Hyperbarics 2 CEUs By: Michelle E. Duffelmeyer, MD. Co-author: Ellen Smithline, RN. Objectives

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1 Hyperbarics 2 CEUs By: Michelle E. Duffelmeyer, MD Co-author: Ellen Smithline, RN Objectives By the end of this lecture, the participant should be able to Describe the basic principles that explain the effects of air pressure on gases - Boyle's Law, Dalton's Law, Henry's Law 2. Describe the spectrum of diving injuries including injuries on water's surface, injuries during descent, injuries on the bottom and during ascent 3. Explain the management of diving emergencies in general 4. Describe specific treatment plans for the most serious diving emergencies - decompression illness, pulmonary over-pressure accidents, arterial gas embolism, pneumomediastinum, pneumothorax and nitrogen narcosis 5. Explain the basics of hyperbaric oxygen therapy 6. Be familiar with the Divers Alert Network SCUBA SCUBA diving is a popular recreational sport. More than 250,000 new divers are certified annually. SCUBA is an abbreviation for Self-Contained Underwater Breathing Apparatus. With more and more inexperienced divers, the risk increases for diving emergencies. 1. Kizer, K. Diving medicine. Emergency Med Clin North Am. 1984; 2: Mechanical Effects of Pressure on Gases To understand how dive injuries occur is it essential to understand 3 physical laws that explain the effects of pressure on gases.

2 Boyle's Law The volume of gas in an enclosed space is inversely proportional to the pressure exerted on it. In effect, as pressure increases, volume decreases. An example would be a balloon. If a balloon were inside a chamber, as pressure increases the volume of the balloon decreases. Deflating the balloon. As the pressure inside the chamber decreases, the balloon size would expand, and the volume would increase. 1. Tibbles, P., & Edelsberg, J. S. (1996). Hyperbaric-Oxygen Therapy. New Eng J Med, 334, (25). How Boyle's Law applies to seawater In thinking about SCUBA diving emergencies, realize that saltwater has a density and this density can be equated to pressure. As a diver goes deeper and deeper the pressure increases. As Boyle's Law states, the volume of air is therefore compressed. At 66 feet underwater, one liter of air would be compressed to 333-1/3rd ml. 1. Richardson, D. (1999). Open Water Diver Manual PADI. Santa Margarita, CA: International PADI, Inc. Dalton's Law The total pressure of a mixture of gases is equal to the sum of the partial pressure of the individual gases. Henry's Law Henry's Law states that the amount of gas dissolved in a given volume of fluid is proportional to the pressure of the gas above it. This seems like high school physics all over again but this law has important implications for SCUBA divers. Lets review what happens to nitrogen and oxygen as a diver descends.

3 What happens to the nitrogen? As the diver descends, the nitrogen is dissolving in the blood and the tissues of the diver's body. When the diver now ascends toward the surface (sea level) again the gases that were dissolved are now under less pressure and come out of the blood and tissues. Pathophysiology of Dive Emergencies Now that you can understand the basic laws of physics and how they apply to gases under pressure, we can review what happens when a diver gets in trouble. Accidents can occur at all 4 stages of diving: 1. On the surface 2. During descent 3. On the bottom 4. During ascent Surface Injuries Boating accidents Entanglement of lines or in kelp beds Fatigue Cold injury producing shivering or blackout Marine life - sharks, eels, man-o-war

4 Injuries During Descent Barotrauma injuries occur at this phase of diving - "the squeeze." Barotrauma is injury due to the pressure. To equilibrate pressure between the middle ear and the nasopharynx, a diver needs a patent eustachian tube. Do not dive if you have an upper respiratory infection. 1. Richardson, D. (1999). Open Water Diver Manual PADI. Santa Margarita, CA: International PADI, Inc. Injuries at the Bottom While at the bottom, divers can be caught in the "raptures of the deep." This is really a description for nitrogen narcosis. o Nitrogen narcosis is a state of stupor that develops secondary to nitrogen's anesthetic effect on cerebral function. 2. Richardson, D. (1999). Open Water Diver Manual PADI. Santa Margarita, CA: International PADI, Inc. Injuries During Ascent Barotrauma can occur again during ascent as pressures are changing. Decompression illness or "the bends." Divers going below 40 feet are required to do a staged ascent to prevent the nitrogen from forming bubbles. If the ascent is too rapid, nitrogen will form bubbles causing severe pain especially in the abdomen and in the joints. This is the bends. Pulmonary over-pressure. Air compressed in the lungs expands and can rupture alveoli if not exhaled. This can happen if the diver holds his or her breath during ascent. Arterial gas embolism. An air bubble that enters the blood stream from a damaged lung. Pneumomediastinum. Air (gas) that ruptures through the pleura of the lungs into the center of the chest putting pressure on major vessels and the heart. Pneumothorax. Rupture of alveoli causing air (gas) to be in the space surrounding the lung placing pressure and collapsing the lung.

5 2. Rosen, P. et al. (1992). Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby- Year Book Inc. pp Management of Diving Emergencies History is critical. At what phase of diving did the injury occur? Timing of symptoms. When were symptoms first noted? This can help pinpoint whether the injury is related to ascent, descent, or at the bottom. Type of breathing equipment used. Garments warn. Is hypothermia an issue? Parameters of the dive The 3 D's 1. Depth 2. Dives 3. Duration. What was the depth of the dive, the number of dives, and the duration of the dive/s? Rate of ascent. Was panic a factor? Did that cause the ascent to be too rapid? Diver's experience Old injuries Medications Alcohol 2. Rosen, P. et al. (1992). Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby- Year Book Inc. pp

6 Decompression Illness "The Bends" Nitrogen bubbles collecting in the joints, tendons, inner ear, spinal cord, skin and brain cause decompression illness. It occurs 15 minutes to 12 hours after a dive. Decompression illness can come on gradually and persist or symptoms can be intermittent. Signs and Symptoms of Decompression Illness Abdominal pain Joint pain Fatigue Paresthesias Paralysis Shock Weakness Breathing difficulties 2. Richardson, D. (1999). Open Water Diver Manual PADI. Santa Margarita, CA: International PADI, Inc. Treatment of Decompression Illness Assess ABC's CPR if needed. 100% O2 by non-rebreather if conscious; otherwise intubate. Place patient in supine position. IV fluids - NS or Lactated Ringer's. IV fluid should be in collapsible plastic bags. No glass. (glass can break in the chamber) Any catheters should be filled with saline not air. Rapid transport to nearest ER or facility with hyperbaric oxygen chamber. The longer recompression therapy is delayed the higher the morbidity. If transported by un-pressurized helicopter, the pilot should fly as low as possible or cabin pressure should be maintained at sea level. Contact the Diver's Alert Network if unsure of the nearest location of a recompression chamber.

7 2. Rosen, P. et al. (1992). Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby- Year Book Inc. pp Arterial Gas Embolism (AGE) Arterial Gas Embolism (AGE) is caused by pressure building up in the lungs and subsequent alveoli rupture allowing an air bubble to enter the circulation. Once in the circulation, the air embolism can obstruct blood flow leading to ischemia, infarct and stroke. The onset can occur within 2 to 10 minutes of ascent. Signs and Symptoms of Arterial Gas Embolism Sharp tearing pain Focal neurological deficits Confusion Vertigo Loss of consciousness Visual disturbances 2. Rosen, P. et al. (1992). Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby- Year Book Inc. pp Treatment of AGE Treat AGE as with decompression illness. Place patient in lateral decubitus/trendelenburg position to minimize the chance the air embolism will go to the heart or brain.

8 Again, rapid transport to recompression chamber by pressurized aircraft or low altitude flying. 1. Rosen, P. et al. (1992). Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby- Year Book Inc. pp Treatment of Pneumomediastinum/pneumothorax 100% O2 via non-rebreather IV lactate Ringer's or normal saline Rapid transport Signs and Symptoms of Nitrogen Narcosis Altered levels of consciousness and impaired judgment are the classic symptoms. Treatment Simply return to shallow depth. This resolves on ascent. To avoid this problem in deep dives a mixture of oxygen and helium is used. Helium does not cause the anesthetic effect of nitrogen. 2. Richardson, D. (1999). Open Water Diver Manual PADI. Santa Margarita, CA: International PADI, Inc. Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy is defined as Breathing 100% oxygen intermittently while in a pressurized environment. It can be compared to scuba diving without the water.

9 Hyperbaric Oxygen Chambers Your facility can be equipped with either a monoplace or multiplace hyperbaric chamber. Monoplace chamber A monoplace chamber Is pressurized with 100% oxygen, not air. Size allows only one adult or possibly 2 children to occupy the chamber. Advantage is that it does not require a health care attendant (i.e.; physician, nurse, RRT, or EMT) to accompany the patient. Disadvantage is the there is no "hands on" contact. Multiplace chamber The multiplace chamber Pressurized with air. Patient breathes 100% oxygen via hood, mask, or endotracheal tube. Two or more patients, depending on the size of the chamber, plus a health care attendant can be treated at one time. Advantage - allows for a hands on ICU environment. Disadvantage -A full complement of staff is required. The attendants are exposed to a pressurized environment while accompanying the patient(s), therefore exposing them to a risk of decompression sickness. The number of monoplace chambers exceeds the number of multiplace chambers in the United States. Mechanism of Action Hyper-oxygenation: Remember, the patient breathes 100% oxygen while under pressure, therefore increasing the oxygen content of blood by increasing tissue oxygen tensions via the plasma and hemoglobin. Help produce small blood vessels known as capillaries. It can also act as an antibiotic against certain organisms that thrive on low oxygen levels. Thought to increases cell production quicker.

10 Mechanism of Action Continued Normal arterial oxygen (pao2) levels in the body are 80mmHg-100mmHg. HBO can allow the body to increase its oxygen uptake to a maximum of 2183mmHg during a treatment. This effect is used for indications such as carbon monoxide poisoning, cyanide poisoning, burns, severe anemia, gas gangrene, crush Injury, compartment syndrome, other acute traumatic Ischemia and adjunctive therapy for enhancement of healing in selected problem wounds. Hyperbaric Oxygen (HBO) Therapy is an ADJUNCTIVE treatment. Continue conventional therapy BCLS IV Debridement if indicated Wound care if indicated Acute Indications for Hyperbaric Oxygen Therapy Air or Gas Embolism Carbon Monoxide Poisoning and Smoke Inhalation Cyanide Poisoning Clostridial Myonecrosis (Gas Gangrene) Crush Injury, Compartment Syndrome and other Acute Traumatic Ischemia Decompression Sickness Air /Gas Embolism Acquired iatrogenically (in hospital) by Central line insertion O.R. procedure such as coronary arterial bypass graft Other procedures Also can occur with o Collapsed lung o Scuba diving o Swimming o Oral Sex

11 Effects of HBO on Air /Gas Embolism Decreases size of air/gas embolism as pressure increases in chamber Hyper oxygenate hypoxic tissues Carbon Monoxide (CO) Poisoning Product of incomplete combustion Can be produced by burning any fuel o Gasoline o Propane o Natural gas o Oil o Wood o Coal o CO (carboxyhemoglobin) levels build up in blood in relation to amount in air and time of exposure o A group of people in same area of exposure for same length of time can have varying levels and different presentation of symptoms Effects of HBO on Carbon Monoxide Levels Decrease the half-life of carboxyhemoglobin levels. This means faster clearing of carbon monoxide. Hyper-oxygenates hypoxic tissues Clostridial Myonecrosis (Gas Gangrene) A toxin that thrives in arterial levels of 300 mmhg or less Spreads 1-6 inches an hour Crush Injury, Compartment Syndrome and other Acute Traumatic Ischemia Acute insult to tissues leading to hypoxia caused by trauma and/or circumferential constriction of tissues Effects of HBO on Crush Injury, Compartment Syndrome and other Acute Traumatic Ischemia Hyper-oxygenate hypoxic tissues

12 Decompression Sickness Nitrogen bubble formation that can develop in areas such as blood stream, spinal fluid, joint areas, inner ear and others Found in SCUBA divers, attendants in the hyperbaric environment or High Altitude Flying Can occur even after the diver is out of the water, especially if flying within 12 hours of the dive Effects of HBO on Decompression Sickness Decreases size of air/gas embolism as pressure increases in chamber Hyper-oxygenate hypoxic tissues Transportation of Patient Can be transported by car, ambulance, helicopter, or plane UNLESS PATIENT IS DIAGNOSED WITH DECOMPRESSION SICKNESS OR AIR/GAS EMBOLISM! Increase in altitude will decrease barometric pressure therefore increasing bubble size and increasing symptoms Can only be transported in surface transportation, low altitude helicopter or in a pressurized aircraft which does not exceed a cabin atmosphere of 800 feet of altitude. Commercial airlines are not rated for transport since they exceed this cabin atmosphere. Hyperbaric Medicine Resources Divers Alert Network (DAN) A nonprofit organization associated with Duke University Medical Center that has ability to refer SCUBA divers and other people in need of a hyperbaric chamber facility. Dan's Diving Emergency Hotline can be reached 24 hours a day, 365 days a year at (919) 684-4DAN or you can call collect at (919) Undersea and Hyperbaric Medical Society (UHMS) Professional organization including physicians, nurses, respiratory therapist, divers and other groups Reviews scientific literature Recommends guidelines for use of HBOT Baromedical Nurses Association (BNA) Professional organization which includes nurses. Reviews scientific literature. Recommends nursing guidelines for use of HBOT.

13 Conclusion In conclusion, hyperbaric medicine is being utilized to help both improve and save lives of patients diagnosed with these diseases/conditions. As research continues in this field, advances will be made to understand more fully the potential of hyperbaric oxygen therapy. 1. Davis, JC and TK Hunt. Hyperbaric Oxygen Therapy. Undersea Medical Society, Bethesda, Kindwall, E. Hyperbaric Medicine Practice. Best Publishing Company, Flagstaff, Shilling, C and C Carlston, et all. The Physician's Guide to Diving Medicine. Undersea Hyperbaric Medical Society, Bethesda, Additional References 1. Davis, J. C. & Hunt, T. K. (1977). Hyperbaric Oxygen Therapy. Undersea Medical Society, Bethesda, MD. 2. Kindwall, E. (1994). Hyperbaric Medicine Practice Best Publishing Company, Flagstaff. 3. Shilling, C. & Carlston, C. (1984). The Physician's Guide to Diving Medicine. Undersea Hyperbaric Medical Society, Bethesda, MD. 4. Rosen, P. (1992). Emergency Medicine Concepts and Clinical Practice. Mosby Year Book, St. Louis, MO. 5. Richardson, D. (1999). Open Water Dive Manual. International PADI, Inc., Santa Margarita, CA. 6. Tibbles, P. & Edelsberg, J. S. (1996). Hyperbaric-Oxygen Therapy. New England Journal of Medicine, 334, An Overview of Hyperbaric Medicine. Patient Care, July 15, Ernst, A. & Zibrak, J. D. Carbon Monoxide Poisoning. New England Journal of Medicine, 339, Bledsoe, B. E., Porter, R. S. & Cherry, R. A. (2001). Paramedic Care: Priniples and Practice Medical Emergencies. Prentice-Hall Inc., Upper Saddle River, NJ. 10. Good Pressure: What you need to know about hyperbaric chambers. (November/December 1999). Alert Diver: The Magazine of Divers Alert Network.

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