Decompression Sickness - Dr Guritno

8/11/2019 Decompression Sickness - Dr Guritno

1/34

!"#$%&'"(()$* ()#,*"(( -*! .-( "%/$0)(%

%1234435 .6789:1 (;'


2/34

!"#$%&'"(()$* ()#,*"((

Decompression sickness (DCS) refers to the clinicalsyndrome of neurological deficits, pain, or other clinical

disorders resulting from the body tissues being

supersaturated with inert gas after a reduction in the

ambient pressure.

-'="')-0 .-( "%/$0)(%

Arterial Gas Embolism (AGE) refers to gas bubbles inthe systemic arterial system resulting from pulmonarybarotrauma, iatrogenic entry of gas into the arterialsystem, or arterialized venous gas emboli.


3/34

Classification of DI

1. The traditional or

Golding Classification2. The descriptive or

Francis & Smith Classification

3. The ICD-10 Classification


4/34

Modified Golding Classification for DI

-79>783? .3@ "4A1?8@4

!>B14C7>@@81: (8BD:>@@

EF =GC> ) H %6@B6?1@D>?>93? &38:I (D8:I

0G4C23JBI "K97>4> L3JM6>I&>78C2>73? *>7N16@ (G4C914@

OF =GC> )) H *>671?1M8BI #375817>@C873917GI

-6581PN>@JA6?37I (21BD

QF =GC> ))) H #14A8:>5 !>B14C7>@@81: (8BD:>@@

3:5 -79>783? .3@ "4A1?8@4


5/34

Table The Francis & Smith Classificationfor Dysbaric Illness

Evolutiono Spontaneously Recovery (Clinical improvement is

evident)

o Static (No change in clinical condition)

o

Relapsing (Relapsing symptoms after initial recovery)

Progressive (Increasing number or severityof signs)

Organ System:

o Neurological

o Cardiopulmonary

o Limb pain exclusively

o Skin

o Lymphatic

o

Vestibular


6/34

Table The Francis & Smith Classificationfor Dysbaric Illness

Time of onset:o

Time before surfacingo

Time after surfacing (or estimate)

Gas Burdeno Low (e.g., within NDL)

o Medium (e.g., Decompression Dive)o

High (e.g., Violation of Dive Table)

Evidence of Barotraumao Pulmonary (Yes / No)

o Ears

o

Sinuses

Other Comments


7/34

The ICD-10 Classification

The ICD-10 codes most frequently used are:o T70 (Effects of air pressure and water

pressure)

o T70.0 (Otitic barotrauma)

o

T70.1 (Sinus barotrauma)o T70.3 (Caissons disease)o T70.4 (Effects of high-pressure fluids)

o T70.8 (Other effects of air pressure and water

pressure)o T79.0 (Traumatic air embolism)

o T79.7 (Traumatic subcutaneous emphysema)o M90.3 (Osteonecrosis in caisson disease

T70.3+)


8/34

Clinical Setting

1. Diving2. Flying

3. HBOT


9/34

PATHOGENESIS OF DCS

Denaturation of Plasma Proteins

Endothelial Damage

Interaction of Bubbles with the Blood

Coagulation System

General Aspect :Most of the clinical manifestations of DCS arethought to result from tissue distortion of vascularobstruction produced by bubbles


10/34

Presenting Symptoms Type Cases (%)

Local Pain

ArmLeg

Vertigo (staggers)

ParalysisShortness of breath (chokes)

Extreme fatigue with pain

Collapse + unconsciousness

Type I

Type 2

89

3070

5.3

2.31.6

1.3

0.5

Frequency of Various Symptoms of DCS


11/34

The time of onset ofsymptoms after surfacing

30 % occurred < 30 minutes

85 % occurred < 1 hour

95 % occurred < 3 hours

1 % Delayed more than 6hours


12/34

Predisposing Factors

Exercise

Injury

Cold

Obesity

Increased FractionalConcentration of CO2 toinspired Gas

Age

Ingestion of Alcohol

Dehydration

Fatigue


13/34

=7>394>:9 1R !#(

&7>P'>B14C7>@@81: "#$%&' () *+, -./0 1&2&134.1 5627 41 8&56'8 3693&

:6;&'/ .' 2'4/ 0&68 84-'?

@4';'


14/34

Treatment of DCS

Type I Treatment Table 5 (TT5) Musculoskeletal pain

Skin bends

Lymphatic bends

Type II Treatment Table 6 (TT6) Includes all other manifestations of DCS

Recompress to 60 FSW on 100% O2 and begin TT6

Diving Medical Officer (DMO) has option to go to 165 early if

patient has unsatisfactory response at 60 FSW

*Note: Severe Type II signs/symptoms warrant full extensions of 60 FSWoxygen breathing periods even if S/S resolve during the first oxygenbreathing period

Deep Uncontrolled Ascents Treatment Table 8 (TT8) 225 FSWtable for treating deep, uncontrolled ascents when more than 60minutes of decompression have been missed.


15/34


16/34


17/34

Treatment of DCS

Persistent Symptoms at 60 FSW

Extend TT6 for two 25-minute periods at 60 FSW


DMO may recommend customized treatment

Stay at 60 FSW for 12 hours or longer come out on TT7

'>B677>:B> 1R (>7816@ (G4C914@ 5678:M

!>B14C7>@@81:

If shallower than 60 FSW go to 60 FSW

If deeper than 60 FSW go to 165 FSW


18/34

Treatment of DCS Persistent Symptoms at 60 FSW



DMO may recommend customized treatment

Stay at 60 FSW for 12 hours or longer come out on TT7

'>B677>:B> 1R (>7816@ (G4C914@ 5678:M

!>B14C7>@@81:

If shallower than 60 FSW go to 60 FSW

If deeper than 60 FSW go to 165 FSW


19/34

Treatment of DCS

In-Water RecompressionOnly when:

No recompression facility on site

Significant signs/symptoms

No prospect of reaching chamber in 12-24 hrs

No improvement after 30 min of 100% oxygen onsurface

Thermal conditions are favorable

Not for unconsciousness, paralysis, respiratorydistress, or shock

Keep these individuals on the surface with 100% O2


20/34

Treatment of DCS

In-Water RecompressionOnly when:

In-Water Recompression with oxygen preferred

Purge rebreather 3 times with oxygen

30 FSW with stand-by diver

60 min at rest for Type 1

90 min at rest for Type II

20 FSW for 60 min

10 FSW for 60 min

100% O2 for additional 3 hours on the surface


21/34

Treatment of DCS

In-Water Recompression with air (if no oxygenavailable) Follow TT1A

Full face mask or surface-supplied helmet preferred

SCUBA used only as last resort Stand-by diver required

* Note: In divers with severe Type II symptoms or symptoms ofarterial gas embolism (e.g. unconsciousness, paralysis, vertigo,respiratory distress (chokes), shock, etc), the risk of increasedharm to the diver from in-water recompression probablyoutweighs any anticipated benefit.


22/34


23/34


24/34


25/34


26/34


27/34

!#( &'"S"*=)$*

EF

!8N>7 (>?>BJ1:

Screening for Patent Foramen Ovale (PFO)

History of DCS Disqualifying for diving duty Deselection of divers for repeated episodes of DCS Not

recommended

2. &7>P!8N> !#( &7>N>:J1:

:1&O8.3& &1I.2&P Q4 recommendation

Table modifications based on water temp No recommendation

Hydration (in warm water diving)

Dive depth limits: For SCUBA dives maximum depth of 130 ft(on-site chamber recommended for military diving if dive depth isgreater than100 ft)

Clean times: Surface interval required for the diver to beconsidered clean for the next dive: 2 hours 20 minutes forrepetitive group Alpha 15 hours 50 minutes for repetitive groupZulu


28/34

DCS PREVENTION

3. DCS Prevention (During the Dive)

Ascent Rate 30 feet per minute

4. DCS Prevention (Post-Dive)

Exercise restrictions Both aerobic (e.g. running) andanaerobic (e.g. weight lifting) exercise performed

within 4 hours after a compressed gas dive with

significant decompression stress may be associated

with an increased risk of DCS

Ascent to altitude restrictions (Up to 10,000 ft) Time/

ascent Table - up to 29:15 for Repet Group Zulu 48

hours for Exceptional Exposure Dives


29/34

Manifestations of AGE

Loss of consciousness

Confusion Focal neurological deficits

Cardiac arrhythmias or ischemia

Cardiac arrest and death 4%


30/34

Causes of AGE

Pulmonary barotrauma Iatrogenic events (radiologic

procedures and cardiac bypass

surgery) Right-to-left shunt

(43?? >4A1?8 8: 92> N>@@>?@ 1R 92> @D>?>93?

46@B?>@ 17 N8@B>73 37> T>?? 91?>739>5U A69

>4A1?8V3J1: 91 92> B>7>A73? W#-."X 17

B171:37G B87B6?3J1: 43G 7>@6?9 8: @>N>7>

417A8589G 17 5>392


31/34

Treatment of AGE

The primary goal of treatment is theprotection and maintenance of vitalfunctions

Pre-hospital 100% oxygen by rebreathing face mask

Supine position

Maintain hydration

HBO is the treatment of choice Adjunctive therapy: lidocaine,

anticoagulant, corticosteroid


32/34

Benefits of HBOT

1.Compression of existing gas bubbles

2. Establishment of a high diffusion gradient tospeed dissolution of existing bubbles

3. Improved oxygenation of ischemic tissues

and lowered intracranial pressure

4. Reduction of ischemic-reperfusion injury


33/34

Treatment table selection

Initial treatment USNTT6 extend Table 6 orUNSTT6A

Follow-up treatments

Daily or twice daily

Until complete relief of symptoms or until there isno further clinical improvement after 2 consecutivetreatments

Until complete relief of symptoms or until there isno further clinical improvement after 2 consecutivetreatments

No consensus: table 5, 6 and 9


34/34

=>7843D3@82

Documents

Decompression Sickness - Dr Guritno