A review of decompression sickness and arterial gas embolism

Accuracy of a SET of Screening Parameters Developed for the Diagnosis of Arterial Gas Embolism: The SANDHOG Criteria

BACKGROUND

Arterial gas embolism (AGE) is a major cause of morbidity and mortality in self-contained underwater breathing apparatus (SCUBA) diving and certain medical procedures. There are currently no well-defined criteria to diagnose AGE. Emergency physicians often find themselves facing a decision whether or not a patient with dive-related symptoms has an AGE and needs to be transferred to a hyperbaric facility.

OBJECTIVES

The objective of this study was to test the accuracy of diagnostic criteria developed by the San Diego Hyperbaric Oxygen Group (SANDHOG) for the diagnosis of AGE.

METHODS

This was a retrospective review of consultations completed by the Hyperbaric Medicine Department (HBO) at the University of California San Diego where the diagnosis of AGE was considered. HBO staff blinded to the purpose of the study identified potential cases of AGE. The criterion standard was the final diagnosis by a panel of HBO specialists also blinded to the purpose of this study. Descriptive statistics and comparisons evaluating SANDHOG criteria compared to the criterion standard were performed.

RESULTS

Twenty-six patients were identified for inclusion. Twenty-three of 26 (88%) were SCUBA divers, 2 had intravascular gas injections, and 1 patient had a military training chamber accident. Nineteen of 26 (73%) patients were diagnosed with AGE. A SANDHOG score of 2 had 94.7% sensitivity (95% confidence interval [CI] 71.9-99.7), 85.7% specificity (95% CI 42.0-99.2), positive likelihood ratio of 6.6 (95% CI 1.1-40.8), and negative likelihood ratio of 0.06 (95% CI 0.01-0.43) for AGE. A SANDHOG score <2 had a negative predictive value of 100% for AGE.

CONCLUSION

The SANDHOG criteria appear to be reliable in diagnosing AGE. AGE is unlikely with SANDHOG scores <2, whereas SANDHOG scores ≥2 resulted in high sensitivity and specificity for AGE. Emergency physicians may find this tool useful in evaluating patients for suspected AGE, and it may assist in determining whether to transfer the patient to a hyperbaric facility. Future studies should be performed to further examine and validate the accuracy and inter-rater reliability of this tool.

Environmental insults: smoke inhalation, submersion, diving, and high altitude

In the expanding search for recreation, we spend more and more of our time in various environments. Whether the air is thin or compressed or smoke-filled or there is no air at all, emergency physicians continue to meet and treat the various pulmonary emergencies that the environment may create. The authors present the background, diagnosis, and management of a few of the more common pulmonary emergencies that the environment may produce.

Decompression illness in divers: a review of the literature

BACKGROUND

Neurologists may be consulted to diagnose and treat the severe neurologic injuries that can occur in divers with decompression illness (DCI).

REVIEW SUMMARY

Subclinical bubbles form during normal diving activity. DCI, a diffuse and multifocal process, results when bubbles cause symptoms by exerting mass effect in tissues, or obstructing venous or arterial flow. The lower thoracic spinal cord is a commonly affected area of the central nervous system. The most commonly described form of brain DCI is cerebral arterial gas embolism with middle cerebral artery or vertebrobasilar distribution involvement. Bubbles exert secondary damage to the vascular endothelium, causing activation of numerous biochemical cascades.

CONCLUSIONS

Divers can develop DCI on very short dives or in shallow water, even when adhering to protocols. DCI should be strongly considered when divers experience pain after diving. Any neurologic symptoms after a dive are abnormal and should be attributed to DCI. Even doubtful cases should be treated immediately with hyperbaric oxygen (HBO), after a chest x-ray to rule out pneumothorax. The Divers Alert Network should be contacted for emergency consultation. Delay to treatment can worsen outcome; however, the overwhelming majority of divers respond to HBO even days to weeks after injury. Although DCI is a clinical diagnosis, magnetic resonance imaging, somatosensory evoked potentials, single-photon emission tomography, and neuropsychologic testing help to document disease and monitor response to therapy. Divers should be treated with HBO until they reach a clinical plateau. Complete relief of symptoms occurs in 50% to 70% of divers; 30% have partial relief.

Diving and marine medicine review part II: diving diseases

Diving is a high-risk sport. There are approximately between 1 to 3 million recreational scuba divers in the USA (with over a quarter-million learning scuba annually); there are about 1 million in Europe and over 50,000 in the United Kingdom. In this population 3-9 deaths/100,000 occur annually in the US alone, and those surviving diving injuries far exceeds this. Diving morbidity can be from near-drowning, from gas bubbles, from barotrauma or from environmental hazards. In reality, the most common cause of death in divers is drowning (60%), followed by pulmonary-related illnesses. The mean number of annual diving fatalities in the USA from 1970 to 1993 was 103.5 (sd 24.0) and the median was 106. This article will focus primarily upon pressure effects on the health of a diver. There are two principle ways pressure can affect us: by direct mechanical effects and by changing the partial pressures of inspired gases. Dysbarism is a general term used to describe pathology from altered environmental pressure, and has two main forms: barotrauma from the uncontrolled expansion of gas within gas-filled body compartments and decompression sickness from too rapid a return to atmospheric pressure after breathing air under increased pressures. Greater than 90% of the human body is either water or bone, which is incompressible; the areas directly affected by pressure changes thus are those that are filled with air or gas. These sites include the middle ear, the eustachian tube, the sinuses, the thorax, and the gastrointestinal tract. Air in these cavities is compressed when the ambient pressure rises because the pressure of inhaled air must equilibrate with the ambient pressure.