Steven Elsbecker D.O.
University of Nevada School of Medicine
January 18th 2012
45 year old male with toe pain secondary to
gout presents to your ED. While establishing IV
access, the nurse forgets to f...
Steven Elsbecker D.O. / Troy Aikman / Duffman
University of Nevada School of Medicine
January 18th 2012
Review our dive facility and procedures
Physics of Hyperbaric Oxygen Therapy (HOT)
Physiology of HOT
Indications
Review ba...
First hyperbaric chamber built in 1662 by British
clergyman Nathaniel Henshaw
Compressed manually with a bellows using
roo...
In 1967, the Undersea and Hyperbaric Medicine
Society (UHMS) was founded to help facilitate
the exchange of knowledge in t...
Two types of chambers
Monoplace
Just patient inside. Desired gas delivered to whole chamber
Multiplace
Can treat multiple ...
Duration is variable depending on indication
Pressurized to 2.0 – 2.2 ATA
FiO2 between 21 – 100%
Nurse in chamber with pat...
Average bill generated for a single dive = $2600
Average repayment from Medicare is $360
Average number of dives required ...
A neutron walks into Frankie’s and says “how
much for a Fink Bomb?” The bartender replies
“for you, no charge.”
Boyle’s La...
p1v1=p2v2
Useful when thinking about gas
embolic phenomenon, DCS
(p1v1)/T1=(p2v2) /T2
Used to explain temperature
changes when compressing or
decompressing patients.
P=KhC
Higher concentrations of a gas dissolved in
blood will yield a higher partial pressure.
Diffusion
Wound healing, DCS...
Hyperoxygenation
Fibroblast proliferation
Decreases gas bubble load
Vasoconstriction
Angiogenesis
Enhances leukocyte oxida...
Hb saturation on room air 97-100%
Also have small amount of O2 dissolved in
plasma
Human tissue at rest requires approxima...
Main physiologic force behind healing complex
wounds
More “healing” cells
Larger matrix to rebuild upon
Hunt TK, {ai MP, e...
Poorly understood mechanism of action
Only ever studied in rats / mice
Important for complex wounds and
compromised grafts...
Boyle’s Law
patmvatm = pHOTvHOT
As partial pressures in plasma increase, Boyles
law states that the volume of undissolved
...
Tina McProzac, a 35 yo pregnant female with known
history of bipolar disorder and SI is brought in by EMS
for AMS. She was...
Hyperoxemia leads to vasoconstriction
O2 delivery(ml/min) = O2 carry(ml/dl) x Flow (dl/min)
No change in net O2 delivery
D...
Enhances SOD
Augments oxidative destruction of
phagocytosed bacteria
Slows progression of necrotizing fasciitis
Limited use
Conservative management
Waiting for surgeon
Awaiting transfer for h...
Generation of free radicals assists in bacterial
killing
Very limited studies done on HOT in the setting
of sepsis. Again,...
Who named the following gas law: p1v1=p2v2
Robert Boyle
Ross Berkeley
Jacques Charles
Amedeo Avogardo
Acute CO poisoning
Decompression Sickness
Gas Embolism
Necrotizing Fasciitis
Acute Traumatic Peripheral Ischemia
Crush Inj...
Acute CO Poisoning
Decompression Sickness
Gas Embolus
Crush Injury / Compartment Syndrome
Central Retinal Artery Occlusion...
HOT not always indicated
Treatment indicated for CNS depression, severe
acidosis, CO-Hb > 20% or >10% in pregnant
females
...
Hyperbaric oxygen is used to DIFFUSE more O2
into plasma.
Increases total oxygen dissolved in plasma from
0.5 – 1.0 ml/dl ...
How many divers does it take to circumcise a
blue whale?
Four Skin Divers
As partial pressure of O2 and N2 decrease in
plasma, N2 and O2 dissolved in the tissues
diffuse back into the bloodstream
...
Breath Hold Divers?
Snorkelers?
Recirculating Tanks?
SCUBA?
Type I – musculoskeletal sxs, fatigue
Type II – CNS and cardiorespiratory depression,
shock
Type III – any spinal deficit,...
Increasing the partial pressure of dissolved
gasses in plasma will decrease the volume load
of undissolved gasses.
Balloon...
Rare, but very little treatment options
Nursing error
IJ Central line not in Trendelenburg
DCS
Pulmonary barotrauma
Vascul...
Both have a myriad of complications
Edema is controllable with HOT without
compromise of O2 delivery
Decreases reperfusion...
Hyperoxemia causes vasoconstriction and
decreases edema
Proven efficacy with compartment and crush
Many types of edema, po...
Sudden onset painless monocular visual loss
Theory for HOT is that the small amount of
blood still getting to the retina c...
HOT reduces inflammatory response, reduces
edema, and is protective against severe
superimposed infection.
2/2 to vasocons...
Concept useful in DCS, air embolism, PTX
The use of HOT or a NRB yields oxygen rich,
nitrogen poor plasma.
The pockets of ...
Absolute
PNEUMOTHORAX
Disulfiram
Chemotherapeutic Agents
Relative
Asthma
Claustrophobia
COPD
Spherocytosis
High Fever
Pace...
Barotrauma
Middle ear, Sinus, dental, and pulmonary
Cataract formation
Hyperthermia
Decreased seizure threshold
You are in a single coverage ER near the Pacific
coast, you have a chamber, what will you do?
Asymptomatic healthy 23 yo m...
HACE / Altitude
Sickness
HAPE
Traumatic Cerebral
Edema
HOT in severe sepsis
Human shrinking??!?
Very useful tool, but costly and limited
indications
P1 – O2 diffused in plasma
P2 – increased partial pressure of dissolv...
BrubakkA, Neuman T. Bennett and Elliot’s Physiology and Medicine of Diving. 5th
edition. Great Britain. Elseiver Science L...
For a Bentley’s gift card…
What does SCUBA stand for?
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
Hyperbaric oxygen therapy   elsbecker
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Hyperbaric oxygen therapy elsbecker

  1. 1. Steven Elsbecker D.O. University of Nevada School of Medicine January 18th 2012
  2. 2. 45 year old male with toe pain secondary to gout presents to your ED. While establishing IV access, the nurse forgets to flush the IV tubing and the 10ft extension tubing that she decided to use forcing a large quantity of air into your patient’s vein. He quickly becomes short of breath with concurrent drop in O2 sats Diagnosis? Treatment?
  3. 3. Steven Elsbecker D.O. / Troy Aikman / Duffman University of Nevada School of Medicine January 18th 2012
  4. 4. Review our dive facility and procedures Physics of Hyperbaric Oxygen Therapy (HOT) Physiology of HOT Indications Review basic principles for using HOT Disadvantages / Complications Evidence for use in EM To get ONE resident to implement HOT ONE time in 2012
  5. 5. First hyperbaric chamber built in 1662 by British clergyman Nathaniel Henshaw Compressed manually with a bellows using room air and did not reach pressures that had any clinical significance Up until 1955, much of hyperbarics remained “of little clinical significance”
  6. 6. In 1967, the Undersea and Hyperbaric Medicine Society (UHMS) was founded to help facilitate the exchange of knowledge in the field Eventually became the governing body for the application of HOT
  7. 7. Two types of chambers Monoplace Just patient inside. Desired gas delivered to whole chamber Multiplace Can treat multiple critical patients at once. Nurse typically inside. Desired gas mixture given to patients individually.
  8. 8. Duration is variable depending on indication Pressurized to 2.0 – 2.2 ATA FiO2 between 21 – 100% Nurse in chamber with patients Plasma TV with cable in the tank
  9. 9. Average bill generated for a single dive = $2600 Average repayment from Medicare is $360 Average number of dives required for a chronic wound is 30 $78,000 for a diabetic foot ulcer Just CUT IT OFF!!!
  10. 10. A neutron walks into Frankie’s and says “how much for a Fink Bomb?” The bartender replies “for you, no charge.” Boyle’s Law Charles’ Law Henry’s Law Ideal Gas Law
  11. 11. p1v1=p2v2 Useful when thinking about gas embolic phenomenon, DCS
  12. 12. (p1v1)/T1=(p2v2) /T2 Used to explain temperature changes when compressing or decompressing patients.
  13. 13. P=KhC Higher concentrations of a gas dissolved in blood will yield a higher partial pressure. Diffusion Wound healing, DCS, CO poisoning
  14. 14. Hyperoxygenation Fibroblast proliferation Decreases gas bubble load Vasoconstriction Angiogenesis Enhances leukocyte oxidative killing Inhibition of Clostridial toxins Antibiotic synergy
  15. 15. Hb saturation on room air 97-100% Also have small amount of O2 dissolved in plasma Human tissue at rest requires approximately 250ml/min of O2 At 3atms, plasma concentration of O2 rises from 0.5 – 1.0 ml/dl to 6 ml/dl
  16. 16. Main physiologic force behind healing complex wounds More “healing” cells Larger matrix to rebuild upon Hunt TK, {ai MP, et al. The effect of varying ambient oxygen tensions on wound metabolismand collagen synthesis. Surg Gynecol Obstet. Oct 1972; 135(4):
  17. 17. Poorly understood mechanism of action Only ever studied in rats / mice Important for complex wounds and compromised grafts. Limited applicability to EM Knighton DR, Silver IA, Hunt TK, Regulation of wound healing angiogenesis-effect of oxygen gradients and inspired oxygen concentrations. Surgery. Aug 1981;
  18. 18. Boyle’s Law patmvatm = pHOTvHOT As partial pressures in plasma increase, Boyles law states that the volume of undissolved gasses must decrease
  19. 19. Tina McProzac, a 35 yo pregnant female with known history of bipolar disorder and SI is brought in by EMS for AMS. She was found in her home after police were called by a neighbor for her odd behavior. The patient is unresponsive, but hemodynamically stable. Basic AMS labs drawn at UMC are WNL. The female medical student rotating at UMC then comments on the patients beautiful shade of red lipstick. At what CO-Hb level should you dive these patients? Are there other indications for diving them?
  20. 20. Hyperoxemia leads to vasoconstriction O2 delivery(ml/min) = O2 carry(ml/dl) x Flow (dl/min) No change in net O2 delivery Decreased edema Nylander G, Lewis D, Nordstrom H, et al. Reduction of postischemic edema with hyperbaric oxygen. Plast Reconstr Surg. Oct 1985; 76 (4): 596-603
  21. 21. Enhances SOD Augments oxidative destruction of phagocytosed bacteria
  22. 22. Slows progression of necrotizing fasciitis Limited use Conservative management Waiting for surgeon Awaiting transfer for higher level of care No studies to date on HOT in the setting of severe C. diff infection
  23. 23. Generation of free radicals assists in bacterial killing Very limited studies done on HOT in the setting of sepsis. Again, only rat models available. Showed good outcomes. Hill GB: Hyperbaric oxygen exposures for intrahepatic abscesses produced in mice by non–spore-forming anaerobic bacteria. Antimicrob Agents Chemother 1976; 9:312-317.
  24. 24. Who named the following gas law: p1v1=p2v2 Robert Boyle Ross Berkeley Jacques Charles Amedeo Avogardo
  25. 25. Acute CO poisoning Decompression Sickness Gas Embolism Necrotizing Fasciitis Acute Traumatic Peripheral Ischemia Crush Injuries Acute Peripheral Arterial Insufficiency Preservation of Skin Grafts Refractory Osteomyelitis Radionecrosis Cyanide Poisoning Actinomycosis Diabetic Wounds of the Lower Extremeties Acute Thermal Burns
  26. 26. Acute CO Poisoning Decompression Sickness Gas Embolus Crush Injury / Compartment Syndrome Central Retinal Artery Occlusion Acute Thermal Burns
  27. 27. HOT not always indicated Treatment indicated for CNS depression, severe acidosis, CO-Hb > 20% or >10% in pregnant females Time to displace CO from Hb with room air, 100% NRB, and HOT is 300 minutes, 90 minutes, and 32 minutes respectively Halts lipid peroxidation by restoring cytochrome function
  28. 28. Hyperbaric oxygen is used to DIFFUSE more O2 into plasma. Increases total oxygen dissolved in plasma from 0.5 – 1.0 ml/dl up to 6ml/dl O2 Content = 1.34 (HgB) (% Saturation) + PO2 (.003) 1.34 x 14 x 1.0 (18.76) + 760 x 3 x 0.003 (6.84) Pigs
  29. 29. How many divers does it take to circumcise a blue whale? Four Skin Divers
  30. 30. As partial pressure of O2 and N2 decrease in plasma, N2 and O2 dissolved in the tissues diffuse back into the bloodstream Severity depends on total amount of gas dissolved in tissue and rapidity of ascent Why Hyperbarics staff and SCUBA dive masters have a limited number of allowable dives per day
  31. 31. Breath Hold Divers? Snorkelers? Recirculating Tanks? SCUBA?
  32. 32. Type I – musculoskeletal sxs, fatigue Type II – CNS and cardiorespiratory depression, shock Type III – any spinal deficit, usually irreversible Sxs 2/2 to bubble formation in vasculature leading to micro infarcts. BrubakkA, Neuman T. Bennett and Elliot’s Physiology and Medicine of Diving. 5th edition. Great Britain. Elseiver Science Limited; 2003;Chapter 10
  33. 33. Increasing the partial pressure of dissolved gasses in plasma will decrease the volume load of undissolved gasses. Balloon in a room Gas Emboli and DCS
  34. 34. Rare, but very little treatment options Nursing error IJ Central line not in Trendelenburg DCS Pulmonary barotrauma Vascular surgery No absolute amount of gas needed. Dependent on patient comorbidities and rapidity of buildup
  35. 35. Both have a myriad of complications Edema is controllable with HOT without compromise of O2 delivery Decreases reperfusion injury Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed.; CHAPTER 79
  36. 36. Hyperoxemia causes vasoconstriction and decreases edema Proven efficacy with compartment and crush Many types of edema, possibility of future indications
  37. 37. Sudden onset painless monocular visual loss Theory for HOT is that the small amount of blood still getting to the retina can be hyperoxigenated Needs to be initiated within first 8 hours for greatest efficacy Visual improvement with HOT 82% vs 30% w/o Beiran I, Goldberg I, Adir Y, Tamir A, Shupak A, Miller B, et al. Early hyperbaric oxygen therapy for retinal artery occlusion. Eur J Opthamol. Oct-Dec 2001;11(4):345-50 Hertzog LM, Meyer GW, Carson S, et al. Central retinal artery occlusion treated with hyperbaric oxygen. J Hyperbaric Medicine. 1992;7:33-42
  38. 38. HOT reduces inflammatory response, reduces edema, and is protective against severe superimposed infection. 2/2 to vasoconstrictive, improved wound healing, and bacteriostatic/bacteriocidal properties. Hart GB, O’Reiley RR, Broussard ND, et al. Treatment of burns with hyperbaric oxygen. Surg Gynecol Obstet. Nov 1974; 139(5) 693-6 Niezgoda JA, Cianci P, Folden BW, et al. The effect of hyperbaric oxygen therapy on a burn wound model in human volunteers. Plast Reconstr Surg. May 1997; 99(6). 1620-5
  39. 39. Concept useful in DCS, air embolism, PTX The use of HOT or a NRB yields oxygen rich, nitrogen poor plasma. The pockets of gas in the aformentioned scenarios are mostly comprised of notrogen. Larger gradient leads to quicker reabsorption of gas pockets
  40. 40. Absolute PNEUMOTHORAX Disulfiram Chemotherapeutic Agents Relative Asthma Claustrophobia COPD Spherocytosis High Fever Pacemaker/ AICD Pregnancy (no eveidence showing harm)
  41. 41. Barotrauma Middle ear, Sinus, dental, and pulmonary Cataract formation Hyperthermia Decreased seizure threshold
  42. 42. You are in a single coverage ER near the Pacific coast, you have a chamber, what will you do? Asymptomatic healthy 23 yo male pulled from a house fire with no burns 45 yo male returning from SCUBA trip with decreased CNS fxn and generalized weakness 33 yo male with nec fasc and a surgeon who says “this doesn’t need surgery” 55 yo female frequent flyer with chronic pain asking for “the one that starts with a D” 24 yo male construction worker with radial and ulnar fxs who is complaining of increasing pain, parasthesias, and his hand feeling cold
  43. 43. HACE / Altitude Sickness HAPE Traumatic Cerebral Edema HOT in severe sepsis Human shrinking??!?
  44. 44. Very useful tool, but costly and limited indications P1 – O2 diffused in plasma P2 – increased partial pressure of dissolved gasses yield smaller volumes of undissolved gasses P3 – hyperoxemia leads to decreased edema Be aware that as you practice in different areas, the common reasons for using HOT may change depending on your surroundings
  45. 45. BrubakkA, Neuman T. Bennett and Elliot’s Physiology and Medicine of Diving. 5th edition. Great Britain. Elseiver Science Limited; 2003;Chapter 10 Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed.; CHAPTER 79 Beiran I, Goldberg I, Adir Y, Tamir A, Shupak A, Miller B, et al. Early hyperbaric oxygen therapy for retinal artery occlusion. Eur J Opthamol. Oct-Dec 2001;11(4):345-50 Hertzog LM, Meyer GW, Carson S, et al. Central retinal artery occlusion treated with hyperbaric oxygen. J Hyperbaric Medicine. 1992;7:33-42 Hart GB, O’Reiley RR, Broussard ND, et al. Treatment of burns with hyperbaric oxygen. Surg Gynecol Obstet. Nov 1974; 139(5) 693-6 Niezgoda JA, Cianci P, Folden BW, et al. The effect of hyperbaric oxygen therapy on a burn wound model in human volunteers. Plast Reconstr Surg. May 1997; 99(6). 1620-5 Latham E, Hare M, Neumeister, et al. Hyperbaric Oxygen Therapy. Emedicine specialties. May 2010. Auerbach: Wilderness Medicine. 6th edition. Chapters 75,77,78.
  46. 46. For a Bentley’s gift card… What does SCUBA stand for?
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