Angeles University Foundation

School of Medicine
Decompression Sickness
By: Daryl S. Mangalino MD1B #13

OBJECTIVES

• At the end of this conference, the student must be able to:

1. Describe what Decompression sickness is
2. Enumerate the signs and symptoms Decompression sickness
3. Identify the cause and describe the pathophysiology of Decompression sickness
4. Identify the treatment for Decompression sickness

CASE STUDY

Subjective
• 30 year old patient
• Male
• CC: Pain in the left knee

History of Present Illness

• Pain presented three hours post surfacing after saturation dive
• Pain was insidious onset dull aching type on the medial aspect of the left knee
• Mild exacerbation on full extension
• Mild relief in semi-flexed position
• No radiating and referred pain

Physical Examination
• Heart Rate: 80/min
• Blood pressure 118/70 mmHg
• Temperature: 37°C

Pertinent PE Findings
• BMI 22.78

Work up
• Normal CBC
Assessment – Differential Diagnosis

RULE IN RULE OUT

Decompression Sickness Left knee pain
Type I History of Saturation dive
and past history of right
shoulder pain from wet
diving
Knee Sprain Left knee pain No swelling no deformity and
redness.
No radiation or referred
pain, nor involvement of any
other joint.
No history of definitive
trauma or physical exertion
Knee strain Left knee pain No swelling no deformity and
redness.
No radiation or referred
pain, nor involvement of any
other joint.
No history of definitive
trauma or physical exertion
Acute arthritis Left knee pain No swelling no deformity and
redness.
No radiation or referred
pain, nor involvement of any
other joint.
No history of definitive
trauma or physical exertion
Initial assessment: Decompression Sickness Type I

OVERVIEW

• DCS is caused by sudden ascent of a diver to the sea surface after being under for a long
period of time

• Acute DCS is a purely clinical diagnosis that requires a fair amount of clinical suspicion to
avoid missing cases. Most of the time the diagnostic yield is improvement with hyperbaric
oxygen (HBO) therapy. No specific tests exist for DCS. When diving is involved, consider
determining whether the patient has any pressure-related injuries. Obtain baseline
diagnostic studies, but these have no bearing on initial management. They may be useful
in the differential diagnosis while HBO therapy is administered, especially if there is no
 improvement with HBO. They may also be useful in expanding the knowledge base about
this disorder.

TYPES

• DCS TYPE I - usually characterized by musculoskeletal pain and mild cutaneous, or skin,
symptoms. Common Type 1 skin manifestations include itching and mild rashes (as distinct
from a clear mottled or marbled and sometimes raised discoloration of the skin — a
condition that is known as cutis marmorata that may presage the development of the more
serious symptoms of Type 2 DCS). Less common but still associated with Type 1 DCS is
obstruction of the lymphatic system, which can result in swelling and localized pain in the
tissues surrounding the lymph nodes — such as in the armpits, groin or behind the ears.

• DCS TYPE II - Type 2 symptoms are considered more serious. They typically fall into
three categories: neurological, inner ear and cardiopulmonary. Neurological symptoms
may include numbness; paresthesia, or an altered sensation, such as tingling; muscle
weakness; an impaired gait, or difficulty walking; problems with physical coordination or
bladder control; paralysis; or a change in mental status, such as confusion or lack of
alertness. Inner-ear symptoms may include ringing in the ears, known as "tinnitus";
hearing loss; vertigo or dizziness; nausea; vomiting; and impaired balance.
Cardiopulmonary symptoms, known commonly as "the chokes," include a dry cough;
chest pain behind the sternum, or breastbone; and breathing difficulty, also known as
"dyspnea." The respiratory complaints, which are typically due to high bubble loads in
the lungs, can compromise the lungs' ability to function — threatening the affected
diver's health, and even life, if treatment is not sought promptly.

PATHOPHYSIOLOGY

When a diver is exposed to an environment of elevated pressure, inert gases (nitrogen, for
example) accumulate in tissues. The deeper a dive is, the faster the body's absorption, or
"uptake," of such gases. When the diver ascends, the drive is reversed, and gas leaves tissues.
A diver's ascent must be controlled to allow for an orderly elimination, or "washout," of the
accumulated gas. A slow ascent, conducted either continuously or in stages, usually allows for
safe decompression, whereas a too rapid ascent following gas accumulation can sometimes
result in DCS.
 Boyles Law

Changes in pressure affect only compressible substances in the body. The human body is made
primarily of water, which is noncompressible; however, the gases of hollow spaces and viscous
organs, and those dissolved in the blood, are subject to pressure changes. Physical
characteristics of gases are described by the following four gas laws, which quantify the
physics and problems involved in descending under water.

Daltons Law

In a mixture of gases, the pressure exerted by any given gas is the same as the pressure the gas
would exert if it alone occupied the same volume. Thus, the ratio of gases does not change,
even though the overall pressure does. The individual partial pressures, however, change
proportionally.

Henry’s Law

At a constant temperature, the amount of gas that dissolves in a liquid with which it is in contact
is proportional to the partial pressure of that gas (ie, a gas diffuses across a gas-fluid interface
until the partial pressure is the same on both sides).

CLINCAL MANIFESTATIONS

Type I
• Musculoskeletal pain
• Mild cutaneous skin symptoms
-itching and mild rashes
*Cutis marmorata- clear mottled or marbled sometimes raised discoloration of the skin
Type II
• Neurological Symptoms
 Numbness
 Paresthesia
 Tingling and muscle weakness
 Impaired gait
 Problems with physical coordination
 Paralysis
 Confusion or lack of alertness
• Inner ear symptoms
 Tinnitus
 Hearing loss
 Impaired balance
 Nausea and vomiting
• Cardiopulmonary (the chokes)
 Dry cough
 Chest pain
 Dyspnea

DIAGNOSIS
• symptoms that occur following scuba diving need to be considered as possible
decompression sickness (DCS). Many times, the only way to assist with this
determination is a trial hyperbaric oxygen (HBO) recompression. However, some have
symptoms temporally linked to diving that ultimately are determined to be nondiving-
related issues. Doctors always consider DCS if the patient has a history of diving
because DCS is a high-profile diving injury because of its potential severity.

COMPLICATIONS
• Arterial Gas Embolism
• Immersion Pulmonary Edema

TREATMENT
• Care in the hospital
• Hyperbaric Chamber
• First aid oxygen