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• 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
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
• 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.
• 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