eMedicine Specialties > Emergency Medicine > Environmental

Barotrauma: Follow-up

Author: Joseph Kaplan, MD, MS, FACEP, Attending Physician, Department of Emergency Medicine, Martin Army Community Hospital, Fort Benning, Georgia
Coauthor(s): Marshall E Eidenberg, DO, Staff Emergency Physician, Via Christi Regional Medical Center
Contributor Information and Disclosures

Updated: Sep 29, 2009

Follow-up

Further Inpatient Care

  • Patients may require multiple recompression "dives" in a hyperbaric oxygen chamber to reverse neurologic impairment or to treat air emboli.
  • Patients with continued pain despite appropriate treatment at sea level require recompression.
  • Patients who are seriously ill or do not respond to initial treatment may require higher pressure recompressions at 4-5 atm of absolute pressure and may need breathing gas of 50% helium/50% oxygen mixture (heliox).
  • No definitive studies have proven that other modalities provide increased long-term benefit.

Further Outpatient Care

  • Outpatient care is based on the type of dysbaric injury.
  • Adequate hydration and pain control are the hallmarks of outpatient care.
  • Of key importance, the patient must be warned against either traveling to significant altitudes or diving again too soon after barotrauma.
  • Recommendations for recovery time vary depending on the individual and amount of barotrauma.
  • Consult a dive medical officer (hyperbaric specialist) prior to giving recommendations to patients.

Inpatient & Outpatient Medications

  • Sinus and middle ear squeeze are treated identically.
    • Decongestants are used to reduce the pressure differential. Administer oxymetazoline (Afrin) 0.05%, 2 squirts each nostril bid. Performing the Valsalva maneuver immediately after spray forces the medication into the osteo and helps to open them quickly.
    • Administer pseudoephedrine (Sudafed) 60-120 mg PO bid/qid.
    • Anti-inflammatory medications treat the pain. Administer aspirin 325-650 mg PO q4-6h. NSAIDs also may be used in standard dosages.
    • Narcotic analgesics may be appropriate to treat more severe pain, eg, acetaminophen 300 mg with codeine 30 mg (Tylenol #3) 1-2 tablets PO q4-6h.

Transfer

  • Patients with DCS type II or severe AGE should be transferred to a recompression chamber. The chamber specialist must be contacted prior to any transfer to determine availability. When presenting the case, the dive medical officer needs to know the following signs and symptoms:
    • Vital signs
    • Pertinent medical symptoms (especially neurologic)
    • Time last dive finished
    • Onset of symptoms
    • Length of dive
    • Depth of dive
    • Decompression stops (length of time and depth)
    • Any flight or change in altitude after dive
  • If the patient is to be transferred by air, the aircraft must stay below 1000 ft if possible, depending on the terrain, or be transported in a pressurized aircraft. Flight crew must be aware of the patient's condition to assist the pilot in keeping the aircraft fully pressurized before attaining altitude.

Deterrence/Prevention

  • Any patient who sustains pulmonary barotrauma should not dive again.
  • Patients with asthma, Marfan syndrome, or COPD are at very high risk of pneumothorax and should be warned against diving.
  • Avid divers should be warned against multiple daily dives, diving and flying on the same day, and trying to "shave" their dive profile.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis of decompression sickness in a patient who has been diving or in a patient who has been found unresponsive in an environment that is frequented by divers
  • Failure to consider this diagnosis in someone who has been performing training dives in a swimming pool (since most decompression injuries occur at relatively shallow depth)
  • Failure to appropriately counsel a patient against flying after complaints and history suggestive of barotrauma
  • Attributing extremity symptoms to hypothermic insult instead of DCS of the extremities or nerves
  • Attributing musculoskeletal pain after a history of diving or being under compression to simple sprains or strains

Special Concerns

  • Children younger than 12 years should not use self-contained underwater breathing apparatus (SCUBA) equipment. In this article, all patients are considered adults. Pulmonary barotrauma can occur even on the surface while training for other activities, so children are not exempt from these conditions.
  • Newer dive computers that "promise" longer bottom times modify the US Navy dive tables, potentially causing an increased risk of DCS.
  • Women are theoretically at a slightly higher risk for DCS as a result of the increased fat percentage in their bodies. More nitrogen gas can dissolve in the fat, which eventually must come out as the patient surfaces.
  • Pregnant women should not dive due to the increased risk of birth defects and risk of fetal decompression disease. Therapeutic abortion is not recommended, and several normal uncomplicated pregnancies have been reported in women who continued to dive.
  • During their training, divers are instructed not to fly for 24 hours after diving. This should be slightly modified to no flying for 24-48 hours after resolution of DCS type I injuries. The longer the interval between resolution of symptoms and flying, the greater the reduction of risk of DCS injuries in the air.
 


More on Barotrauma

Overview: Barotrauma
Differential Diagnoses & Workup: Barotrauma
Treatment & Medication: Barotrauma
Follow-up: Barotrauma
Multimedia: Barotrauma
References
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References

  1. Blatteau JE, Gempp E, Galland FM, et al. Aerobic exercise 2 hours before a dive to 30 msw decreases bubble formation after decompression. Aviat Space Environ Med. Jul 2005;76(7):666-9. [Medline].

  2. Dujic Z, Palada I, Obad A. Exercise during a 3-min decompression stop reduces postdive venous gas bubbles. Med Sci Sports Exerc. Aug 2005;37(8):1319-23. [Medline].

  3. Hickey MJ, Zanetti CL. Delayed-onset cerebral arterial gas embolism in a commercial airline mechanic. Aviat Space Environ Med. Sep 2003;74(9):977-80. [Medline].

  4. Tschopp S, Keel M, Schmutz J, Maggiorini M. Abdominal compartment syndrome after scuba diving. Intensive Care Med. Nov 2005;31(11):1595. [Medline].

  5. [Best Evidence] Eckmann DM, Zhang J, Lampe J, Ayyaswamy PS. Gas embolism and surfactant-based intervention: implications for long-duration space-based activity. Ann N Y Acad Sci. Sep 2006;1077:256-69. [Medline].

  6. Ball R, Auker CR, Ford GC, Lawrence D. Decompression sickness presenting as forearm swelling and peripheral neuropathy: a case report. Aviat Space Environ Med. Jul 1998;69(7):690-2. [Medline].

  7. Bond JP, Kirschner DA. Spinal cord myelin is vulnerable to decompression. Mol Chem Neuropathol. Apr 1997;30(3):273-88. [Medline].

  8. Boussuges A, Blanc P, Molenat F, et al. Haemoconcentration in neurological decompression illness. Int J Sports Med. Jul 1996;17(5):351-5. [Medline].

  9. Bove AA. Risk of decompression sickness with patent foramen ovale. Undersea Hyperb Med. 1998;25(3):175-8. [Medline].

  10. Butler WP, Topper SM, Dart TS. USAF treatment table 8: treatment for altitude decompression sickness. Aviat Space Environ Med. Jan 2002;73(1):46-9. [Medline].

  11. Camporesi EM. Diving and pregnancy. Semin Perinatol. Aug 1996;20(4):292-302. [Medline].

  12. Cogar WB. Intravenous lidocaine as adjunctive therapy in the treatment of decompression illness. Ann Emerg Med. Feb 1997;29(2):284-6. [Medline].

  13. Colebatch HJ, Ng CK. Decreased pulmonary distensibility and pulmonary barotrauma in divers. Respir Physiol. Dec 1991;86(3):293-303. [Medline].

  14. Colebatch HJ, Smith MM, Ng CK. Increased elastic recoil as a determinant of pulmonary barotrauma in divers. Respir Physiol. Feb 1976;26(1):55-64. [Medline].

  15. Evans DE, Kobrine AI, LeGrys DC, Bradley ME. Protective effect of lidocaine in acute cerebral ischemia induced by air embolism. J Neurosurg. Feb 1984;60(2):257-63. [Medline].

  16. Files DS, Webb JT, Pilmanis AA. Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents. Aviat Space Environ Med. Jun 2005;76(6):523-9. [Medline].

  17. Germonpre P, Dendale P, Unger P, Balestra C. Patent foramen ovale and decompression sickness in sports divers. J Appl Physiol. May 1998;84(5):1622-6. [Medline].

  18. Goldenberg I, Shupak A, Shoshani O. Oxy-helium treatment for refractory neurological decompression sickness: a case report. Aviat Space Environ Med. Jan 1996;67(1):57-60. [Medline].

  19. Gustavsson LL, Hultcrantz E. [Medical aspects of diving--a sport for both women and men]. Lakartidningen. Feb 17 1999;96(7):749-53. [Medline].

  20. Hyldegaard O, Madsen J. Influence of heliox, oxygen, and N2O-O2 breathing on N2 bubbles in adipose tissue. Undersea Biomed Res. May 1989;16(3):185-93. [Medline].

  21. Kieser J, Holborow D. The prevention and management of oral barotrauma. N Z Dent J. Dec 1997;93(414):114-6. [Medline].

  22. Kimbro T, Tom T, Neuman T. A case of spinal cord decompression sickness presenting as partial Brown-Sequard syndrome. Neurology. May 1997;48(5):1454-6. [Medline].

  23. Melamed Y, Shupak A, Bitterman H. Medical problems associated with underwater diving. N Engl J Med. Jan 2 1992;326(1):30-5. [Medline].

  24. Moon RE, de Lisle Dear G, Stolp BW. Treatment of decompression illness and latrogenic gas embolism. Respir Care Clin N Am. Mar 1999;5(1):93-135. [Medline].

  25. Moon RE, Sheffield PJ. Guidelines for treatment of decompression illness. Aviat Space Environ Med. Mar 1997;68(3):234-43. [Medline].

  26. Morgenstern K, Talucci R, Kaufman MS, et al. Bilateral pneumothorax following air bag deployment. Chest. Aug 1998;114(2):624-6. [Medline].

  27. Muehlberger PM, Pilmanis AA, Webb JT, Olson JE. Altitude decompression sickness symptom resolution during descent to ground level. Aviat Space Environ Med. Jun 2004;75(6):496-9. [Medline].

  28. Parell GJ, Becker GD. Inner ear barotrauma in scuba divers. A long-term follow-up after continued diving. Arch Otolaryngol Head Neck Surg. Apr 1993;119(4):455-7. [Medline].

  29. Payne SJ, Chappell MA. Automated determination of bubble grades from Doppler ultrasound recordings. Aviat Space Environ Med. Aug 2005;76(8):771-7. [Medline].

  30. Petri NM, Andric D. Differential diagnostic problems of decompression sickness--examples from specialist physicians' practices in diving medicine. Arch Med Res. Jan-Feb 2003;34(1):26-30. [Medline].

  31. Raymond LW. Pulmonary barotrauma and related events in divers. Chest. Jun 1995;107(6):1648-52. [Medline].

  32. Reuter M, Tetzlaff K, Warninghoff V, et al. Computed tomography of the chest in diving-related pulmonary barotrauma. Br J Radiol. May 1997;70(833):440-5. [Medline].

  33. Russi EW. Diving and the risk of barotrauma. Thorax. Aug 1998;53 Suppl 2:S20-4. [Medline].

  34. Segev Y, Landsberg R, Fliss DM. MR imaging appearance of frontal sinus barotrauma. AJNR Am J Neuroradiol. Mar 2003;24(3):346-7. [Medline].

  35. Sheffield PJ. Flying after diving guidelines: a review. Aviat Space Environ Med. Dec 1990;61(12):1130-8. [Medline].

  36. Sheridan MF, Hetherington HH, Hull JJ. Inner ear barotrauma from scuba diving. Ear Nose Throat J. Mar 1999;78(3):181, 184, 186-7 passim. [Medline].

  37. Shupak A, Melamed Y, Ramon Y, et al. Helium and oxygen treatment of severe air-diving-induced neurologic decompression sickness. Arch Neurol. Mar 1997;54(3):305-11. [Medline].

  38. Smerz RW. Age associated risks of recreational scuba diving. Hawaii Med J. May 2006;65(5):140-1, 153. [Medline].

  39. US Navy. US Navy Diving Manual. Rev 4. Vol 1-5. Claitor's Publishing Division; 1999: 1:1-5, 2:13-21, 3:19-31, 8:1-68, H:1-27.

  40. Webb JT, Pilmanis AA, Balldin UI, Fischer JR. Altitude decompression sickness susceptibility: influence of anthropometric and physiologic variables. Aviat Space Environ Med. Jun 2005;76(6):547-51. [Medline].

  41. Wherrett CG, Mehran RJ, Beaulieu MA. Cerebral arterial gas embolism following diagnostic bronchoscopy: delayed treatment with hyperbaric oxygen. Can J Anaesth. Jan 2002;49(1):96-9. [Medline].

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Further Reading

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Keywords

barotrauma, the bends, caisson disease, dive medicine, hyperbaric medicine, squeeze, sinus squeeze, decompression sickness, DCS, decompression sickness type I, decompression sickness type II, middle ear squeeze, arterial gas embolism, AGE, decompression chamber, recompression, diving-related disease, diving barotrauma

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Contributor Information and Disclosures

Author

Joseph Kaplan, MD, MS, FACEP, Attending Physician, Department of Emergency Medicine, Martin Army Community Hospital, Fort Benning, Georgia
Joseph Kaplan, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Marshall E Eidenberg, DO, Staff Emergency Physician, Via Christi Regional Medical Center
Marshall E Eidenberg, DO is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital
David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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