eMedicine Specialties > Emergency Medicine > Environmental

Decompression Sickness: Follow-up

Author: Stephen A Pulley, MS, DO, FACOEP,, Assistant Professor, Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine; Attending Faculty, Emergency Medicine Residency, Albert Einstein Medical Center; Attending Physician, Montgomery Hospital Medical Center
Contributor Information and Disclosures

Updated: Sep 17, 2009

Follow-up

Further Inpatient Care

  • Admission is indicated at an institution only with HBO capability.

Further Outpatient Care

  • A patient with DCS is most likely not discharged from the ED to outpatient care. Patients can dramatically improve or have complete resolution in type I or mild type II DCS with just oxygen and rehydration. However, this improvement should not dissuade the practitioner from referral or transfer for HBO, as relapses have occurred with worse outcomes. Therefore, referral to a hyperbaric facility is strongly advised.

Inpatient & Outpatient Medications

  • Nonsteroidal anti-inflammatory drugs provide some benefit for musculoskeletal complaints. This decision is best left to the specialists.

Transfer

  • Transfer to a hyperbaric facility is strongly advised.
    • An important issue is timely transport of the patient to the closest hyperbaric facility.
    • This is frequently accomplished by land transport; however, air transportation is occasionally required. An effort should also be made to minimize the transport time. 
    • Helicopter transport requires the pilot to maintain an altitude of less than 500 ft (152 m) above the departure point (which could be more than 500 ft above sea level depending on the dive location).73 Flight paths through mountainous regions may make this difficult. In this situation, explore options other than rotary-wing transportation to the closest chamber. Fixed-wing transport should be limited to aircraft that can maintain cabin pressure at normal surface pressure of 1 atm (eg, Lear Jet, Cessna Citation, military C-130 Hercules).

Deterrence/Prevention

  • The key to preventing DCS is exercising conservatism in the diving profile and always putting safety first. Even with those, DCS can still occur. The total amount of saturated nitrogen was thought at one time to be the primary determinant of an individual's risk of developing DCS. Thus, the diving tables reflected close attention to the time spent at depths and surface intervals for repetitive dives. Recent research and thought suggests that the rate of ascent from depths may be a more critical factor.
    • Early diving instruction recommended a rate of ascent no faster than 60 ft (18 m) per minute. The more recent recommendation was to ascend no faster than 30 ft (10 m)per minute and to make a 3- to 5-minute safety stop at 15-20 ft (4.6-6 m).74,75 Therefore, the time of ascent was increased for a 60-ft dive from 1 minute to a maximum of 7 minutes.
    • Doppler bubble research has revealed that the release of bubbles from tissues is a critical factor in the development of DCS. The tissues that appear to saturate the fastest are in the spinal cord, with maximum saturation occurring in as few as 12 minutes. Desaturation, or offgassing, is much slower. Thus, even a no-decompression dive at 60 ft (20 m) for 20 minutes maximally saturates spinal tissues. As mentioned above, these are the tissues most commonly affected in type II DCS.
    • Even the slower 7-minute ascent to reach the surface from a 60-ft (20 m) dive still leaves a sizable amount of dissolved nitrogen in the faster-saturating spinal tissues. The remaining nitrogen can then bubble even on this slower ascent.
    • According to DAN, recent data from a European study revealed that increasing this ascent time to 18 minutes eliminated the dangerous bubbles. Therefore, one or more additional stops at deeper level(s) are likely needed to lengthen ascent time adequately and thus protect against DCS. Research has shown that a safety stop at 50 ft (15 m) of 2.5-5 minutes in addition to another stop at 20 ft (6 m) for 3-5 minutes will decrease venous bubble formation at least for a no-decompression dive of 82 ft (25 m). The supposition here is that this can decrease the risk of DCS.75 Obviously, this requires that more of the air reserve is allotted for the ascent. In addition, premeasured weighted ropes attached to the diving platform for the set safety stops can help maintain the desired depth and prevent drifting away from the surface vessel. Additional scuba tanks could be added at each safety level in case diver air supplies reach a critical level.
  • Being active during the decompression stops may also decrease the likelihood of bubble formation.76,77,78
  • Close attention to adequate hydration before and immediately after a dive may also have protective effects. In an individual with normally functioning kidneys, the frequency of urination and the concentration color of the urine are easy indicators of whether sufficient fluids are being taken in. A long time between urinating and a deep color are signs of inadequate intake. Note that these fluids should not be heavily caffeinated and should be alcohol free.
  • The culture of diving, at least in military naval diving, may have some impact upon prevention of diving accidents. The two most common causes of diving accidents, or near misses, were leadership failures and decreased situational awareness. These came into play when the overall risk was underestimated and the time was not closely monitored. In addition, the need for junior divers to ask questions was rebuffed by the posture of the senior divers not being interested in providing answers.79 While this was found in the US Navy, correlations could be considered in the average dive situation, namely daily dive charters. A lack of leadership, in the form of a divemaster, and the generally isolated situation of a number of divers not knowing each other, could lead to the same overall environment.
  • Everyone loves to play with bubbles. Children, pets, even scuba divers live to watch and even play with bubbles whether they be soap bubbles in the air, or air bubbles floating up in water. However, when bubbles are inside, such as a trapped gas bubble in the intestine or stomach, everyone gets uncomfortable. This is even truer for divers. The effects of trapped gas in various body cavities are discussed in Dysbarism. Microscopic bubbles, in particular those made of nitrogen that cause DCS, are discussed.
    • It is believed that the nitrogen bubbles start as minute gas nuclei, present before the dive, rather than supersaturation of the blood and tissues, that act as the seed for large bubble formation.80 Once the bubbles form, they create a foreign body interface which platelets then adhere to.81 In severe DCS, significant decreases in platelet count have been documented. These decreases may some day be used as a marker for severity of injury.82,83
    • To this point, the major way to avoid this bubbling has been through conservative diving using tables or computers that are based on the experiences of fit military divers. By staying "within" the tables, it was hoped that excessive tissue nitrogen saturation could be avoided so that it would not come out of solution as bubbles on ascent. Computer models are being validated that may lead to more accurate determination of these tables.84
    • The next step in the efforts to avoid DCS was to ascend slowly. Over recent years, the recommended ascent rate has decreased steadily, as mentioned above, to the point where it is recommended to stop ascent at decompression stops to allow the exhalation of nitrogen gas, rather than its bubbling in the blood.
  • Research has continued to look for the "holy grail" "ahah" starting point for the nitrogen bubbling in a hope that it can be influenced. The researchers may be almost there.
    • The gas nuclei and nitrogen interface appear to hold the key to better prevention strategies regarding DCS. In particular, the protection appears to be related to nitric oxide and nitric oxide synthase. A progression of studies from rats to trained, fit, military divers and now in experienced recreational divers is showing that inhibiting nitric oxide synthase increases the number and sizes of bubbles and that administering a nitric oxide donor decreases the number and size of bubbles.85 This effect occurred with a long-acting agent at 20 hours and 30 minutes before the dive. More recently, a short-acting nitric oxide donor, the common sublingual medication nitroglycerin (0.4 mg), administered 30 minutes prior to the dive, also provides this same level of "protection" by decreasing the bubble formation.86
    • There has also been work looking at the toxic effects of oxygen under pressure. It is possible that oxidation and free radicals may also be an important instigating factor. It causes vasoconstriction, which causes ischemia, activation of the inflammation cascade, and subsequent damage of the vascular endothelium. Antioxidants, maintaining normal hemostasis, and prevention of inflammatory responses may help stop the DCS process from starting.87
    • Another significant event has been the discovery of the positive benefit of a period of aerobic exercise at around 80% of maximal oxygen uptake in humans and 85-90% in rats.88
      • The timing of this exercise appears to be the key. A period of exercise of 90 minutes in rats and 40 minutes in humans timed at 20 hours and 24 hours, respectively, before the dive, was found to have significant long-lasting effects on the number and size of nitrogen bubble formation.89,90,91,88 When the same exercise is completed at 2 hours and 30 minutes prior to the dive, the results are less clear. In some groups, a benefit was noted; in others, no benefit was noted.92,93
      • In one study, it was demonstrated that the positive effect of the exercise the day before was wiped out by a second period of exercise prior to the dive. It has also been demonstrated that, it is not the overall level of fitness, but rather the timing of the exercise that provided the protection. This level of protection appears to be similar to that offered by the nitric oxide donor.94,95
      • It has also been demonstrated that regular exercise, physical conditioning, and diving also appear to have a protective effect against bubble formation and DCS.96
    • The next step is to see exactly what biochemical effects the exercise causes. It appears that nitric oxide is the protective agent in the predive exercise.{Ref46}
    • A controversy has long existed about post dive activity and exercise. It was believed that intense activity after a dive would promote bubble formation. In small studies on trained, fit, military divers, a positive benefit has been found to mild exercise, at 30% of maximal oxygen uptake, during the 3-minute decompression stop on ascent. Other recent studies incorporating similar aerobic exercise, at 80% of maximal oxygen uptake, starting at 30 and 40 minutes post dive, have failed to demonstrate any adverse effects on trained, fit, military divers.78
  • So, the question is, what should the average diver do, or not do, based upon the research?
    • As with anything in medicine, broad recommendations can only be reached after a sufficient number of large studies show benefit. This level of weight has not yet been reached in the diving literature.
    • Clearly, the benefit of aerobic exercise the day prior to a dive is evident. For the many recreational divers that are relatively sedentary as they fly long distances to remote areas and then start diving soon after arrival, this may have important consequences.
    • As with any physical activity, including scuba diving, the person must be physically fit before engaging in a stressful activity. This should be completed in consultation with a physician, in particular one with experience with the recreational activity.
    • All medications should only be taken on the recommendation of a physician who is familiar with the patient and the patient’s health history and only after consideration of the risks and benefits of the medication. In this specialized, off-label use, a specialist in diving medicine should be the consultant. Nitroglycerin is mentioned above. Nitroglycerin has many adverse effects such as dilation of blood vessels, lowering of blood pressure, and headaches.
    • A period of pre-breathing normobaric (regular oxygen bottle) oxygen for 30 minutes was found to decrease venous bubble formation for the subsequent dive and repetitive dives afterwards with no further prebreathing.97 In swine models, pre-breathing oxygen at depth for as little as 5 minutes before rapid decompression helped prevent type II DCS and when breathed for 15 or 45 minutes, it decreased type I DCS symptoms.98 It also was found in swine models to decrease venous ischemia and osteonecrosis from DCS.99 As with the statement about nitroglycerin above, oxygen is a medical gas and its use needs to prescribed by a physician.
    • In addition, a 30-minute predive sauna session at 65 º C (149 º F) was shown to decrease venous bubble formation, though the mechanism is not known.100
    • What to do after the dive is less clear and needs more investigation in less fit populations. While the research appears promising that there is at least no adverse effect to exercise after diving, and that some benefit may exist, there is insufficient weight to the research to recommend any changes.
  • A puzzling situation is when an individual experiences DCS when all facets of the dive appeared normal and highly conservative. This lead to a search for other possible influencing etiologies. The identification of the injured diver’s thrombotic state was found to be a possible explanation.
    • A high percentage of the unexplained DCS injured divers were found to have moderate increases in total plasma homocysteine, a substance found to be implicated in the formation of atherosclerosis (hardening of the arteries), and deficiencies in folate and vitamin B-12, common nutritional substances.101,102 These 3 chemicals are easily screened for with common laboratory testing.
    • Correction of folate and B-12 deficiencies are easily treated with vitamin supplementation. Studies suggest that the homocysteine level increase can be treated favorably with folate and vitamin B-6 supplements. Again, this should also be completed under the advice of a physician.
  • Current research is aiming at fine-tuning the prevention of DCS. Transcranial, precordial, and subclavian vein Doppler examination; echocardiography; and regular ultrasonographic imaging have been used to detect the presence of bubbles in the vascular system of the volunteers being studied.71,103,104 At the same time, various HBO decompression models are being evaluated using the same studies.105,106 As the database expands across the full spectrum of divers (not just young, healthy divers), the tables and recommended dive profiles will continue to improve. However, since people respond differently to DCS, a universal profile is unlikely to be established. For this reason, all divers should fully understand their dive profiles (especially if generated by computer) and should always be conservative and allow plenty of room for individual variation and error.
  • Future trends are promising. Efforts are underway to identify specific biomarkers for DCS.107 Promising animal research on changes that occur within 30 minutes of surfacing has been underway. Likewise, promising research related to the use of intravenous perfluorocarbons is underway as well.108,109 They appear to decrease DCS symptoms through a combination of decreasing bubble formation, hemodynamic protection against gas embolism, enhanced oxygen delivery to tissues, and increased pulmonary nitrogen washout though this last effect is hypothesized but not shown.110,111 The effects are further enhanced by oxygen prebreathing (before HBO treatment) with increased oxygen delivery.112

Complications

  • Residual paralysis, myocardial necrosis, and other ischemic injuries may occur without immediate recompression. These may occur even in adequately treated patients.

Prognosis

  • Early symptom recognition, prompt diagnosis, and appropriate treatment are keys to a positive outcome with DCS. With these, a success rate of greater than 75-85% can be achieved.

Patient Education

  • Diver education is paramount. The symptoms, signs, and management of DCS and AGE must be learned to facilitate early recognition and treatment.
    • Of 590 patients with DCS whose characteristics were studied (results discussed in Epidemiology), 9 continued to dive after developing neurologic symptoms, including 1 patient with paralysis in both legs.
    • Approximately 7% of patients who reported to DAN reported a delay in seeking treatment until more than 96 hours after symptom onset, and 35% of all cases were reported to DAN more than 4 hours after symptom onset.
  • For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center. Also, see eMedicine's patient education articles Barotrauma/Decompression Sickness and The Bends - Decompression Syndromes.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose DCS can be disastrous because DCS can cause long-term neurologic disability even with treatment.
  • All patients treated for diving-related injuries should be instructed not to return to diving until they have consulted with a diving medicine specialist. The specialist can determine when a return to diving is appropriate. If DCS symptoms are serious and AGE is present, the specialist will most likely attempt to dissuade the patient from future participation in diving.

Special Concerns

  • Diving while pregnant is not recommended because of unknown effects of nitrogen diffusion across the maternal-placental membrane. The fetus is not believed to be protected from decompression problems and is at risk of malformation and gas embolism. However, normal pregnancies have been reported even after repetitive dives.113
  • While no absolute lower age limit has been established, children younger than 12 years should not dive. Though one limited study found no venous bubble formation after a routine single shallow dive,114 diving can be a dangerous activity that requires respect, common sense, and absolute adherence to safety rules. The inherent nature of children to be distracted and have no sense of mortality or time makes it difficult for them to dive safely without close supervision.
  • Advanced age brings increased medical problems. As with any physical activity, the advice and recommendations of a physician familiar with diving medicine should be sought.
  • Most divers use a compressed air source. Dive shops usually refill dive tanks. The equipment is typically a gasoline-powered air compressor that uses filtered ambient air. An improper setup or malfunctioning equipment may compress carbon monoxide from exhaust fumes (or other gases nearby) along with the air. This is a recognized danger in the diving industry. Filling stations should have safeguards in place; however, the potential for injury still exists. According to the Dalton law, even small amounts of carbon monoxide in the tanks have higher partial pressures at depth that may exacerbate clinical effects.
  • Because the symptoms of carbon monoxide poisoning (eg, dyspnea, headache, fatigue, dizziness, visual changes, unconsciousness) can mimic DCS or AGE, differentiate these conditions by looking for carbon monoxide specifically with co-oximetry. Failure to recognize carbon monoxide poisoning is not a serious omission as long as the patient is recognized as having a diving injury. The hyperbaric treatment of DCS and AGE is also the treatment of choice for carbon monoxide poisoning. For more information on this topic, please see the article on Toxicity, Carbon Monoxide.
  • Two other situations deserve mention. The first is related to the use of special "technical diving" gases such as Trimix (a combination of oxygen, nitrogen, and helium).
    • There is a practical limit to the use of compressed air in scuba diving of around 132 ft (40 m, 4 atm) where the bottom times are so short (or actually nonexistent using standard tables) and the risk of nitrogen narcosis is high. Since many interesting sites, such as wrecks, are deeper than that, many divers have started using a Trimix that lowers the nitrogen load to avoid narcosis, decreases the oxygen content to avoid toxicity, and replaces the two with helium that also is a lighter gas.
    • Depending on the goal depth, multiple tanks with different mixes for different depth ranges may need to be carried. This is a highly technical and riskier activity.
    • Even with the Trimix, the limit is still fuzzy as the overall gas density increases. This increases the work of breathing and thus respiratory fatigue. If this is added to the additional load of general physical exertion, a situation of hypercapnia (increasing carbon dioxide in the bloodstream) can ensue that causes worsening of the overall fatigue. If not corrected by ascending, death can, and has, occurred.115
    • Trimix has been used in HBO treatment to shorten treatment courses with success.
  • The other situation relates to breath-hold diving (without scuba tanks). In the past, a breath-hold dive was simply a free dive from the surface without supplemental air.
    • The average person was limited by his or her physical prowess for how deep he or she could go, or the length of time he or she could stay under. Neither was a major concern except in the circumstance of forced hyperventilation thinking this would help just before the dive. The result here could be hypoxia with loss of consciousness before the hypercapnic, carbon dioxide, need to take a breath.
    • The addition of fins increased the depth and distance but again not to a concerning level. In recent years, oversized fins have appeared on the market, as have motorized underwater scooters. Both of these have allowed much greater depths in the free dives and can allow more rapid ascent and then immediate dive again. Professional and recreation spear fisherman, especially in tournaments, are now achieving depth and underwater times where they can start accumulating nitrogen loads and with the rapid ascents, DCS has been reported.116
    • Another group of note are the extreme-depth unlimited free divers. They use a weighted sled to achieve record depths measured in the several hundreds. The combination of extreme depth and 5- to 7-minute times involved allow sufficient nitrogen loads that again can result in DCS.
      • The risk is even greater in those that are preparing for a competition where in the course of a day they can have repeated weighted free dives to increasing depths with limited surface intervals.
      • Frequent Valsalva on descent to equalize pressure also can unmask a previously unknown PFO or ASD and allow neurological DCS.117
      • Morbidity and mortality is increasing in these extreme free divers who keep pushing physiologic limits to dangerous extremes due to reasons elucidated above plus various barotraumas causing disabling symptoms.118
 


More on Decompression Sickness

Overview: Decompression Sickness
Differential Diagnoses & Workup: Decompression Sickness
Treatment & Medication: Decompression Sickness
Follow-up: Decompression Sickness
Multimedia: Decompression Sickness
References
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Further Reading

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Keywords

decompression sickness, DCS, diving emergency, diving injury, the bends, the staggers, the chokes, niggles, underwater ascent, free dive, assisted dive, self-contained breathing apparatus, SCUBA, scuba diving, deep-pressure injury, decompression injury, altitude sickness, arterial gas embolization, type I decompression sickness, type I DCS, skin bends, type II decompression sickness, type II DCS, negative scotomata, labyrinthine decompression sickness, labyrinthine DCS, hypovolemic shock, pulmonary decompression sickness, pulmonary DCS, acclimatization, Divers Alert Network, DAN, pressure-related injury, no-decompression limits, decompression tables, hyperbaric oxygen recompression, HBO therapy, dysbaric injury, hyperbaric repressurization, neurologic decompression sickness, neurologic DCS, decompression illness, DCI

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Contributor Information and Disclosures

Author

Stephen A Pulley, MS, DO, FACOEP,, Assistant Professor, Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine; Attending Faculty, Emergency Medicine Residency, Albert Einstein Medical Center; Attending Physician, Montgomery Hospital Medical Center
Stephen A Pulley, MS, DO, FACOEP, is a member of the following medical societies: American College of Osteopathic Emergency Physicians and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center
Eric M Kardon, MD, FACEP is a member of the following medical societies: 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

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
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

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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