UHM 2016, Vol. 43, No.

1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis

Seizures during hyperbaric oxygen therapy: retrospective analysis

of 62,614 treatment sessions
A. Hadanny, M.D. 1,2,3, O. Meir, B.A. 1, Y. Bechor, B.A. 1, G. Fishlev, M.D. 1 ,
J. Bergan, S. Efrati, M.D. 1,2,3,4
1
2
3
4

The Sagol Center for Hyperbaric Medicine and Research, Assaf Harofeh Medical Center, Zerifin, Israel
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Research and Development Unit, Assaf Harofeh Medical Center, Zerifin, Israel
Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel

CORRESPONDING AUTHORS: Amir Hadanny amir.had@gmail.com and Shai Efrati efratishai@013.net

______________________________________________________________________________________________________________________________________________________

ABSTRACT

Introduction: Hyperbaric oxygen (HBO2) therapy is

considered to be a generally safe therapy. However,
data regarding seizure incidence during HBO2 therapy
as a clinical presentation of central nervous system(CNS) related oxygen toxicity are conflicting (ranging from 1:10,000 to 1:600 seizures:hyperbaric
sessions). The risk for seizures is of significant importance for the growing population of patients
suffering from chronic neurological disorders such
as traumatic brain injury and stroke who are treated
with HBO2. The aim of this study was to evaluate
the incidence of seizures during HBO2 therapy in
a large cohort of patients and determine whether
patients with known chronic neurological disorders
are at increased risk.
Methods: Retrospective analysis of 2,334 patients
treated at the Sagol Center of Hyperbaric Medicine
and Research, Assaf Harofeh Medical Center, Israel,

between June 2010 and December 2014. Patients

were grouped into one of three categories according
to indication for HBO2 therapy: Category A nonneurological indications; Category B neurological
indications; and Category C acute indications.
Results: A total of 62,614 hyperbaric sessions, administered to 2,334 patients, were included in the
analysis. The overall incidence of seizures during
hyperbaric sessions was 0.011% (1:8,945), occurring
in seven (0.3%) patients. Only one patient had a
clear oxygen toxicity-induced seizure, with an overall
incidence of 1:62,614.
Conclusions: Seizures induced by oxygen toxicity
during HBO2 therapy are extremely rare. Moreover,
in relation to oxygen-induced seizures, HBO2 therapy can be considered safe for patients suffering with
chronic neurological disorders except for uncontrolled epilepsy.

______________________________________________________________________________________________________________________________________________________

Introduction
Hyperbaric oxygen (HBO2) therapy is being utilized
for a growing number of patients with a wide diversity
of comorbid illnesses. In particular, the number of
patients with chronic neurological disorders such as
traumatic brain injury and stroke has grown significantly.
Patients with chronic neurological disorders are being
referred for HBO2 therapy for non-healing wound indications (such as diabetic ulcers and crush injuries) and
for the neurotherapeutic effects of HBO2 therapy [1-3].

The possibility that oxygen can induce hyperactivation of the central nervous system (CNS) was first suggested in 1878 [4]. Breathing hyperbaric oxygen can
culminate in grand mal seizures, secondary to so-called
oxygen toxicity, with or without preceding symptoms
and signs. CNS hyperactivation and the development
of seizures depend upon the partial pressure of oxygen
and the duration of exposure [5]. The exact mechanism
underlying CNS-related oxygen toxicity is not fully
understood. One suggested mechanism involves reactive

_______________________________________________________________________________________________________________________

KEYWORDS: hyperbaric oxygenation, hyperbaric oxygen therapy, central nervous system oxygen toxicity, complications,
adverse effects, side effects
Copyright 2016 Undersea & Hyperbaric Medical Society, Inc.

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UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis
oxygen species during HBO2 therapy that cause membrane lipid peroxidation and enzyme inhibition and/or
modulations that lead to alterations in brain metabolism
and its related electrical activity [6]. There is no clear
evidence that seizures are related to oxygen induced
metabolic changes, however, an increase of glucose
utilization precedes the onset of electrophysiological
manifestations of CNS oxygen-toxicity [5]. Another
suggested mechanism relates to increased nitric oxide
(NO) levels in the brain, which may cause vasodilation in cerebral vessels and further increase oxygen
delivery to the brain [7].
HBO2 therapy is considered to be a generally safe
therapy. However, as clinical presentations of CNSrelated oxygen toxicity, seizures are reported with
conflicting incidence range, from 1:10,000 and up to
1:600 seizures:hyperbaric sessions [8]. HBO2-induced
seizures are defined as brief, oxygen-related, generalized tonic-clonic convulsions usually occurring toward
the end of the treatment [5]. Non-oxygen-related seizures in epileptic patients treated with HBO2 therapy,
even though rare, should be differentiated from oxygen
toxicity-related seizures [5]. Interestingly, in some
cases where there is an epileptic focus secondary to
circulatory and metabolic disturbances, HBO2 may
even abort seizures by correcting these abnormalities [9].
CNS-related oxygen toxicity risk factors include
fever, hypoglycemia, carbon monoxide poisoning,
hypercapnia, alcohol dependence and several medications (such as antidepressants, disulfiram, tramadol
and cephalosporins) [5,10]. In addition, neurological
disorders such as cerebral palsy, head trauma, stroke,
autism and others are thought to lower seizure threshold [5,11]. The aim of this study was to evaluate the
incidence of seizures during HBO2 therapy in a large
cohort of patients and determine whether patients with
known neurological disorders are at increased risk.
Methods
The study included all patients treated in the Sagol
Center of Hyperbaric Medicine and Research, Assaf
Harofeh Medical Center, Israel, between June 2010 and
December 2014 (since June 2010, adverse effects were
strictly recorded in the medical records). Data collected

22

retrospectively from patients medical files included

age, sex, chronic diseases, medications, indication for
HBO2, HBO2 protocol (pressure and duration), number
of sessions, side effects and reason for stopping treatment. The study was approved by the Helsinki Ethics
Committee of Assaf Harofeh Medical Center.
Patient categorization
Patients were categorized into one of the following
three groups:
Category A Patients with non-neurological
indications including non-healing wounds, nonneurological radiation injury, osteomyelitis,
avascular necrosis (AVN), complex fractures,
Crohns disease and idiopathic hearing loss.
Category B Patients with neurological disorders
due to stroke (both ischemic and hemorrhagic),
traumatic brain injury, cerebral palsy, pervasive developmental disorder and radiation injury to the brain.
Category C Patients with acute indications for
HBO2 including decompression sickness, carbon
monoxide (CO) poisoning, acute limb ischemia or
central retinal artery occlusion.
Pre-HBO2 therapy evaluation
Prior to the first session all patients were evaluated
by a hyperbaric physician. Chest X-ray was obtained
for each patient. Electrocardiogram (ECG) was performed in patients with a history of cardiovascular
disease. History of epilepsy or seizures mandated a
seizure-free interval of at least six months and a normalized electroencephalogram (EEG). Before each
session, heart rate, blood pressure and temperature
were obtained in all patients. Blood glucose was
measured before each session in diabetic patients.
Contraindication for HBO2 therapy
Closed pneumothorax was a contraindication for
HBO2 therapy. Relative contraindications included
active uncontrolled bronchial asthma, severe obstructive pulmonary disease and pregnancy (depending on
the urgency of the indication for HBO2 therapy).
Patients with fever did not receive HBO2 therapy until
the fever was under control with antipyretic medications or resolved.

Hadanny A, Meir O, Bechor Y, et al.

UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis
HBO2 therapy protocols
HBO2 therapy was performed in a multiplace chamber
equipped with video cameras and an intercom for patient
observation. In addition, a registered nurse certified as
a hyperbaric attendant was present inside the chamber
during each session for patients care. Patients were
treated five times per week with different protocols
depending on the indication: 100% oxygen at 1.5 atmospheres absolute (atm abs) for 60 minutes with no
air breaks and 0.8-meter-per-minute compression and
decompression; 100% oxygen at 2 atm abs for 90 minutes with five-minute air breaks every 30 minutes and
1-meter-per-minute compression and decompression;
and 100% oxygen at 2.4 atm abs for 90 minutes
with five-minute air breaks every 30 minutes and
1-meter-per-minute compression and decompression.
In addition, decompression sickness HBO2 treatments were performed according to U.S. Navy Treatment Tables: USN 5, USN 6, USN 6A [12]. Oxygen
was supplied via masks or hoods.
In-chamber seizure protocol
In cases of suspected seizures during the treatment, the
nurse attendant removed the patients mask or hood,
examined the patient by advanced cardiac life support
(ACLS) protocols and checked the patients blood
glucose. The on-site physician then decided whether
anti-convulsions drugs such as benzodiazepines should
be given. Whether these medications were given or they
were not, the patient was immediately decompressed
and removed from the chamber for further evaluation.
Statistical analysis
Data are expressed as frequencies and percentages
for non-parametric variables. Univariate analysis was
performed using chi-square/Fishers exact test to
identify significant variables (p<0.05). Numeric
variables analysis was performed using one-way
ANOVA and Bonferroni post-hoc multiple comparison. Methods were performed using the SPSS v.21
software (SPSS Inc., Chicago, Illinois).
Results
A total of 62,614 hyperbaric sessions, administered
to 2,334 patients, were included in the analysis.
The mean age of the patients was 52.3 22.5 years,

Hadanny A, Meir O, Bechor Y, et al.

while 240 (10.3%) were children under the age of

16 years. The male-to-female ratio was 1.8:1. Regarding
the indication for treatment:
25,072 sessions (783 patients) were under Category A;
36,195 sessions (1,236 patients) were under
Category B, which included neurological indications;
1,347 sessions (310 patients) were under
Category C, which included emergency indications.
Most of the non-emergent treatments were carried
out at 2 atm abs (99% in Category A and 78% in
Category B), while the majority (92%) of emergent
exposures were at 2.4 atm abs or higher pressures.
Table 1 summarizes patients characteristics.
The overall incidence of seizures during hyperbaric
sessions was 0.011% (1:8954), occurring in seven
(0.3%) patients. Of the seven patients who developed
seizures during HBO2 therapy:
Five patients had a history of seizures prior to HBO2
therapy. Three of the five patients treated urgently
for an acute air embolism suffered from seizures a
few minutes to several hours prior to the hyperbaric
exposure secondary to their primary diagnosis of
acute air embolism. They experienced similar
seizures during HBO2 therapy. The seizures were
treated with intravenous benzodiazepines and
phenytoin. Two of the five patients had a history of
epilepsy prior to HBO2 therapy, and their epilepsy
was treated with anti-epileptic medications prior
to HBO2 initiation. One patient was being treated
for a traumatic brain injury and the other for a non healing wound. During HBO2 therapy, they both had
seizures episodes very similar to those they typically
suffer from. The seizures were treated in the
chamber using intravenous benzodiazepines.
Two patients were seizure-nave, i.e., without any
record or history of prior seizures. One patient
was being treated for a non-healing wound and
experienced a seizure at her home, 34 hours after
her eighth session, which excluded oxygen toxicity
as a possibility. The other patient was being treated
for stroke-related neurological damage and
suffered a true oxygen toxicity seizure during her
second hyperbaric session (100% at 2 atm abs). The
seizure stopped after mask removal and the patient
regained consciousness after 10 minutes. The seizure
incidence per group is summarized in Figure 1.

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UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis
_______________________________________________________________________________________________________________________________________________

Table1: Patients baseline characteristics

total
A
B
C

comparison
between
A-B Groups#

comparison
between
A-B-C Groups#

number of
2334
783
1236
310
patients
_____________________________________________________________________________________________________________________________________________
sessions
62,614
25,072
36,195
1347
_____________________________________________________________________________________________________________________________________________
mean sessions
26.8 22.5
32.0 231 29.3 21.5
4.3 4.9
*0.01
*<0.0001
per patient
_____________________________________________________________________________________________________________________________________________
age
52.3 22.5
55.4 17.6 52.6 24.6
42.8 21.9
*0.017
*<0.0001
_____________________________________________________________________________________________________________________________________________
children 16
240 (10.3%) 18 (2.3%)
190 (15.3%) 32 (10.3%)
*<0.0001
*<0.0001
_____________________________________________________________________________________________________________________________________________
sex
males
1495 (64%)
455 (57.9%) 8727 (66.8%) 213 (68.7%) *<0.0001
*<0.0001
___________________________________________________________________________________________________________________________________________
females
839 (36%)
321 (42.1%) 411 (33.2%) 97 (31.3%)
_____________________________________________________________________________________________________________________________________________
treatment protocol
1.5 atm abs
271 (11.6%)
0
270 (21.8%)
0
*<0.0001
*<0.0001
_____________________________________________________________________________________________________________________________________________
2 atm abs
1768 (75.7%) 270 (99%) 968 (78.2%) 23 (7.4%)
_____________________________________________________________________________________________________________________________________________
2.4 atm abs
295 (12.6%) 8 (1.0%)
0 (0%)
287(92.6%)
_____________________________________________________________________________________________________________________________________________
Category A included patients with non-healing wounds, non-neurological radiation injury, osteomyelitis, AVN, fractures,
Crohns disease, idiopathic hearing loss.
Category B included patients with stroke (both ischemic and hemorrhagic), traumatic brain injury, cerebral palsy,
autism and radiation injury to the brain.
Category C included patients with acute indications including decompression sickness, CO poisoning, acute limb
ischemia, central retinal artery occlusion. Inter-group differences significance was calculated using chi-square test
for non-para-metric variables and one-way ANOVA for continuous parameters.
Category C patients, treated for emergency indications, were significantly different from the chronic subgroups A and B.
Accordingly, post-hoc analysis comparing subgroups A and B was performed. Continuous parameters are expressed as
mean SD. Statistical significance was considered as p<0.05.
# Comparison between A-B-C groups were by chi-square and ANOVA tests and comparison between A-B groups were
by chi-square and Bonferroni post-hoc tests.
* Statistical significance (p<0.05)

The overall incidence of clear oxygen toxicity seizures

was 1:62,614. At hyperbaric pressure of 1.5 atm abs no
seizure events were recorded (0:12,303). At 2 atm abs,
the seizure incidence was 4:49,049, from which clear
oxygen toxicity was 1:49,049. At 2.4 atm abs or higher
pressure, the incidence of seizures increased to 1:419,
but none could be attributed to clear oxygen toxicity
(0:1,259) (Figure 2). There was no significant difference in seizures incidence between neurological and
non-neurological indications (Fishers exact test=1).

24

Discussion
This study summarizes one of the largest cohorts of
patients treated with HBO2 therapy. From a total of
62,614 HBO2 sessions, seven seizure events were
recorded while only one case could be considered to
be true oxygen toxicity seizure a calculated incidence of 1.59:100,000. Based on these numbers, HBO2
therapy can thus be considered to be safe for all treatment categories including in patients with neurologic
disorders such as traumatic brain injury, stroke, cerebral palsy, autism and radiation injury to the brain.

Hadanny A, Meir O, Bechor Y, et al.

UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBo2 THERAPY: RETRoSPEcTIVE ANAlYSIS
________________________________________________________________________________________________________________________________________

Figure 1: Hyperbaric pressure and seizures

n seizures n oxygen toxicity seizures

1,000

100

10

1
1.5 atm abs

2 atm abs

2.4 atm abs

number of seizures per 100,000 sessions

The calculated seizure incidence per 100,000 sessions in the different hyperbaric pressures.
________________________________________________________________________________________________________________________________________

Figure 2: Seizures per diagnosis

1,000

n seizures n oxygen toxicity seizures

100

10

non-neurological indications

neurological indications

emergency indications

number of seizures per 100,000 sessions

The calculated seizure incidence per 100,000 sessions per category.

Hadanny A, Meir O, Bechor Y, et al.

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UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis
Seizures during HBO2 therapy should be classified
as oxygen toxicity seizures or non-oxygen related
seizures. In order to define the seizure as oxygenrelated, a careful history should be obtained in order
to rule out seizures/unexplained loss of consciousness
prior to HBO2 therapy. In addition, oxygen toxicity
seizures occur during the oxygen exposure itself, and
are usually resolved easily once the partial pressure of
oxygen is reduced (by removing the patients mask or
hood). Non-oxygen-related seizures are a result of a
prior epileptogenic focus, which may be activated in
sporadic times irrespective of the hyperbaric oxygen
environment. In addition to non-oxygen related seizures, hypoglycemia should also be part of the differential diagnosis. Hypoglycemia can cause alteration in
consciousness level and cause tremor or other limb
movements that may be misdiagnosed as oxygen
toxicity. Hyperbaric exposure increases the risk for
hypoglycemia mostly in diabetic patients due to increased metabolism and glucose consumption as
well as the temporary fast during treatment [13].
Therefore, patients with suspected seizures during
HBO2 therapy should have their oxygen source
removed and their blood glucose tested.
In the literature, there are mixed reports regarding
the rate of oxygen toxicity seizures. The commonly
accepted value of 10 per 100,000 was based on several
studies from the 1980s [14,15]. Later studies showed
higher rates, which may have reflected changes in
patient selection and treatment protocols [8,16-18].

HBO2 protocol
Banham showed that hyperbaric oxygen at pressures
higher than 2 atm abs increases the risk for oxygen
toxicity seizures [8]. In our study, most of the patients
(87%) were treated with 1.5-2 atm abs. At treatments
with pressures between 1.5 to 2.0 atm abs, no oxygen
toxicity seizures were recorded. This is in agreement
with a recent work by Heyboer, et al., recording zero
seizures in 16,430 sessions at 2 atm abs [19,20]. However, a low incidence of oxygen toxicity was also
noticed in hyperbaric pressure exposures higher than
2 atm abs.
Our overall low incidence of oxygen toxicity can be
explained by several factors. First, one of the key reasons
is that hyperbaric oxygen exposure was kept to the
lowest dose considered effective. Hyperbaric pressures of up to 2 atm abs were administered in most of
the sessions (~97%). The duration of the session did
not exceed 90 minutes of continuous oxygen exposure
with air breaks, or 60 minutes without air breaks.
Second, we used masks instead of hoods: it has
been previously suggested that hoods increase oxygen
toxicity due to increased oxygen partial pressure
and carbon dioxide accumulation [7]. We used tight
masks as the default, while only children treated
at 1.5 atm abs (0.3%) used hoods.
Third, patients with known epilepsy were screened
using EEG prior to HBO2 therapy. Epileptic patients
had to be well controlled, with a seizure-free period
of at least six months prior to HBO2 therapy.

Patient selection
Yildiz et al. [11] had the lowest incidence of seizures
reported in the literature: 2.4:100,000. This low proportion could be attributed to excluding patients with
known neurological pathology due to stroke, head
trauma and cerebral palsy from their analysis. In the
Yildiz study patients were using masks, not hoods, with
five-minute air breaks every 30 minutes. In the current
study, while all adult patients were also treated by
masks and had air breaks, the very low incidence of
oxygen toxicity was preserved even though patients with
neurological disorders were included in the analysis.

Emergency indications
Emergency indications such as CO poisoning are
considered to increase the risk for seizures [8,21]. In
our study, no seizures were recorded in this patient
population. With regard to CO poisoning, the low rate
of seizures might be explained by the treatment protocol used: first session at 2.4 atm abs followed by two
2-atm abs sessions instead of the previously used
protocol of 2.8-3 atm abs [22,23]. Three patients treated for air emboli, in accordance with USN 6A protocol,
who had seizures as part of their clinical presentation
before entering the chamber, suffered from seizures
during their hyperbaric exposure. Although they were
treated with high oxygen pressure (3.0 atm abs at

26

Hadanny A, Meir O, Bechor Y, et al.

UHM 2016, Vol. 43, No. 1 SEIZURES DURING HBO2 THERAPY: Retrospective analysis
50 msw and 2.8 atm abs at 18 msw, as per USN 6A
protocol) these seizures were probably not related
to oxygen toxicity.
STRENGTHS AND LIMITATIONS
The current study has several strengths and limitations. Most of the limitations are related to the fact
that data was collected retrospectively. Retrospective
cohort study may increase the risk for selection bias.
However, in order to eliminate this risk, all patients
treated in our institute in the past four and a half years
were included without any exclusions. With regard to
strengths, this is one of the largest cohorts of HBO2
therapy analyzed for seizure incidence that also included patients with known neurological disorders.

Conclusion
Seizures induced by oxygen toxicity during HBO2
therapy are rare. Moreover, in relation to oxygeninduced seizures, our findings suggest that HBO2
therapy can be considered to be safe for all treatment
categories including in patients with neurologic indications such as traumatic brain injury, stroke, cerebral
palsy, autism and radiation injury to the brain.
Conflict of interest
The authors have declared that no conflict of interest exists
with this submission.

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