some consider multiple joint involvement qualifies as Type II | ||
*Spinal cord involvement | *Spinal cord involvement | ||
**Ascending paralysis | **Ascending [[weakness|paralysis]] | ||
**Signs often cannot be traced to single location in the cord (may have skip lesions) | **Signs often cannot be traced to single location in the cord (may have skip lesions) | ||
***Limb weakness, paresthesias, or paralysis | ***Limb weakness, paresthesias, or paralysis | ||
***Urinary retention, fecal incontinence, or priapism | ***[[Urinary retention]], fecal incontinence, or [[priapism]] | ||
*Vestibular ("staggers") involvement | *Vestibular ("staggers") involvement | ||
**Vertigo, hearing loss, tinnitus | **[[Vertigo]], [[hearing loss]], [[tinnitus]] | ||
***Differentiated from inner ear barotrauma which usually occurs on descent | ***Differentiated from inner ear barotrauma which usually occurs on descent | ||
*Pulmonary "chokes" | *Pulmonary "chokes" | ||
**Cough, hemoptysis, dyspnea, substernal chest pain | **[[Cough]], [[hemoptysis]], [[dyspnea]], substernal [[chest pain]] | ||
===Type III (Type II + [[Arterial gas embolism|gas embolism]])=== | ===Type III (Type II + [[Arterial gas embolism|gas embolism]])=== | ||
*Variety of stroke symptoms/signs | *Variety of [[stroke]] symptoms/signs | ||
**May spontaneously resolve | **May spontaneously resolve | ||
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*If due to high altitude aviation or hypobarics | *If due to high altitude aviation or hypobarics | ||
**Descend to ground level ASAP | **Descend to ground level ASAP | ||
*Contact Divers Alert | *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 | ||
**O2 with tight fitting mask during flight | **[[O2]] with tight fitting mask during flight | ||
*Consider adjuncts | *Consider adjuncts such as [[Lidocaine]], Perfluorocarbon emulsions | ||
==Disposition== | ==Disposition== | ||
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==External Links== | ==External Links== | ||
==References== | ==References== |
Revision as of 17:29, 28 September 2019
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
- Pruritus, 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.