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Barotrauma: Treatment & Medication
Updated: Sep 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Prehospital Care
Prehospital care should consist of assessing the ABCs and correcting any immediate life-threatening conditions while maintaining adequate oxygenation and perfusion. Patients should be placed on high-flow oxygen and have large-bore venous access with isotonic fluid infusion to maintain blood pressure and pulse. Although research is being done on the use of surfactants being given prior to high-risk activities such as deep dives or space missions, it is still in the bench research stage of development.5 Several in vitro studies have been promising, and there is hope that surfactant use will someday greatly decrease the frequency of barotrauma.
Emergency Department Care
- Stabilize the airway, breathing, and circulation.
- Intubation
- Perform endotracheal intubation on a patient who has an unstable airway or has persistent hypoxia despite breathing 100% oxygen.
- Perform tube thoracostomy to evacuate a pneumothorax or hemothorax.
- Perform nasotracheal or orotracheal intubation when appropriate.
- Needle decompression of the chest is indicated for suspected tension pneumothorax. A large-bore needle is inserted over the rib in the second intercostal space, midclavicular line.
- Foley catheterization
- Place a Foley catheter in patients who present with shock to assist in assessing volume and hydration status. Normal urine output is 1 mL/kg of body weight per hour.
- Place a Foley catheter in patients with spinal cord manifestations of DCS who are unable to void due to a neurogenic bladder.
- Continue intravenous hydration to maintain adequate blood pressure.
- Recompression therapy should be performed at a dive chamber by a dive medical officer or personnel certified in hyperbaric medicine. Indications include spinal cord injury and neurologic impairment.
- Sinus squeeze
- Symptomatic therapy with decongestants, both oral and nasal, is indicated.
- Pain control should be instituted with nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic analgesic medications.
- Middle ear squeeze: Severity and treatment are based on the Teed scale.
- Mild (Teed 0-2): Decongestants, both nasal (0.05% oxymetazoline hydrochloride spray bid for 3 d) and oral (pseudoephedrine 60-120 mg bid/qid) are administered.
- Moderate (Teed 3-4): Treatment is same as above, but a short course of oral steroids, such as prednisone 60 mg/d for 6 days then tapering over 7-10 days, may be needed. If TM has ruptured or water is contaminated, consider antibiotics that treat acute otitis media.
- Severe (Teed 5): Treatment is same as above. Consider myringotomy if the above have failed. Control pain with Tylenol with codeine (acetaminophen 300 mg with codeine phosphate 30 mg) 1-2 tablets every 4-6 hours.
- Decompression sickness type I
- These patients should receive high-flow oxygen via a nonrebreather mask.
- After establishing intravenous access, administer isotonic fluids (isotonic sodium chloride solution or lactated Ringer solution) to maintain urine output at 1-2 mL/kg/h.
- These patients should also receive aspirin 325-650 mg for antiplatelet effects as well as pain control.
- Obtain appropriate radiographs to evaluate for fractures or dislocations.
- If a patient's medical condition continues to deteriorate, he or she is then classified as having DCS type II.
- Currently, the United States Air Force is developing a new, shorter Treatment Table 8 (TT8) that allows for dives of shorter duration (lasting 30 min with air breaks between each 2 atmospheric absolute [ATA] dive). This is done with 4 dives each for 30 minutes with 10-minute air breaks. The TT8 should only be used to treat DCS type I when symptoms occur within 2 hours of altitude chamber or flight and when partial response on oxygen after 10 minutes has occurred. Treatment Table 6 (TT6) should be used immediately if symptoms persist after the first 30-minute interval or recur within 24 hours.
- Decompression sickness type II
- All of the interventions for DCS type I are appropriate for DCS type II.
- These patients need recompression therapy to resolve their symptoms.
- The most appropriate management is to transfer the patient to the nearest hyperbaric chamber.
- Arterial gas embolism
- Patients with AGE can have mild symptoms from a small embolism that may improve with therapy for DCS type I, including intravenous hydration, high-flow oxygen, and aspirin.
- Patients with severe AGE (ie, unstable blood pressure, respirations, neurologic status) require immediate recompression therapy in a hyperbaric chamber.
Consultations
Consult a specialist at a recompression chamber for any patient with DCS type II or an unstable AGE.
- The recompression chamber specialist must be contacted prior to transfer to determine chamber availability.
- A complete list of recompression chambers is available from the Divers' Alert Network and is only provided by calling (919) 684-8111 or (919) 684-4326.
Medication
The primary medications in treatment of dysbaric injuries are oxygen, isotonic fluids, anti-inflammatory medications, decongestants, and analgesics.
Acetylsalicylic acid
This agent is used to control pain and inflammation and to inhibit platelet aggregation.
Aspirin (Anacin, Ascriptin, Bayer aspirin)
Blocks prostaglandin synthetase action, which, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2. By inhibiting prostaglandin synthesis, aspirin may also inhibit key steps in the inflammation process.
Adult
325-650 mg/d PO
Pediatric
15 mg/kg/d PO
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome, do not use in children ( <16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, history of blood coagulation defects, or patients taking anticoagulants
Decongestants
These agents are used to open blocked sinuses or eustachian tubes to allow for equalization of pressure.
Oxymetazoline (Afrin, Allerest)
Stimulates alpha-adrenergic receptors and causes vasoconstriction when applied directly to mucous membranes. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.
Adult
2 sprays of 0.05% solution in each nostril bid
Pediatric
<6 years: 2-3 gtt of 0.025% solution in each nostril bid, am and hs
>6 years: Administer as in adults
Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in an increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents, such as ephedrine, may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine; phenothiazines may reverse action of nasal decongestants such as oxymetazoline; TCAs potentiate vasopressor response and may result in dysrhythmias
Documented hypersensitivity; MAOI therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, coronary artery disease, ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, patients with hypertension may experience change in blood pressure; do not use topical decongestants for longer than 3-5 d
Pseudoephedrine (Silfedrine, Sudafed)
Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors.
Adult
60-120 mg PO bid/qid
Pediatric
<6 years: Not established
6-12 years: 30 mg PO qid
>12 years: Administer as in adults
Propranolol, MAOIs, and sympathomimetic agents may increase toxicity of pseudoephedrine; methyldopa and reserpine may reduce effects of pseudoephedrine
Documented hypersensitivity; severe anemia; postural hypertension and hypotension; closed-angle glaucoma; head trauma; cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure
Narcotic analgesics
These agents are used to treat severe pain resulting from dysbaric injuries.
Acetaminophen with codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain.
Adult
1-2 tabs PO q4-6h prn
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Glucocorticoids
In studies of patients with spinal cord trauma, methylprednisolone has been shown to improve long-term neurologic outcome. It has not yet been approved for DCS but should be considered a treatment option.
Methylprednisolone (Solu-Medrol, Depo-Medrol)
By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation. May also prevent neuronal damage by inhibiting prostaglandin synthesis.
Adult
30 mg/kg IV bolus initial, followed by 5.4 mg/kg/h IV
Pediatric
Administer as in adults
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Inert gas
Heliox may initially accelerate bubble shrinkage when administered on the surface. Heliox may be superior to 100% oxygen for treatment at sea level.
Inert Gas
Oxygen
First line of treatment in dysbaric injuries. Administer at high flow with a tight-fitting nonrebreather mask.
Adult
15 L/min via a high-flow nonrebreather mask (In military operations, patient is administered oxygen via an aviator's mask labeled ground-level oxygen [GLO]; is standard treatment used in all cases of dysbarism involving military missions and patient descent)
Pediatric
Administer as in adults
None reported
None reported
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Inspired oxygen concentrations from 50-100% carry substantial risk of lung damage
Helium-oxygen (heliox)
Consists of 50% helium and 50% oxygen.
Adult
Administer high flow via a tight-fitting nonrebreather mask
Pediatric
Administer as in adults
None reported
None reported
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Oxygen toxicity can be mistaken for pulmonary fibrosis
More on Barotrauma |
| Overview: Barotrauma |
| Differential Diagnoses & Workup: Barotrauma |
 Treatment & Medication: Barotrauma |
| Follow-up: Barotrauma |
| Multimedia: Barotrauma |
| References |
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References
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].
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].
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].
Tschopp S, Keel M, Schmutz J, Maggiorini M. Abdominal compartment syndrome after scuba diving. Intensive Care Med. Nov 2005;31(11):1595. [Medline].
[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].
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].
Bond JP, Kirschner DA. Spinal cord myelin is vulnerable to decompression. Mol Chem Neuropathol. Apr 1997;30(3):273-88. [Medline].
Boussuges A, Blanc P, Molenat F, et al. Haemoconcentration in neurological decompression illness. Int J Sports Med. Jul 1996;17(5):351-5. [Medline].
Bove AA. Risk of decompression sickness with patent foramen ovale. Undersea Hyperb Med. 1998;25(3):175-8. [Medline].
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].
Camporesi EM. Diving and pregnancy. Semin Perinatol. Aug 1996;20(4):292-302. [Medline].
Cogar WB. Intravenous lidocaine as adjunctive therapy in the treatment of decompression illness. Ann Emerg Med. Feb 1997;29(2):284-6. [Medline].
Colebatch HJ, Ng CK. Decreased pulmonary distensibility and pulmonary barotrauma in divers. Respir Physiol. Dec 1991;86(3):293-303. [Medline].
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].
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].
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].
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].
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].
Gustavsson LL, Hultcrantz E. [Medical aspects of diving--a sport for both women and men]. Lakartidningen. Feb 17 1999;96(7):749-53. [Medline].
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].
Kieser J, Holborow D. The prevention and management of oral barotrauma. N Z Dent J. Dec 1997;93(414):114-6. [Medline].
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].
Melamed Y, Shupak A, Bitterman H. Medical problems associated with underwater diving. N Engl J Med. Jan 2 1992;326(1):30-5. [Medline].
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].
Moon RE, Sheffield PJ. Guidelines for treatment of decompression illness. Aviat Space Environ Med. Mar 1997;68(3):234-43. [Medline].
Morgenstern K, Talucci R, Kaufman MS, et al. Bilateral pneumothorax following air bag deployment. Chest. Aug 1998;114(2):624-6. [Medline].
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].
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].
Payne SJ, Chappell MA. Automated determination of bubble grades from Doppler ultrasound recordings. Aviat Space Environ Med. Aug 2005;76(8):771-7. [Medline].
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].
Raymond LW. Pulmonary barotrauma and related events in divers. Chest. Jun 1995;107(6):1648-52. [Medline].
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].
Russi EW. Diving and the risk of barotrauma. Thorax. Aug 1998;53 Suppl 2:S20-4. [Medline].
Segev Y, Landsberg R, Fliss DM. MR imaging appearance of frontal sinus barotrauma. AJNR Am J Neuroradiol. Mar 2003;24(3):346-7. [Medline].
Sheffield PJ. Flying after diving guidelines: a review. Aviat Space Environ Med. Dec 1990;61(12):1130-8. [Medline].
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].
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].
Smerz RW. Age associated risks of recreational scuba diving. Hawaii Med J. May 2006;65(5):140-1, 153. [Medline].
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.
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].
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].
Further Reading
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
