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Decompression Sickness Workup

  • Author: Stephen A Pulley, DO, MS, FACOEP; Chief Editor: Joe Alcock, MD, MS  more...
Updated: Jul 12, 2016

Laboratory Studies

Acute decompression sickness (DCS) is a purely clinical diagnosis that requires a fair amount of clinical suspicion to avoid missing cases.[28] Most of the time, the "test" is improvement with hyperbaric oxygen (HBO) therapy. No specific tests exist for DCS. When diving is involved, consider determining whether the patient has any pressure-related injuries. Obtain baseline laboratory studies, but these will have no bearing on initial management. They may be useful in the differential diagnosis while HBO therapy is administered. They may also be useful in expanding the knowledge base about this disorder.

Do not delay HBO therapy (and transfer, if necessary). In individuals with change in mental status, prudence dictates obtaining studies to help further evaluation. If the individual is in extremis (eg, shock), obtain appropriate resuscitation studies.

For changes in mental status, evaluate the following:

  • Blood glucose level, CBC count
  • Sodium, magnesium, calcium, and phosphorous levels
  • Oxygen saturation
  • Ethanol level and drug screen
  • Carboxyhemoglobin level

For shock, evaluate the following:

  • Blood glucose level, CBC count
  • Electrolytes and BUN level
  • Creatinine levels, lactic acid
  • Type and screen/cross
  • Prothrombin time/international normalized ratio, activated partial thromboplastin time
  • Carboxyhemoglobin level

Imaging Studies

Chest radiography

Because dysbaric injuries involving the lungs and chest can occur concomitantly with DCS, obtain a chest radiograph to screen for overpressurization injuries. Chest radiography reveals evidence of pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumopericardium, alveolar hemorrhage, and decreased pulmonary blood flow caused by nitrogen pulmonary emboli.

Head CT scanning

If mental status does not initially improve in response to hyperbaric repressurization, consider other etiologies.


MRI has been found useful in the management of neurologic DCS.[108, 109, 110, 111] The diagnosis is still clinical, and the patient's transfer to an HBO facility should not be delayed. MRI has revealed focal spinal lesions that correlated with the patient's symptoms and examination. MRI readily detects cerebral damage in arterial gas embolization (AGE),[112] but iy yields low sensitivity in DCS. MRI may prove useful in patients who do not show initial improvement to HBO therapy. In these individuals, the MRI may localize the area of DCS injury or exclude other etiologies for the patient's symptoms.

Spinal MRI found lesions more commonly in divers with severe spinal DCS and none at all in those that ultimately had a favorable outcome. Therefore, in an HBO center, it may be a useful diagnostic adjunct to help guide management.[29]

MRI is also useful for monitoring injured divers through successive HBO treatments.

Cerebral MRI has even identified abnormalities in the brain that correlated with hours of diving in the air-breathing range even when no clinical or historical signs of neurologic DCS were present.[113]

Note that negative MRI findings cannot be used to exclude AGE or DCS. Also, improvement in MRI findings does not necessarily correlate with clinical improvement.[114] It has also been correlated with neuropsychological deficits in older divers.[115]

Diffusion Tensor MRI (DTI) has been demonstrated to be useful for investigating DCS.[116]

MRI in a guinea pig model was able to identify small bubbles and blood in the inner ear. It may have future utility in management of inner-ear DCS.[117]

The decision to pursue HBO referral is based on purely clinical presentation and should not be guided, or delayed, by obtaining MRI or other diagnostic findings.


Other Tests

Other tests may include ECG and/or oxygen saturation evaluation.



Diagnostic repressurization

If diagnosis of DCS versus dysbarism or some other entity is unclear, order repressurization in a hyperbaric chamber (transfer if necessary) for diagnostic and therapeutic reasons.


Intubation delivers 100% oxygen when less-invasive delivery methods do not work or are inappropriate.

Needle decompression and thoracostomy

These procedures help in the treatment of tension pneumothorax, simple pneumothorax, and subcutaneous emphysema.

Contributor Information and Disclosures

Stephen A Pulley, DO, MS, FACOEP Clinical Professor, Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine; Attending Physician, Mercy Suburban Hospital; Costin Scholar, Midwestern University

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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, American Medical Informatics Association, Medical Association of Georgia

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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