RISK FACTORS: Prolonged dive at depth over 33 feet, Obesity, Multiple, repetitive scuba dives, Cold water diving, Poor physical conditioning, Vigorous physical activity, Dehydration, Local injury, Patent foramen ovale
GENERAL MEASURES : SEND TO nearest hyperbaric facility for recompression test. The specific treatment may vary from institution to institution, but is based on the procedures first established in the Armed Services (e.g., US Navy Table 6). Patients may be sent home when cutaneous symptoms only are present, if the appropriate response to therapy is observed in the emergency department.
GENERAL MEASURES :
β’ 100% oxygen via tight nonbreathing mask
β’ Fluid resuscitation (avoid D5W or hypotonic IV solutions with cord injury). Despite the theoretical advantages
of volume expanders (dextran, albumin, etc.), no experimental or clinical studies support their use since they are not without risk.
β’ Rapid referral to hyperbaric chamber facility
β’ Position recumbent - not Trendelenburg
β’ Transport via ground, low-altitude airplane, or aircraft pressurized to sea level
ACTIVITY : Bedrest when neurologic involvement present
DRUG(S) OF CHOICE : 100% oxygen; diazepam 5-15 mg IV (IM absorption unpredictable) for inner ear decompression sickness. Symptoms of vertigo, nausea and vomiting may get signifi cant relief. The use of steroids has been advocated by some for the assumed vasogenic edema seen in decompression sickness. This form of therapy remains controversial and not proven in controlled clinical trials. If steroids are prescribed, they should not be used for more than 4-5 days for neurological symptoms.
ALTERNATIVE DRUGS :
. Adjunctive therapy:
. Digitalization for CHF/tachycardia
. Aminophylline NOT useful for chokes
. Roles of steroids and heparin not determined
PATIENT MONITORING : Symptomatic assessment for relapse/progression which occurs in 25%
PREVENTION/AVOIDANCE :
β’ Follow decompression tables (Navy, NAUI, PADI) for diving to depth (> 33 feet) or use dive computers that
calculate nitrogen content of various tissues
β’ Allow adequate time between diving and flying to altitude (24 hours)
POSSIBLE COMPLICATIONS :
β’ Oxygen toxicity with seizures (infrequent and unpredictable)
β’ Neurologic sequelae for non-responders
β’ Long-term risk of aseptic necrosis
EXPECTED COURSE/PROGNOSIS :
β’ Excellent for early symptomatic presentation, referral and treatment
β’ Related to duration and severity of symptoms prior to treatment
β’ Although recompression therapy is best administered early as possible, some patients may still benefi t even
at six to nine days after the incident, referral is critical, even if symptoms resolve, since 25% of patients will
relapse
OTHER NOTES :
β’ The diagnosis may be difficult due to the variable clinical manifestations. The most important clue is recent
decompression.
β’ 71% of nervous system decompression sickness present as skin or limb bends
β’ Limb bends with musculoskeletal complaints frequently diagnosed as malingering due to vague nature
β’ Only way to exclude the diagnosis in patient at risk is a negative test of pressure