eMedicine Specialties > Emergency Medicine > Environmental

Dysbarism: Treatment & Medication

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

Treatment

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. More is discussed about this in Decompression Sickness.
  • 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.49
  • 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.50
  • 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 patient into 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.51 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).

Emergency Department Care

  • Administer 100% oxygen. Intubate if indicated.
  • Do not put the patient into the Trendelenburg position.
    • Placing the patient into a head-down, Trendelenburg position previously was considered standard in the ED management of diving injuries to prevent cerebral gas embolization.
    • Do not put patient into 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.51 It also wastes time and complicates movement of the patient.
  • Intravenous fluids should be administered for rehydration until urinary output is 1-2 mL/kg/h.
  • Provide aggressive resuscitation, if required.
  • 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.50
  • The patient should be treated for nausea, vomiting, pain, and headache.
  • Needle chest decompression and chest tube thoracostomy may be indicated to treat simple or tension pneumothorax.
  • Try to keep all diving gear with the diver.

Consultations

  • Diving medicine or HBO specialists
    • Symptoms temporally related to diving indicate that consultation with a diving medicine or HBO specialist is needed.
    • The goal of this discussion is to determine the likelihood that symptoms are diving-related and the appropriateness of treatment with HBO therapy.
  • Otorhinolaryngologist
    • Urgent consultation with an ENT specialist may be useful.
    • The barotraumas of the middle and inner ears are caused by failure of the eustachian tube to release pressure. Early investigation into the use of natural or artificial eustachian tube surfactant shows promise as a potentially effective way to aid this process.52
    • Divers who experience inner ear DCS or barotrauma require detailed ENT diagnostic evaluation at follow-up. Most are asymptomatic but still have significant cochleovestibular deficits.22 Inner ear barotrauma has a better short- and long-term outcome than inner ear DCS.
    • The specialist may often request sending the patient to the office. In such cases, consider inquiring about the ENT specialist's comfort with diving-related issues.
  • Divers Alert Network: Divers Alert Network (DAN) is an excellent resource, especially if local support is not available. Using this service should be considered similar to the use of a poison control center. It maintains a database of diving-related injuries and provides 24-hour-a-day consultative services including extent of injury assessment, recommendations for management, and referral to HBO therapy or local diving medicine specialists. Emergency contact 24 hours a 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)

Medication

Oxygen is the main therapy used in the treatment of diving injuries. Predive treatment with nonsedating decongestants (specifically pseudoephedrine-see below) can decrease the incidence of ear discomfort and clinical trauma to the tympanic membrane by 75%. No data are available concerning the efficacy of this medication in postdive treatment.

Decongestants

By promoting nasal or sinus drainage, these agents may prevent ear discomfort. However, their exact mechanism of action is not yet understood.


Pseudoephedrine (Actifed, Sudafed)

Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of respiratory mucosa, which may improve sinus drainage.

Adult

60 mg PO q4-6h; do not exceed 4 doses in 24 h or 120 mg of long-acting q12h

Pediatric

<6 years: Not established
6-12 years: 30 mg PO q4-6h; not to exceed 4 doses in 24 h
>12 years: Administer as in adults

Propranolol, MAOIs, and sympathomimetic agents may increase toxicity; methyldopa and reserpine may reduce effects

Documented hypersensitivity; severe anemia; postural hypertension or 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


Oxymetazoline hydrochloride 0.05% nasal spray (Afrin, Sinarest, Allerest)

Stimulates alpha-adrenergic receptors and causes vasoconstriction when applied directly to mucous membranes. Decongestion occurs without drastic changes in blood pressure (BP), vascular redistribution, or cardiac stimulation.

Adult

2-3 sprays in each nostril q12h

Pediatric

<6 years: Not recommended
>6 years: Administer as in adults

May reverse hypotensive action of guanethidine; methyldopa may result in increased vasopressor response; concurrent MAOI 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; TCAs potentiate vasopressor response and may result in dysrhythmias

Documented hypersensitivity; concomitant 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 and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, hypertensive patients may experience change in BP; do not use topical decongestants for longer than 3-5 d

Bronchodilators

These agents act to decrease muscle tone in both the small and large airways in the lungs, thereby increasing ventilation.


Ipratropium bromide nasal spray (Atrovent)

Chemically related to atropine. Has antisecretory properties, and when applied locally, inhibits secretions from serous and seromucous glands lining nasal mucosa.

Adult

Metered dose inhaler:
2 sprays in each nostril q4h; do not exceed 12 inhalations in 24 h

Pediatric

Metered dose inhaler:
<3 years: Not established
3-12 years: 1-2 inhalations tid; not to exceed 6 inhalations in 24 h
>12 years: Administer as in adults

Drugs with anticholinergic properties, such as dronabinol, may increase toxicity; albuterol increases effects

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

Do not use for more than 5 d; not indicated for acute episodes of bronchospasm; caution in narrow-angle glaucoma, prostatic hypertrophy, and bladder neck obstruction

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.


Beclomethasone dipropionate 0.042% nasal spray (Vancenase)

Inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, may decrease number and activity of inflammatory cells, and may decrease airway hyperresponsiveness.

Adult

2 sprays in each nostril q12h

Pediatric

<6 years: Not established
>6 years: Administer as in adults

Ketoconazole may increase plasma levels, but this does not appear to be clinically significant

Documented hypersensitivity; bronchospasm; status asthmaticus; other types of acute episodes of asthma

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

Weight gain, increased bruising, cushingoid features, acneiform lesions, mental disturbances, and cataracts may occur (taper medication slowly if these changes occur)

Antiplatelet agents

Because dysbaric illness has the potential for activation of coagulation factors, as discussed in the article on DCS, therapy aimed at mitigating this effect may be helpful. Guidance should be obtained from either a diving medicine or HBO specialist.


Aspirin (Anacin, Ascriptin, Bayer Aspirin)

Blocks prostaglandin synthetase action, which, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2. Acts on hypothalamus heat-regulating center to reduce fever.

Adult

Not established; doses used in treating cardiac disease would appear the best choice

Pediatric

Generally avoided in children because of potential for Reye syndrome in viral illness

Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; anticoagulants may have additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid; may 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 taking anticoagulants

More on Dysbarism

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

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Keywords

decompression sickness, DCS, the bends, ear squeeze, sinus squeeze, tooth squeeze, mask squeeze, barotrauma, Boyle law, Dalton law, Henry law, Charles law, scuba diving, diving, self-contained underwater breathing apparatus, SCUBA, air embolism, hyperbaric chamber, pressure during descent, high altitude, dysbaric injury

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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

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
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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