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Home | CCC | Decompression Sickness

Decompression Sickness

by Dr Chris Nickson, last update April 9, 2019

OVERVIEW

Decompression sickness, is a form of decompression illness, where a reduction in ambient pressure (‘decompression’) leads to de no intravascular and extravascular bubble formation with pathological consequences

  • decompression sickness = ‘small bubbles’
  • arterial gas embolism (AGE) is the other form of decompression illness, characterised by ‘big bubbles’ that are introduced into the circulation following alveolar rupture during decompression
  • the altitude threshold for DCS is generally 18,000 ft
  • most diving is done @ 2-4 atmospheres

PATHOPHYSIOLOGY

Typically affects

  • divers
  • caisson workers
  • aviators
  • astronauts

Mechanism

  1. release of bubbles of inert gas into the blood and tissues with mechanical, embolic and biochemical effects
  2. hypoxia induced vasoconstriction -> increased pulmonary capillary pressure, alveolar fluid transudation, decreased alveolar fluid clearance
  3. endothelial activation -> capillary leak
  4. increased leukocyte adhesion, inflammatory response and reperfusion injury
  5. vessel obstruction
  6. tissue distortion causing pain
  7. embolisation (25% of people have PFO so can embolise to the brain)

CLINICAL FEATURES

  • cough -> respiratory failure

Type I Decompression Sickness

  • musculoskeletal pain (limbs, shoulders, elbows, hips, knees)
  • anorexia
  • malaise
  • fatigue
  • orange appearance of skin from local lymphatic obstruction
  • pruritis (ears, trunk, wrists, hands -> trunk)
  • cyanosis

Type II Decompression Sickness

  • substernal discomfort
  • pleuritic chest pain
  • tachypnoea
  • non-productive cough
  • right heart strain
  • cardiovascular collapse
  • paraesthesia
  • full paralysis
  • convulsions
  • cerebellar signs

MANAGEMENT

Prevention

  • no flying for 24 hours after a dive

Proven Benefit

  • FiO2 1.0 (enhanced de-nitrogenation)
  • CPR
  • isotonic fluid resuscitation — dehydration due to capillary leak, cold diuresis and immersion diuresis
  • hyperbaric therapy (even very late) — 2-3 atm, repeated until no further benefil
  • intubate and fill cuff with saline

Unproven Benefit

  • Trendelenburg position (not longer than 30min c/o cerebral oedema)
  • avoid glucose IV
  • avoid hypertension and anxiety
  • corticosteroids
  • benzodiazepine for seizures
  • aspirin

Questionable Benefit

  • Ca2+ blockers
  • lignocaine 1mg/kg
  • NSAIDS, heparin, prostaglandin
  • induced hypothermia
  • cerebral venoarterial perfusion

Proven Detrimental

  • recompression while submerged
  • alcohol
  • analgesics
  • delayed transport to hyperbaric center
  • additional hypobaric exposures

Transfer by helicopter at 300m, on land or pressurize to sea-level


References and Links

  • Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. Recompression and adjunctive therapy for decompression illness. Cochrane Database Syst Rev. 2012 May 16;5:CD005277. PMID: 22592704.
  • Lynch JH, Bove AA. Diving medicine: a review of current evidence. J Spec Oper Med. 2009 Fall;9(4):72-9. PMID: 20112651.
  • McMullin AM. Scuba diving: What you and your patients need to know. Cleve Clin J Med. 2006 Aug;73(8):711-2, 714, 716 passim. PMID: 16913196.
  • Sebel PS. 20,000 leagues under the sea. Anesth Analg. 2010 Sep;111(3):589-90. doi: 10.1213/ANE.0b013e3181eb64de. PubMed PMID: 20733161.
  • Tetzlaff K, Shank ES, Muth CM. Evaluation and management of decompression illness–an intensivist’s perspective. Intensive Care Med. 2003 Dec;29(12):2128-36. PMID: 14600806.
  • Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet. 2011 Jan 8;377(9760):153-64. doi: 10.1016/S0140-6736(10)61085-9. Review. PubMed PMID: 21215883.

CCC 700 6

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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