Decompression sickness: Difference between revisions
No edit summary |
|||
| (24 intermediate revisions by 6 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Also known as the bends | *Also known as "the bends" | ||
*Dissolved | *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 | |||
{{Diving Physiology}} | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 10: | Line 13: | ||
===Type I (Pain only DCS)=== | ===Type I (Pain only DCS)=== | ||
*Involves the joints | *Involves the [[arthralgia|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 | |||
**[[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)=== | ===Type II (Serious DCS)=== | ||
*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") | *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 | ||
| Line 33: | Line 46: | ||
==Workup== | ==Workup== | ||
'''Decompression sickness is a clinical diagnosis''' | '''Decompression sickness is a clinical diagnosis''' | ||
*In patients that are ambiguous or decompensated, consider additional | *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 | *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 | ||
** | **[[O2]] with tight fitting mask during flight | ||
* | *Consider adjuncts such as [[Lidocaine]], Perfluorocarbon emulsions | ||
==Disposition== | ==Disposition== | ||
| Line 68: | Line 86: | ||
*[[Scuba diving emergencies]] | *[[Scuba diving emergencies]] | ||
*[[Arterial gas embolism]] | *[[Arterial gas embolism]] | ||
*[[Diving Medicine]] | |||
*[[Hyperbaric Medicine]] | |||
==External Links== | ==External Links== | ||
== | |||
==References== | |||
<references/> | <references/> | ||
[[Category: | [[Category:Environmental]] | ||
Latest revision as of 13:13, 18 July 2020
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
Diving Physiology
- Pascals Law applies to the diving body (without air filled areas such as lungs) states that the pressure applied to any part of the enclosed liquid will be transmitted equally in all directions through the liquid.
- Boyles Law applies to the diving body's air filled areas such as lungs, sinuses, middle ear, and states that the volume and pressure of a gas at a given temperature are inversely related.
- At 2 ATA (10m/33ft) a given gas would be 1/2 it's volume, at 3 ATA (20m/66ft) it would be 1/3 it's volume and so on.
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.