Ketua Program Studi Kedokteran Hiperbarik Program Pascasarjana Fakultas Kedokteran Unversitas Indonesia, Jakarta email: mguritno@yahoo.com DLCCMkLSSICN SICkNLSS 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. Ak1LkIAL GAS LM8CLISM 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. 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 Arter|a| Gas Lmbo||sm Decompress|on S|ckness 1. 1ype I : Muscu|oske|eta| a|n, Sk|n, Lymphanc, Lxtreme Iangue, er|phera| Nervous Symptoms 2. 1ype II : Neuro|og|c, Card|oresp|ratory, Aud|o-vesnbu|ar, Shock 3. 1ype III : Comb|ned Decompress|on S|ckness and Arter|a| Gas Lmbo||sm 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 (Caissons 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 Denaturation of Plasma Proteins Endothelial Damage Interaction of Bubbles with the Blood Coagulation System General Aspect : Most of the clinical manifestations of DCS are thought to result from tissue distortion of vascular obstruction produced by bubbles Presenting Symptoms Type Cases (%)
Local Pain Arm Leg
Vertigo (staggers) Paralysis Shortness of breath (chokes) Extreme fatigue with pain Collapse + unconsciousness
Type I
Type 2
89 30 70
5.3 2.3 1.6 1.3 0.5 Frequency of Various Symptoms of DCS 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 inspired Gas Age Ingestion of Alcohol Dehydration Fatigue 1reatment of DCS re-kecompress|on Cxygen 13 L/M wlLh reservolr mask or demand valve auenL ln suplne posluon (noL head down) Conunuous monlLorlng Alr LransporL : As low as safely posslble. referably lower Lhan 1000 ressurlze alrcra cabln Lo 1 A1A lf posslble Conslder Lmergency Lvacuauon Pyperbarlc SLreLcher 8ecompress even lf slgns/sympLoms resolve prlor Lo recompresslon Treatment of DCS Type I Treatment Table 5 (TT5) Musculoskeletal pain Skin bends Lymphatic bends Type II Treatment Table 6 (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 kecurrence of Ser|ous Symptoms dur|ng Decompress|on 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 kecurrence of Ser|ous Symptoms dur|ng Decompress|on 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 rebreather 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 kLVLN1ICN 1. D|ver Se|ecnon Screening for Patent Foramen Ovale (PFO) History of DCS Disqualifying for diving duty Deselection of divers for repeated episodes of DCS Not recommended
2. re-D|ve DCS revennon re-dlve exerclse, 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
Sma|| embo|| |n the vesse|s of the ske|eta| musc|es or v|scera are we|| to|erated, but embo||zanon to the cerebra| (CAGL) or coronary c|rcu|anon may resu|t |n severe morb|d|ty 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 1er|makas|h