DECOMPRESSION SICKNESS AND GAS

EMBOLISM
Mohammad Guritno SURYOKUSUMO
Ketua Minatan Kedokteran Hiperbarik
Program Pascasarjana Fakultas Kedokteran
Unversitas Indonesia, Jakarta
email: mguritno@yahoo.com

DECOMPRESSION SICKNESS
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.

ARTERIAL GAS EMBOLISM

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.

Terminology and Classification

The differentiation between illness and sickness

Decompression iIlness (DCI) or Dysbaric illness (DI) is an

inclusive term that encompasses either or both DCS and
AGE.

Various clinical terms have emerged in an ongoing effort to

describe and classify DI.

Clinical syndromes (e.g., the bends, chokes and

staggers)

A presumptive assignment of etiology and severity (e.g.,

type I decompression sickness and arterial gas embolism)

The systematic capture of descriptive clinical and causal

factors associated with the condition (e.g., decompression
illness or dysbarism, and gas bubble illness).

Dilemma & Future Classification Systems

The present trend is towards developing clearly defined
case definitions for DCS, AGE and combined forms.
The dilemma in developing these is that there is
disparity between epidemiological and clinical
objectives.
The ECHM has recommended the development and
acceptance of such an epidemiological classification
system which will allow multi-center, multinational,
retrospective analyses derived from broad-based
classifications that include the type of diving,
chronological data, clinical manifestations and outcome
of a two-year follow up for prognostic purposes.

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

Arterial Gas Embolism
Decompression Sickness
1. Type I : Musculoskeletal Pain; Skin;
Lymphatic; Extreme
Fatigue;
Peripheral Nervous
Symptoms
2. Type II : Neurologic;
Cardiorespiratory;
Audio-vestibular; Shock
3. Type III : Combined Decompression
Sickness
and Arterial Gas Embolism

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:
oTime before surfacing
oTime after surfacing (or estimate)

Gas Burden
o Low (e.g., within NDL)
o Medium (e.g., Decompression Dive)
oHigh (e.g., Violation of Dive Table)

Evidence of Barotrauma
o Pulmonary (Yes / No)
o Ears
oSinuses

Other Comments

The ICD-10 Classification

The ICD-10 codes most frequently used
are:
oT70 (Effects of air pressure and water pressure)
oT70.0 (Otitic barotrauma)
oT70.1 (Sinus barotrauma)
oT70.3 (Caissons disease)
oT70.4 (Effects of high-pressure fluids)
oT70.8 (Other effects of air pressure and water pressure)
oT79.0 (Traumatic air embolism)
oT79.7 (Traumatic subcutaneous emphysema)
oM90.3 (Osteonecrosis in caisson disease T70.3+)

Clinical Setting
1. Diving
2. Flying
3. HBOT

PATHOGENESIS OF DCS
General Aspect :
Most of the clinical manifestations of DCS are
thought to result from tissue distortion of vascular
obstruction produced by bubbles

Denaturation of Plasma Proteins

Endothelial Damage
Interaction of Bubbles with the Blood
Coagulation System

Frequency of Various Symptoms of DCS

Presenting Symptoms
Local Pain
Arm
Leg
Vertigo (staggers)
Paralysis
Shortness of breath (chokes)
Extreme fatigue with pain
Collapse + unconsciousness

Type
Type I

Type 2

Cases (%)
89
30
70
5.3
2.3
1.6
1.3
0.5

Classification of initial and of all eventual manifestations of decompression illness in

2346 recreational diving accidents reported to the Divers Alert Network from 1998 to
2004 Classification of initial and of all eventual manifestations of decompression illness
in 2346 recreational diving accidents reported to the Divers Alert Network from 1998 to
2004 Richard D Vann, Frank K Butler, Simon J Mitchell, Richard E Moon Richard D Vann, Frank K

Elliott DH and Moon RE. Manifestations of the decompression

disorders. In: The Physiology and Medicine of Diving (4th ed.), edited
by Bennett PB and Elliott DH. London: W. B. Saunders, 1993, p.
481505.

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 inspred Gas
Age
Ingestion of Alcohol
Dehydration
Fatigue

Treatment of DCS
Pre-Recompression

Oxygen 15 L/M with reservoir mask or demand valve

Patient in supine position (not head down)
Continuous monitoring
Air transport :

As low as safely possible.

Preferably lower than 1000 ft
Pressurize aircraft cabin to 1 ATA if possible
Consider Emergency Evacuation Hyperbaric Stretcher
Recompress even if signs/symptoms resolve prior to
recompression

Treatment of DCS
Initial Recompression for DCS
The USN Diving Manual treatment algorithms remain the gold standard for
initial recompression of diving-related DCI. The use of alternate tables should
be reserved for trained personnel at facilities with the expertise and hardware to
deal with untoward/unexpected responses to therapy.

Surface oxygen is not a substitute for hyperbaric therapy in diving related DCI.
However, surface oxygen alone can be considered if symptoms are mild and
have been stable for 24 hours, neurological examination is normal, and
evacuation of the patient cannot readily be achieved or is associated with some
risk (3).

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

Recurrence of Serious Symptoms

during Decompression

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

Recurrence of Serious Symptoms

during Decompression

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 PREVENTION
1. Diver Selection
. Screening for Patent Foramen Ovale (PFO)
. History of DCS Disqualifying for diving duty
. Deselection of divers for repeated episodes of DCS Not
recommended

2. Pre-Dive DCS Prevention

. Pre-dive exercise, 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 (onsite 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
Small emboli in the vessels of
the skeletal muscles or
viscera are well tolerated, but
embolization to the cerebral
(CAGE) or coronary circulation
may result in severe

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

Summary
Clinical diagnosis
A sudden loss of consciousness or
hemodynamic collapse during or
immediately after any invasive
procedure may indicate gas embolism
HBOT is treatment of choice for AGE or
VGE with paradoxical embolism

GAS EMBOLISM (GE)

Gas Embolism (GE) refers to all
pathological events related to the entry or
the occurrence of gas bubbles in the
vascular

Two categories
1.Venous gas
embolism (VGE)
2.Arterial gas
embolism (AGE)

Causes of VGE
1. Surgical Procedures
2. Iatrogenic creation of a pressure
gradient for air entry
3. Mechanical insufflation or infusion
4. Positive pressure ventilation
5. Blunt and penetrating trauma to
the chest, abdomen, neck and
face

Causes of AGE
Pulmonary barotrauma
Iatrogenic events (radiologic
procedures and cardiac bypass
surgery)
Right-to-left shunt
Small emboli in the vessels of
the skeletal muscles or
viscera are well tolerated, but
embolization to the cerebral
(CAGE) or coronarycirculation
may result in severe