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bends (Caisson disease, decompression disease)
Etiology:
- expansion of a gas that occurs because of changes in barometric pressure after ascent during scuba diving or deep tunnel work (origin of caisson)
- scuba diving [3]
- high risk patent foramen ovale increases risk of the bends [4]
Pathology:
1) arterial gas embolism
- inhaled compressed air under high pressures of scuba diving results in increased nitrogen & oxygen dissolved in blood
- the bends occurs when dissolved nitrogen forms bubbles in a diver's vasculature due to changes in pressure during ascent [4]
2) potentially lethal disorder
Clinical manifestations:
1) symptoms develop within 1 hour (75%, 90% within 12 hours) of surfacing
2) neurologic symptoms within minutes after surfacing
a) focal motor, sensory or visual deficits
b) unconsciousness
3) fatigue, malaise, headache, joint pain, pruritus, erythema
4) marbling over upper torso
5) focal pallor of the tongue
6) pulmonary
a) pneumothorax 10%
b) pneumomediastinum
c) hemoptysis
d) chest pain
e) interstitial emphysema (> 10%)
7) palpitations, arthralgias, vomiting (case report) [3]
8) violaceous skin mottling (cutis marmorata) [3] (image)
Laboratory:
- serum ALT, serum AST, serum creatine kinase, & serum lactate elevated
Radiology:
- abdominal CT not routine
- may show air in the portal venous system [3]
Complications:
1) damage to spinal cord (lumbar, thoracic) may progress to paraplegia, loss of sphincter control
2) CNS manifestations - memory loss, ataxia Differetial diagnosis:
- nitrogen narcosis
- confusion, poor judgement & or euphoria
Management:
1) hydration
2) oxygen 100%
3) place in left lateral decubitus position with mild Trendelenbug position
3) hyperbaric oxygen therapy
4) Divers should wait 12-48 hours before air travel.
General
barotrauma
References
- Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed)
Lippincott-Raven, Philadelphia, 1998, pg 764-65
- UpToDate 13.3
http://www.utdol.co
- Sun Q, Gao G
Decompression Sickness
N Engl J Med 2017; 377:1568. October 19, 2017
PMID: 29045210
http://www.nejm.org/doi/full/10.1056/NEJMicm1615505
- Lee HJ, Lim DS, Lee J et al.
Decompression illness in divers with or without patent foramen ovale:
A cohort study.
Ann Intern Med 2023 Jul; 176:934-939.
PMID: 37429031
https://www.acpjournals.org/doi/10.7326/M23-0260