Decompression Sickness Treatment & Management

  • Author: Stephen A Pulley, MS, DO, FACOEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Sep 17, 2009
 

Prehospital Care

  • Extricate the patient from water and immobilize if trauma is suspected. Generally, in-water recompression is not believed to be a safe option. Problems with air supply, hypothermia, potential oxygen toxicity, dehydration, and the uncontrolled environment make it less than ideal and increase the risks of drowning.[57] However, in remote areas without reasonable-distance HBO chamber support, this may be the only option.
    • In Thailand, home to the diving Urak Lawoi fishermen, 72.1% exceed the no-decompression limits, yet medical treatment and HBO facilities are distant (10 h and 16 h, respectively). In this population, one third reported having experienced DCS, and in-water recompression has been shown to be an appropriate first-aid measure. Much more research needs to be performed on the concept of in-water decompression, since over half of the Urak Lawoi (not just one third) were classified as experiencing recurring nondisabling DCS and about one quarter as having disabling DCS.[58, 59, 60]
    • A shorter in-water recompression protocol was also developed for use in the remote Northern Pacific Clipperton Atoll in an attempt to address the above concerns.[57]
  • Administer 100% oxygen, intubate if necessary, and intravenously administer saline or lactated Ringer solution.
  • The use of first aid oxygen has proven so beneficial that the Divers Alert Network (DAN) has made a major effort to place oxygen at dive locations, in particular those that are remote with lengthy transport times to the nearest hyperbaric chambers and to ensure that people are trained in its use. A study of the use of first aid oxygen found that the median time to its use after surfacing was 4 hours and 2.2 hours after the onset of DCS symptoms. Forty-seven percent of victims received the oxygen. Complete relief of symptoms was found in 14% of victims. Even more striking was that 51% of victims showed improvement. This was with the oxygen before HBO treatment. Even after a single HBO treatment, those that had received oxygen before the HBO dive, even if many hours earlier, had better outcomes.[61]
  • Aspirin is commonly considered and given in diving accidents for antiplatelet activity if the patient is not bleeding. However, there are no current data to support this practice.[62]
  • Perform cardiopulmonary resuscitation and advanced cardiac life support, if required, as well as needle decompression of the chest if tension pneumothorax is suspected.
  • Do not put the patient into the Trendelenburg position. Placing the patient in a head-down posture used to be considered a standard treatment of diving injuries to prevent cerebral gas embolization. This practice should be abandoned. The process actually increases intracranial pressure and exacerbates injury to the blood-brain barrier.[63] It also wastes time and complicates movement of the patient.
  • Transport to the nearest ED and hyperbaric facility, if feasible, and try to keep all diving gear with the diver. Diving gear may provide clues as to why the diver had trouble (eg, faulty air regulator, hose leak, carbon monoxide contamination of compressed air).
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Emergency Department Care

  • Administer 100% oxygen to wash nitrogen out of the lungs and set up an increased diffusion gradient to increase nitrogen offloading from the body.
  • Do not put the patient into the Trendelenburg position. Placing the patient in a head-down posture used to be considered a standard treatment of diving injuries to prevent cerebral gas embolization. This practice should be abandoned. The process actually increases intracranial pressure and exacerbates injury to the blood-brain barrier.[63] It also wastes time and complicates movement of the patient.
  • Perform intubation, aggressive resuscitation, and chest tube thoracostomy, if indicated.
  • Administer intravenous fluids for rehydration until urinary output is 1-2 mL/h. Rehydration improves circulation and perfusion.
  • Aspirin is commonly considered and given in diving accidents for antiplatelet activity if the patient is not bleeding. However, there are no current data to support this practice.[62]
  • Treat the patient for nausea, vomiting, pain, and headache.
  • Contact the closest hyperbaric facility (or DAN for referral) to arrange transfer and try to keep all diving gear with the diver. The diving gear may provide clues as to why the diver had trouble (eg, faulty air regulator, hose leak, carbon monoxide contamination of the compressed air).
  • Patients with type I or mild type II DCS can dramatically improve and have complete symptom resolution. This improvement should not dissuade the practitioner from HBO referral or transfer, as relapses have occurred with worse outcomes.
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Consultations

  • Diving medicine and HBO specialists: Symptoms temporally related to diving should necessitate a consultation with a diving medicine specialist or HBO specialist to determine if symptoms are related to diving and if HBO therapy is appropriate.
  • DAN: DAN is an excellent resource, especially if local support is not available. Visit their Web site at Divers Alert Network. Use of this service is similar to use of a poison control center. DAN maintains a database of diving-related injuries and provides consultation services, including extent-of-injury assessment, recommendations for management, and referral to HBO therapy or local diving medicine specialists. Emergency contact 24 hours per day can be reached at the following numbers:
    • DAN America: 1-919-684-8111 or 1-919-684-4DAN (4326) (accepts collect calls)
    • DAN Latin America: 1-919-684-9111 (accepts collect calls)
    • DAN Europe: 39-06-4211-8685
    • DAN Southern Africa: 0800-020111 (within South Africa); 27-11-254-1112 (outside South Africa)
    • DAN Japan: 81-3-3812-4999
    • DAN SEAP DES New Zealand: 0800-4DES 111
    • DAN SEAP Singapore Naval: 6758-1733
    • DAN SEAP Malaysia: 05-930 4114
    • DAN SEAP Philippines: 02-815-9911
    • DAN SEAP DES Australia: 1-800-088-200 (within Australia); 61-8-8212-9242 (outside Australia)
  • HBO treatment
    • Patients with mild type I DCS probably do not require treatment other than breathing pure oxygen at sea level for a short time. Divers with type I DCS symptoms do, however, require close observation, as symptoms may portend the onset of more serious problems requiring hyperbaric recompression. Consult a diving medicine or HBO specialist for all diving-related injuries. The only effective treatment for gas embolism is recompression; other treatments are merely for symptoms.
    • Several types of hyperbaric chambers exist, ranging from small monoplace (single person) chambers to complex multiple place, multiple lockout chambers large enough for multiple patients and attendants. All chambers have the ability to maintain critical care monitoring and mechanical ventilation. A major difference with the size of chambers clinically is that some patients experience claustrophobia with the small monoplace chambers. Increased oxygen toxicity issues have been reported with the monoplace chambers because the entire environment is oxygenated, whereas, with the larger chambers, patients breath the oxygen via mask, but the ambient environment is not supplementally oxygenated.
    • The basic theory behind HBO therapy is, first, to repressurize the patient to simulate a depth where the bubbles from nitrogen or air are redissolved into the body tissues and fluids. Then, by breathing intermittently higher concentrations of oxygen, a larger diffusion gradient is established. The patient is taken slowly back to surface atmospheric pressure. This allows gases to diffuse gradually out of the lungs and body. The addition of helium to oxygen has been shown to yield an advantage over oxygen alone even in severe neurologic DCS or treatment-refractory DCS.[64, 65]
    • Treatment tables govern the exact combination of timing and depths. These were developed primarily by the US Navy with some minor modifications by the US Air Force. Table 6 is most commonly used; however, specific details concerning the tables are beyond the scope of this article. While most will improve with a single HBO treatment, 38.5% will have relapses, half of those within 24 hours. Observation for 24 hours is strongly recommended after HBO treatment.[66] Another study reported complete resolution of symptoms in 49% with the first treatment and an additional 26.5% with additional treatments. However, 24.5% had long-term residual symptoms.[67] In Israel, 48% had complete recovery with HBO, while another 48% had partial recovery. Unfortunately, 4% did not respond to the therapy.[68]
    • Traditionally, the treatment protocols were staged, meaning that time would be spent at certain depths as the individual was "brought back to the surface." Recent studies suggest that a linear approach is more effective than the staged approach. Other variations on the tables are being researched to try to find shorter-term approaches. In addition, use of combination gases such as Trimix are being looked at in the same regard.
    • Other mentioned adjuncts to HBO include negative-pressure breathing and intravenous perfluorocarbon emulsion.
    • With early recognition and treatment, more than 75% of patients improve. Even with significant delays in recognition and treatment, positive results are obtained.[69, 70] Studies of the Miskito Indians of Central America highlight this. They are diving seafood harvesters who dive repeatedly without consideration for diving tables or profiles. They have a high prevalence of the bends and neurologic DCS that affects the thoracolumbar spine in particular. Despite very high rates of DCS, and sometimes days' delays in HBO treatment (if sought at all), HBO treatment yields positive results, with 30% regaining strength and many more ambulating. However, HBO treatment is usually only sought for significant neurologic symptoms, while painful DCS, such as the bends, is usually treated with only analgesia.[71, 72]
    • Differentiating inner ear barotrauma or dysbarism from inner ear labyrinthine or alternobaric vertigo is difficult. The difference is that dysbarism responds well to treatment, and inner ear DCS is less responsive and is associated with a higher frequency of permanent damage. Patients with inner ear DCS may be asymptomatic after treatment yet still have vestibular problems at detailed testing. Therefore, both conditions must be considered in the differential diagnosis, and the patient must be treated for both conditions. A recent recommendation is to perform immediate tympanocentesis and then to follow with HBO therapy.
    • Inner ear DCS is less responsive to HBO treatment than is DCS affecting other sites. HBO typically results in significant improvement in severe neurologic DCS if it is identified early and the patient is rapidly transported to an HBO facility.
    • Rapid treatment is also crucial in the face of AGE. Those with AGE who reach recompression within 5 minutes have a death rate of only 5%. This rapid treatment also results in little morbidity. However, when AGE recompression is delayed 5 hours, the mortality rate approaches 10%. More than 50% of the survivors experience residual signs.
    • An important issue is transport of the patient to the closest hyperbaric facility. This is frequently accomplished by land transport; however, air transportation is occasionally required. 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] This can be difficult when there are mountains to traverse in flight. An effort should also be made to minimize the transport time. 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).
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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 Healthcare Network; Attending Physician, Montgomery Hospital Medical Center

Stephen A Pulley, MS, DO, FACOEP, is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

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.

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, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

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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Illustration of Dalton gas law. As an individual descends, the total pressure of breathing air increases and the partial pressures of the individual components have to increase proportionally. Nitrogen at higher partial pressures alters the electrical properties of cerebral cellular membranes, causing an anesthetic effect. Oxygen at higher partial pressures can cause CNS oxygen toxicity.
Illustration of Henry gas law. If nitrogen is added to a bottle, it diffuses into and equilibrates with the fluid. If pressure is suddenly released (decreased), such as when an individual ascends rapidly, a lag occurs before nitrogen can diffuse back to the nonfluid space. This delay causes nitrogen to bubble while still in the fluid.
 
 
 
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