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DECOMPRESSION

 SICKNESS  AND  GAS  EMBOLISM  


Mohammad Guritno SURYOKUSUMO
Ketua Minatan Kedokteran Hiperbarik
Program Pascasarjana Fakultas Kedokteran
Unversitas Indonesia, Jakarta
email: mguritno@yahoo.com
DECOMPRESSION  SICKNESS  
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.

ARTERIAL  GAS  EMBOLISM  


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.
Terminology and Classification
•  The differentiation between illness and sickness
•  Decompression illness (DCI) or Dysbaric illness (DI) is an
inclusive term that encompasses either or both DCS and
AGE.
•  Various clinical terms have emerged in an ongoing effort to
describe and classify DI.
•  Clinical syndromes (e.g., the “bends”, “chokes” and
“staggers”)
•  A presumptive assignment of etiology and severity (e.g.,
type I decompression sickness and arterial gas embolism)
•  The systematic capture of descriptive clinical and causal
factors associated with the condition (e.g., decompression
illness or dysbarism, and gas bubble illness).
Dilemma & Future Classification Systems

•  The present trend is towards developing clearly defined


case definitions for DCS, AGE and combined forms.
•  The dilemma in developing these is that there is disparity
between epidemiological and clinical objectives.
•  The ECHM has recommended the development and
acceptance of such an epidemiological classification system
which will allow multi-center, multinational, retrospective
analyses derived from broad-based classifications that
include the type of diving, chronological data, clinical
manifestations and outcome of a two-year follow up for
prognostic purposes.
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

•  Arterial  Gas  Embolism  


•  Decompression  Sickness  
                         1.  Type  I        :        Musculoskeletal  Pain;  Skin;  
                                                               LymphaGc;  Extreme  FaGgue;    
                                                               Peripheral  Nervous  Symptoms  
             2.  Type  II      :        Neurologic;  Cardiorespiratory;        
                                                               Audio-­‐vesGbular;  Shock  
             3.  Type  III    :        Combined  Decompression  Sickness    
                                                                 and  Arterial  Gas  Embolism  
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 (Caisson’s 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
General Aspect :
Most of the clinical manifestations of DCS are
thought to result from tissue distortion of vascular
obstruction produced by bubbles

•  Denaturation of Plasma Proteins


•  Endothelial Damage
•  Interaction of Bubbles with the Blood
Coagulation System
Frequency of Various Symptoms of DCS
Presenting Symptoms Type Cases (%)

Type I
Local Pain 89
Arm 30
Leg 70
Type 2
Vertigo (“staggers”) 5.3
Paralysis 2.3
Shortness of breath (“chokes”) 1.6
Extreme fatigue with pain 1.3
Collapse + unconsciousness 0.5
ClassificaGon  of  iniGal  and  of  all  eventual  manifestaGons  of  decompression  illness  in  2346  recreaGonal  diving  accidents  
reported  to  the  Divers  Alert  Network  from  1998  to  2004  ClassificaGon  of  iniGal  and  of  all  eventual  manifestaGons  of  
decompression  illness  in  2346  recreaGonal  diving  accidents  reported  to  the  Divers  Alert  Network  from  1998  to  2004  
Richard  D  Vann,  Frank  K  Butler,  Simon  J  Mitchell,  Richard  E  Moon  Richard  D  Vann,  Frank  K  Butler,  Simon  J  Mitchell,  Richard  E  
Moon  
Elliott DH and Moon RE. Manifestations of the decompression
disorders. In: The Physiology and Medicine of Diving (4th ed.), edited
by Bennett PB and Elliott DH. London: W. B. Saunders, 1993, p.
481505.
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
inspred Gas
•  Age
•  Ingestion of Alcohol
•  Dehydration
•  Fatigue
Treatment  of  DCS  
Pre-­‐Recompression  
•  Oxygen  15  L/M  with  reservoir  mask  or  demand  valve  
•  Pa2ent  in  supine  posiGon  (not  head  down)  
•  Con2nuous  monitoring  
•  Air  transport  :    
•  As  low  as  safely  possible.    
•  Preferably  lower  than  1000  feet  
•  Pressurize  aircraA  cabin  to  1  ATA  if  possible  
•  Consider  Emergency  EvacuaGon  Hyperbaric  Stretcher  
•  Recompress  even  if  signs/symptoms  resolve  prior  to  
recompression  
Treatment of DCS
Initial Recompression for DCS

•  The USN Diving Manual treatment algorithms remain the gold standard for
initial recompression of diving-related DCI. The use of alternate tables
should be reserved for trained personnel at facilities with the expertise and
hardware to deal with untoward/unexpected responses to therapy.

•  Surface oxygen is not a substitute for hyperbaric therapy in diving related


DCI. However, surface oxygen alone can be considered if symptoms are
mild and have been stable for 24 hours, neurological examination is normal,
and evacuation of the patient cannot readily be achieved or is associated
with some risk (3).
Treatment of DCS  
•  Type I – Treatment Table 5 USN (TT5)
•  Musculoskeletal pain
•  Skin bends
•  Lymphatic bends

•  Type II – Treatment Table 6 USN (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

•  Recurrence  of  Serious  Symptoms  during  


Decompression
•  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

•  Recurrence  of  Serious  Symptoms  during  


Decompression
•  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 re-breather 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 PREVENTION
1.  Diver Selection
•  Screening for Patent Foramen Ovale (PFO)
•  History of DCS Disqualifying for diving duty
•  Deselection of divers for repeated episodes of DCS Not
recommended

2. Pre-Dive DCS Prevention


•  Pre-dive exercise, 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
 
Small  emboli  in  the  vessels  of  the  skeletal  
muscles  or  viscera  are  well  tolerated,  but  
embolizaGon  to  the  cerebral  (CAGE)  or  
coronary  circulaGon  may  result  in  severe  
morbidity  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
Summary
•  Clinical diagnosis
•  A sudden loss of consciousness or
hemodynamic collapse during or
immediately after any invasive
procedure may indicate gas embolism
•  HBOT is treatment of choice for AGE or
VGE with paradoxical embolism
GAS  EMBOLISM  (GE)  
 
Gas  Embolism  (GE)  refers  to  all  pathological  
events  related  to  the  entry  or  the  occurrence  of  
gas  bubbles  in  the  vascular  

•  Two  categories  
1.  Venous  gas  embolism  (VGE)  
2.  Arterial  gas  embolism  (AGE)  
Causes  of  VGE  
1.  Surgical  Procedures  
2.  Iatrogenic  creaGon  of  a  pressure  
gradient  for  air  entry  
3.  Mechanical  insufflaGon  or  infusion  
4.  PosiGve  pressure  venGlaGon  
5.  Blunt  and  penetraGng  trauma  to  the  
chest,  abdomen,  neck  and  face  
Causes  of  AGE  
•  Pulmonary  barotrauma  
•  Iatrogenic  events  (radiologic  procedures  and  
cardiac  bypass  surgery)  
•  Right-­‐to-­‐lea  shunt  
 
Small  emboli  in  the  vessels  of  the  skeletal  
muscles  or  viscera  are  well  tolerated,  but  
embolizaGon  to  the  cerebral  (CAGE)  or  
coronarycirculaGon  may  result  in  severe  
morbidity  or  death