Decompression sickness: Difference between revisions

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==Background==
==Background==
*Dissolved inert gases (e.g. Nitrogen) come out of solution and form bubbles in blood and tissue
*Also known as the bends
*Dissolved Nitrogen and occasionally helium come out of solution and form bubbles in blood and tissue


==Clinical Features==
==Clinical Features==
*Symptom typically start soon after surfacing
**42% in 1 hr, 60% in 3 hr, and 98% in 24 hr<ref>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. </ref>
**CNS cases present more rapidly – 56% within 10 mins<ref>Francis TJ, et al. Central nervous system decompression sickness: latency of 1070 human cases. Undersea Biomed Res. 1988; 15:403–417.</ref>
**Some symptoms can be delayed for days<ref>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.</ref>
===Type I (Pain only DCS)===
===Type I (Pain only DCS)===
*Involves the joints, extremities, and skin ("cutis marmorata")
*Involves the joints, extremities, skin (livedo reticularis/cutis marmorata), and constitutional symptoms
*Usually only single joint is involved
*Usually only single joint is involved
===Type II (Serious DCS)===
===Type II (Serious DCS)===
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**Cough, hemoptysis, dyspnea, substernal chest pain
**Cough, hemoptysis, dyspnea, substernal chest pain


===Type III (Type II + 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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==Management==
==Management==
'''Treatment based almost solely on case reports and series'''
*ABCs/BLS/ACLS
*100% NRB regardless of SpO2
*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>
*Hyperbaric oxygen
**Effective even in delayed cases
*Contact Divers Alert Medicine (DAN) at 1-800-446-2671
**Similar function as to poison control
*Consider adjuncts
**Lidocaine
**Perfluorocarbon emulsions


==Disposition==
==Disposition==
*Hyperbaric chamber and admission
==Prognosis==
*At an average of 6.1 yrs, almost 50% of patients had impairments<ref>Vann RD, et al. Decompression illness. Lancet. 2011; 377(9760):153-164.</ref>
**These include impaired urination, defication, and sexual function


==See Also==
==See Also==
*[[Scuba diving emergencies]]
*[[Scuba diving emergencies]]
*[[Arterial gas embolism]]


==External Links==
==External Links==

Revision as of 01:39, 2 March 2015

Background

  • Also known as the bends
  • Dissolved Nitrogen and occasionally helium come out of solution and form bubbles in blood and tissue

Clinical Features

  • Symptom typically start soon after surfacing
    • 42% in 1 hr, 60% in 3 hr, and 98% in 24 hr[1]
    • CNS cases present more rapidly – 56% within 10 mins[2]
    • Some symptoms can be delayed for days[3]

Type I (Pain only DCS)

  • Involves the joints, extremities, skin (livedo reticularis/cutis marmorata), and constitutional symptoms
  • Usually only single joint is involved

Type II (Serious DCS)

  • 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") involvment
    • Vertigo, hearing loss, tinnitus
      • Differentiated from inner ear barotrauma which usually occurs on descent
  • 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

Workup

Decompression sickness is a clinical diagnosis

  • In patients that are ambiguous or decompensated, consider additional w/u without delaying definitive treatment
  • Other considerations
    1. Fingerstick
    2. CBC
    3. Chem10
    4. Lactate
    5. PT/PTT
    6. VBG (or ABG)
    7. Ethanol level
    8. Consider UDT

Management

Treatment based almost solely on case reports and series

  • ABCs/BLS/ACLS
  • 100% NRB regardless of SpO2
  • Keep supine, Trendelenburg not recommended[4]
  • Hyperbaric oxygen
    • Effective even in delayed cases
  • Contact Divers Alert Medicine (DAN) at 1-800-446-2671
    • Similar function as to poison control
  • Consider adjuncts
    • Lidocaine
    • Perfluorocarbon emulsions

Disposition

  • Hyperbaric chamber and admission

Prognosis

  • At an average of 6.1 yrs, almost 50% of patients had impairments[5]
    • These include impaired urination, defication, and sexual function

See Also

External Links

Sources

  1. ↑ 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.
  2. ↑ Francis TJ, et al. Central nervous system decompression sickness: latency of 1070 human cases. Undersea Biomed Res. 1988; 15:403–417.
  3. ↑ 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.
  4. ↑ Moon RE, ry sl. Guidelines for treatment of decompression illness. Aviat Space Environ Med. 1997; 68:234–243.
  5. ↑ Vann RD, et al. Decompression illness. Lancet. 2011; 377(9760):153-164.
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