DLCCMkLSSICN SICkNLSS AND GAS LM8CLISM

Mohammad Gur|tno SUkCkUSUMC

Ketua Program Studi Kedokteran Hiperbarik
Program Pascasarjana Fakultas Kedokteran
Unversitas Indonesia, Jakarta
email: mguritno@yahoo.com
DLCCMkLSSICN SICkNLSS
Decompression sickness (DCS) refers to the clinical
syndrome 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.
Ak1LkIAL GAS LM8CLISM
Arterial Gas Embolism (AGE) refers to gas bubbles in
the systemic arterial system resulting from pulmonary
barotrauma, iatrogenic entry of gas into the arterial
system, or arterialized venous gas emboli.
Classification of DI
1. The traditional or
Golding Classification
2. The descriptive or
Francis & Smith Classification
3. The ICD-10 Classification
Modified Golding Classification for DI
Arter|a| Gas Lmbo||sm
Decompress|on S|ckness
1. 1ype I : Muscu|oske|eta| a|n, Sk|n,
Lymphanc, Lxtreme Iangue,
er|phera| Nervous Symptoms
2. 1ype II : Neuro|og|c, Card|oresp|ratory,
Aud|o-vesnbu|ar, Shock
3. 1ype III : Comb|ned Decompress|on S|ckness
and Arter|a| Gas Lmbo||sm
Table The Francis & Smith Classification
for Dysbaric Illness
Evolution
o Spontaneously Recovery (Clinical improvement is
evident)
o Static (No change in clinical condition)
o Relapsing (Relapsing symptoms after initial recovery)
Progressive (Increasing number or severity
of signs)
Organ System:
o Neurological
o Cardiopulmonary
o Limb pain exclusively
o Skin
o Lymphatic
o Vestibular
Table The Francis & Smith Classification
for Dysbaric Illness
Time of onset:
o Time before surfacing
o Time after surfacing (or estimate)
Gas Burden
o Low (e.g., within NDL)
o Medium (e.g., Decompression Dive)
o High (e.g., Violation of Dive Table)
Evidence of Barotrauma
o Pulmonary (Yes / No)
o Ears
o Sinuses
Other Comments
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+)
Clinical Setting
1. Diving
2. Flying
3. HBOT
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 are
thought to result from tissue distortion of vascular
obstruction produced by bubbles
Presenting Symptoms Type Cases (%)


Local Pain
Arm
Leg


Vertigo (staggers)
Paralysis
Shortness of breath (chokes)
Extreme fatigue with pain
Collapse + unconsciousness

Type I




Type 2


89
30
70


5.3
2.3
1.6
1.3
0.5
Frequency of Various Symptoms of DCS
The time of onset of
symptoms after surfacing
30 % occurred < 30 minutes
85 % occurred < 1 hour
95 % occurred < 3 hours
1 % Delayed more than 6
hours
Predisposing Factors
Exercise
Injury
Cold
Obesity
Increased Fractional
Concentration of CO2 to
inspired Gas
Age
Ingestion of Alcohol
Dehydration
Fatigue
1reatment of DCS
re-kecompress|on
Cxygen 13 L/M wlLh reservolr mask or demand valve
auenL ln suplne posluon (noL head down)
Conunuous monlLorlng
Alr LransporL :
As low as safely posslble.
referably lower Lhan 1000
ressurlze alrcra cabln Lo 1 A1A lf posslble
Conslder Lmergency Lvacuauon Pyperbarlc SLreLcher
8ecompress even lf slgns/sympLoms resolve prlor Lo
recompresslon
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 FSW
oxygen breathing periods even if S/S resolve during the first oxygen
breathing period

Deep Uncontrolled Ascents Treatment Table 8 (TT8) 225 FSW
table for treating deep, uncontrolled ascents when more than 60
minutes of decompression have been missed.
Treatment of DCS
Persistent Symptoms at 60 FSW
Extend TT6 for two 25-minute periods at 60 FSW
Extend TT6 for two 75-minute periods at 30 FSW
DMO may recommend customized treatment
Stay at 60 FSW for 12 hours or longer come out on TT7
kecurrence of Ser|ous Symptoms dur|ng
Decompress|on
If shallower than 60 FSW go to 60 FSW
If deeper than 60 FSW go to 165 FSW
Treatment of DCS
Persistent Symptoms at 60 FSW
Extend TT6 for two 25-minute periods at 60 FSW
Extend TT6 for two 75-minute periods at 30 FSW
DMO may recommend customized treatment
Stay at 60 FSW for 12 hours or longer come out on TT7
kecurrence of Ser|ous Symptoms dur|ng
Decompress|on
If shallower than 60 FSW go to 60 FSW
If deeper than 60 FSW go to 165 FSW
Treatment of DCS
In-Water Recompression
Only 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 on
surface
Thermal conditions are favorable
Not for unconsciousness, paralysis, respiratory
distress, or shock
Keep these individuals on the surface with 100% O2
Treatment of DCS
In-Water Recompression
Only 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
Treatment of DCS
In-Water Recompression with air (if no oxygen
available)
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 of
arterial gas embolism (e.g. unconsciousness, paralysis, vertigo,
respiratory distress (chokes), shock, etc), the risk of increased
harm to the diver from in-water recompression probably
outweighs any anticipated benefit.
DCS kLVLN1ICN
1. D|ver Se|ecnon
Screening for Patent Foramen Ovale (PFO)
History of DCS Disqualifying for diving duty
Deselection of divers for repeated episodes of DCS Not
recommended

2. re-D|ve DCS revennon
re-dlve exerclse, no 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 is
greater than100 ft)
Clean times: Surface interval required for the diver to be
considered clean for the next dive: 2 hours 20 minutes for
repetitive group Alpha 15 hours 50 minutes for repetitive group
Zulu

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) and
anaerobic (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
Manifestations of AGE
Loss of consciousness
Confusion
Focal neurological deficits
Cardiac arrhythmias or ischemia
Cardiac arrest and death 4%
Causes of AGE
Pulmonary barotrauma
Iatrogenic events (radiologic
procedures and cardiac bypass
surgery)
Right-to-left shunt

Sma|| embo|| |n the vesse|s of the ske|eta|
musc|es or v|scera are we|| to|erated, but
embo||zanon to the cerebra| (CAGL) or
coronary c|rcu|anon may resu|t |n severe
morb|d|ty or death
Treatment of AGE
The primary goal of treatment is the
protection and maintenance of vital
functions
Pre-hospital
100% oxygen by rebreathing face mask
Supine position
Maintain hydration
HBO is the treatment of choice
Adjunctive therapy: lidocaine,
anticoagulant, corticosteroid
Benefits of HBOT
1. Compression of existing gas bubbles
2. Establishment of a high diffusion gradient to
speed dissolution of existing bubbles
3. Improved oxygenation of ischemic tissues
and lowered intracranial pressure
4. Reduction of ischemic-reperfusion injury
Treatment table selection
Initial treatment USNTT6 extend Table 6 or
UNSTT6A
Follow-up treatments
Daily or twice daily
Until complete relief of symptoms or until there is
no further clinical improvement after 2 consecutive
treatments
Until complete relief of symptoms or until there is
no further clinical improvement after 2 consecutive
treatments
No consensus: table 5, 6 and 9
1er|makas|h