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Decompression

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Decompression Diagnosis Treatment and Hyperbaric Oxygen Tretment HBO

Decompression Diagnosis Treatment and Hyperbaric Oxygen Tretment HBO

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  • 1. Decompression sickness
    Caribbean Emergency Care Conference 2011
    J. van Leeuwen MD Surgeon
  • 2. Introduction
    Classification DS is classified by symptoms
    The earliest descriptions of DS used the terms: "bends" for joint or skeletal pain
    "chokes" for breathing problems
    "staggers" for neurological problems
  • 3. DS in a nutshell
  • 4. Introduction
    Type I ('simple’)
    for symptoms involving only the skin, musculoskeletal system, or lymphatic syste
    Type II ('serious’)
    for symptoms where other organs (such as the central nervous system) are involved
  • 5. Introduction
    Type II DCS
    is considered more serious and usually has worse outcomes
  • 6. Signs and symptoms
  • 7. Bubbles can form anywhere in the body
    Most
    frequently observed in the shoulders, elbows, knees, and ankles. Joint pain ("the bends") accounts for about 60% to 70% of DS cases, with the shoulder being the most common site
  • 8. Musculoskeletal (mostly joints)
    Localized deep pain, ranging from mild to excruciating
    Red rash in skin
    Sometimes a dull ache, but rarely a sharp pain. Active and passive motion of the joint aggravates the pain
  • 9. Itching, usually around the ears, face, neck, arms, and upper torso
    Sensation of tiny insects crawling over the skin
    Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching
    Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)
    CutaneousType I DS
  • 10. Neurologic (brain)Type II DS
    Altered sensation, tingling or numbness paresthesia, increased sensitivity hyperesthesia
    Confusion or memory loss (amnesia)
    Visual abnormalities
    Unexplained mood or behaviour changes
    Seizures, unconsciousness
  • 11. Neurologic (spinal cord)
    Ascending weakness or paralysis in the legs
    Girdling abdominal or chest pain
    Urinary incontinence and fecal incontinence
  • 12. Constitutional (whole body)
    Headache
    Unexplained fatigue
    Generalised malaise, poorly localised aches
  • 13. Audiovestibulair (inner ear)
    Loss of balance
    Dizziness, vertigo, nausea, vomiting
    Hearing loss
  • 14. Pulmonary
    Dry persistent cough
    Burning chest pain under the sternum, aggravated by breathing
    Shortness of breath
  • 15. Frequency symptoms
    Joint pain 89%
    Arm symptoms 70%
    Leg symptoms 30%
    Dizziness 5.3%
    Paralysis 2.3%
    Shortness of breath 1.6%
    Extreme fatigue 1.3%
    Collapse/unconsciousness 0.5%
  • 16. Onset of DS
    within 1 hour 42%
    within 3 hours 60%
    within 8 hours 83%
    within 24 hours 98%
    within 48 hours 100%
    Although onset of DS can occur rapidly after a dive, in extreme cases even before a dive has been completed, in more than half of all cases symptoms do not begin to present until over an hour following the dive
  • 17. What causes DS
    A reduction in ambient pressure that results in the formation of bubbles of inert gases within tissues of the body
    It may happen when leaving a high-pressure environment, ascending from depth, or ascending to altitude
  • 18. Predisposing factors
    Although the occurrence of DS is not easily predictable, many predisposing factors are known
    environmental
    individual
  • 19. Environmental (to increase risk)
    The magnitude of the pressure reduction ratio and duration 
    Repetitive exposures – repetitive dives within a short period of time (a few hours)
    Repetitive ascents to altitudes above 5,500 metres
    The US Navy Dive Manual indicates that ascent rates greater than about 20 m/min (66 ft/min) when diving increase the chance of DS, while recreational dive tables require an ascent rate of 10 m/min (33 ft/min) with the last 6 m (20 ft) taking at least one minute
  • 20. Individual
    Age 
    Previous injury – there is some indication that recent joint or limb injuries to developing decompression-related bubbles
    Ambient temperature –exposure to very cold ambient temperatures may increase the risk of altitude DS
    High body fat content is at greater risk of DS. This is due to nitrogen's five times greater solubility in fat than in water
  • 21. Alcohol consumption and dehydration 
    Maintaining proper hydration is recommended.
    Patent foramen ovale 
    Venous blood with microbubbles of inert gasbypass the lungs, where the bubbles would otherwise be filtered out by the lung capillary system, and return directly to arteries to the brain, spinal cord and heart
    In the arterial system, bubbles (arterial gas embolism) are far more dangerous because they block circulation and cause infarction (tissue death, due to local loss of blood flow). In the brain, results in stroke, and in the spinal cordresults in paralysis
  • 22. Mechanism
    Depressurisation causes inert gases, which were dissolved under higher pressure, to come out of physical solution and form gas bubbles within the body. These bubbles produce the symptoms of decompression sickness
    Bubbles may form whenever the body experiences a reduction in pressure, but not all bubbles result in DS
  • 23. On ascent from a dive, inert gas comes out of solution in a process called "outgassing" or "offgassing". Under normal conditions, most offgassing occurs by gas exchange in the lungs. If inert gas comes out of solution too quickly to allow outgassing in the lungs then bubbles may form in the blood
    The formation of bubbles in the skin or joints results in milder symptoms, while large numbers of bubbles in the venous blood can cause lung damage
  • 24. Diagnosis
    DS should be suspected if any of the symptoms associated with the condition occurs following a drop in pressure, in particular, within 24 hours of diving
    In 1995, 95% of all cases reported to Divers Alert Network had shown symptoms within 24 hours
    The diagnosis is confirmed if the symptoms are relieved by recompression
  • 25. Prevention
    To prevent ascend 10 metres (33 ft) per minute, and carry out a decompression schedule as necessary
    This schedule requires the diver to ascend to a particular depth, and remain at that depth until sufficient gas has been eliminated from the body to allow further ascent
    Dives that contain no decompression stops are called "no-stop dives", but divers usually schedule a short "safety stop" at 3 metres (10 ft), 4.6 metres (15 ft), or 6 metres (20 ft), depending on the training agency
  • 26. Treatment
    100% oxygen until hyperbaric oxygen therapy (100% oxygen delivered in a high-pressure chamber) can be provided
    Mild cases of the "bends" and some skin symptoms may disappear during descent from high altitude
    Neurological symptoms, pulmonary symptoms, and mottled or marbled skin lesions should be treated with hyperbaric oxygen therapy if seen within 10 to 14 days of development
  • 27. Treatment
    Oxygen first aid has been used as an emergency treatment
    If given within the first four hours of surfacing, it increases the success of recompression therapy as well as a decrease the number of recompression treatments required
  • 28. Treatment
    Give fluids, as this reduces dehydration
    In the past, both the Trendelenburg position and the left lateral decubitus position have been beneficial where air emboli are suspected
  • 29. Prognosis
    Immediate treatment with 100% oxygen, followed by recompression in a hyperbaric chamber, will in most cases result in no long term effects
    Three-month follow-ups on diving accidents reported to DAN in 1987 showed 14.3% of the 268 divers surveyed still had residual signs and symptoms from Type II DS and 7% from Type I DS
  • 30. Epidemiology
    The incidence of decompression sickness is rare, estimated at 2.8 cases per 10,000 dives, with the risk 2.6 times greater for males than females
    DS affects approximately 1,000 U.S. scuba divers per year
    From 1998 to 2002, they recorded 50,150 dives, from which 28 recompressions were required — 0.05%
  • 31. Treatment principles
    HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen at normobaric conditions
    Under normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma.
    Because the hemoglobin of the red blood cells is almost saturated with oxygen under atmospheric pressure, this transport cannot be used any further.
    Oxygen transport by plasma, however is significantly increased using HBOT
  • 32. Indications
    Air or gas embolism
    Carbon monoxide poisoning
    Clostridal myositis and myonecrosis (gas gangrene)
    Crush injury, compartment syndrome, and other acute traumatic ischemias
    Decompression sickness
  • 33. Hyperbaric Oxygen Therapy
    Involves intermittently breathing pure oxygen at greater than ambient pressure
    Think of oxygen as a drug and the hyperbaric chamber as a dosing device
    Elevating tissue oxygen tension is the primary effect
  • 34. Hyperbaric Oxygen Therapy
    Primary therapy for:
    Decompression sickness
    Air embolism
    Carbon monoxide poisoning
    Adjunct therapy for:
    Surgical intervention
    Antibiotics
  • 35. Accepted Indications
    Air or gas embolism
    Carbon monoxide poisoning
    Clostridialmyositis and myonecrosis
    Crush injury, compartment syndrome, acute traumatic ischemias
    Decompression sickness
    Enhance healing of wounds
    Necrotizing fasciitis
    Chronic osteomyelitis
    Radiation necrosis, brown recluse spider bites
    Thermal burns
  • 36. Basic Mechanisms
    Boyle’s Law – pressure and volume inversely proportional under constant temperature
    By increasing ambient pressure to 2 atm, decreases the volume by ½
    Henry’s Law – at a given temperature, the amount of gas dissolved in solute is directly proportional to the partial pressure of the gas.
    By increasing ambient pressure, more oxygen can be dissolved in the plasma
  • 37. Mechanism of action
    Angiogenesis in ischemic tissues
    Bacteriostatic/bactericidal actions
    Carboxyhemoglobin dissociation hastened
    Clostridium perfringens alpha toxin synthesis inhibited
    Vasoconstriction
    Temporary inhibition of neutrophil Beta 2 integrin adhesion
  • 38. Monoplace (1 person) or multiplace (2-14 patients) chamber
    Pressures applied inside the chamber are usually 2-3 xatm pressure, plus may have an additional hydrostatic pressure equivalent of 1-2 atm.
    Treatments last from 2-8 hours
  • 39. Complications
    Middle ear barotrauma
    Middle ear barotrauma is the most common adverse effect of HBO treatment
    Hemorrhage or serous effusion develops
    Prevention: teaching patient auto-insufflation technique or use of decongestants
    If auto-insufflation fails, tympanostomy tubes are placed.
  • 40. Complications
    Pulmonary barotrauma
    Rare
    Suspect if pulmonary or hemodynamic changes occur during or shortly after decompression
    Place chest tube if pneumothorax develops
  • 41. Complications
    Oxygen Toxicity
    Can impair elasticity, vital capacity, and gas exchange.
    CNS toxicity
    Seizure
    Risk is higher in hypercapnic, acidotic, or septic patients
    Eyes
    Progressive myopia has been reported in patients undergoing repetitive daily therapy
  • 42. CO Poisoning
    Leading cause of injury and death by poisoning in the world
    Affinity of CO for hemoglobin (forming carboxyhemoglobin) is 200 times that of oxygen
  • 43. ClostridialMyonecrosis(gas gangrene)
    Mortality rates of 11-52%
    Diffused oxygen which raises capillary p02 levels at the wound site, stimulates capillary budding and granulation of new, healthy tissue
  • 44. Necrotizing Fasciitis andFournier’s gangrene
    Addition of HBO to surgical and antibiotic treatment reduced mortality versus surgery and antibiotics alone
    May suppress growth of anaerobic organisms
    May increase leukocyte function and suppress bacterial growth
  • 45. Crush injury
    Reduces infection and wound dehiscence and improves healing
    Improves oxygenation to hypoperfused tissue
    Causes arterial hyperoxia causing vasoconstriction and decreased edema formation.
    Also, intermittent pressure stimulates circulation and reduces edema
    Early use of HBO may reduce compartment pressures enough to avoid fasciotomy
  • 46. Prevention
    Don’t push your limits and do all required decompression stops
    Keep physically fit and within a healthy weight range
    Don't exercise within 12 hours of diving
    Don't ascend to altitude or fly immediately after diving
    Make sure you're adequately hydrated before every dive
    Don't drink alcohol before or after diving and never dive when hungover
    Get checked out by a doctor to find out if you have a PFO
  • 47. MASHA DANKI!