A review article of Decompression Sickness.pdf PDF

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Summary

. DCS also known as Caisson disease or the bends, it is caused by several different factors as sited in this article review. This sickness was also classified into two according to its symptoms; the DCS type I or the less severe and DCS type II the severe type of decompression sickness. Risk factors...

Description

. DCS also known as Caisson disease or the bends, it is caused by several different factors as sited in this article review. This sickness was also classified into two according to its symptoms; the DCS type I or the less severe and DCS type II the severe type of decompression sickness. Risk factors must be observe to avoid this kind of ailment. Several research has been conducted for better understanding of DCS and for developing treatment for this sickness.

Christina L. Javier B.S Biology

3rd year

Subtopics I.

Introduction and History

II. Epidemiology

III. Classification

IV. Causes

V. Signs and symptoms

VI. Pre deposing factors

VII. Mechanism

VIII.

Diagnosis

IX. Prevention

X. Treatment

XI. Prognosis

XII. Conclusion

I.

INTRODUCTION This review article was made to discuss what decompression sickness is,

when and where this illness starts, how it occurs and who is likely to have this kind of sickness. Different references were collected and extracted its important part.

What is decompression sickness? According to Naval Safety Center, decompression sickness also known as caisson disease or the bends is a disorder in which nitrogen dissolved in the blood and tissues by high pressure forms bubbles as pressures decreases (Leo, 2013). Decompression Sickness begins with the formation and the size of extravascular and the intravascular bubbles were increased then the sum of the dissolved gas tension such oxygen, carbon dioxide, nitrogen and helium then water vapours exceeds its local absolute pressure (Vann, 2010). Sickness is cause by several different factors such as dive time, dive depth, surfacing method, diving too long and diving too quickly. This illness may affect variety of organs and can range from mild to severe. It can occurs in divers, compressed air workers, aviators and astronauts.

Where and when decompression sickness begin? Humans are engaged in free diving since 4500 BCE to search for their foods. To survive, many of humans before are just depending on oceans, rivers, and seas to obtain food and some materials such as sponges, pearls and corals. Because of this, few of them are engaging in deep diving at 100 feet depth or much deeper (Nestor, 2014).

The table on the next page represents the significant events in the history of decompression sickness and cerebral arterial gas embolism (Acott, 1999).

Early history

Archaeological evidences in some part 4,500 – 3,200 BC

of Pacific, Atlantic and Indian oceans, shows an ancient free diving cultures.

Divers were used for strategic purpose. 1,194 – 1,184 BC

Breathe hold divers involved in Trojan War wherein they cut the anchor ropes or boring holes in the hull to sabotage the ships of their enemy.

Early swimmers/divers used an air filled 900 BC

balloon to serve as a device

for

buoyancy. This buoyancy device is from the palace of King Assur -Nasir Pal.

Aristotle made a reed snorkel that allows 350 BC

the divers to breathe while head is underwater

and

has

been

throughout the history until now.

used

According

to

the

book

I’ve

read,

Alexander the Great was trained by Aristotle and they claimed that Aristotle requested Alexander the Great to drop 356 – 323 BC

him into the sea in a glass barrel, so that he can explore under water. Alexander the Great made used of diving bell called “Colimphax”. Aristotle described this bell as an upside down kettle filled with air.

Siege of Syracuse was made by the 215 – 212 BC

Greek divers to construct underwater defensive obstacle .

168 BC

Commercial

diving

starts

in

Mediterranean harbors.

Renaissance diving equipment

1450

A diving device that is similar to horses’ nosebag by Mariano Taccola.

Leonardo Da Vinci sketched several 1500 s

underwater aids and inventions but none of its designs were established.

Enlightenment Age

A new diving bell was designed by Franz Kessler. This new equipment has an internal framework where it serves 1616

as a diver seat and it contains series of tiny ports. Kessler’s invention was negatively buoyant so divers can walk on a sea bed.

1620

First

submarine

was

invented

by

Cornelius Drebbel.

Pascal 1649

principle

was

published.

Principle state that the pressure applied is equal to the liquid will be transmitted.

Henshaw used 1662

Domicilium that

is

pressurized by a large pair of bellows to treat medical conditions. This device is

a chamber that is an air tight room where in air was compressed.

Boyle’s Law was published. Robert 1670

Boyle conducted an experiment (e.g. viper

in

a

vacuum)

showing

the

decreases on ambient pressure may lead to bubble formation in tissues.

1677

First used of Cadaques bell.

1680

Rebreathing diving set was made by Boreli.

Dr. Denise Papin designed a diving bell 1689

that has a constant pressure to supply fresh air.

Two cases of unknown illness was seen by Giovani Battista Morgagni. Air in 1769

cerebral circulation was observed by G.B Morgagni, and he assume that the death of the two divers was because of it.

Laplace’ Law was published. Laplace principle state that the size of the vessel 1784

is directly proportional to the tension required to withstand a specific internal fluid pressure.

1787

Charles Law was formulated but not published.

Modern diving bell was designed by 1788

John Smeaton. This equipment was not intended to be submerge.

The 1789

effects

of

long

exposure

to

normobaric oxygen in pulmonary was observed by Sequin and Lavoisier.

J. Smeaton modified the design diving 1790

bell

to

allow

this

equipment

submerge.

1801

Dalton’s Gas Law was published.

to

Henry’s Law was published by William Henry. Wherein the amount of gas dissolves in a specific type and volume 1803

of liquid with a constant temperature, is directly

proportional

to

the

partial

pressure of that gas in equilibrium with specific liquid.

Fatal effect of small amount of air in 1829

cerebral circulation was demonstrated by Bichat.

Hyperbaric chamber was constructed 1834

by

Junod.

hyperbaric

This air

to

chamber treat

used

pulmonary

diseases.

Trigger invented the Caisson and he 1841

also

noted

the

first

case

of

decompression sickness in two miners.

In the study of Pol and Wattelle, they observed caisson workers of Lordes. The used of recompression as a 1847

treatment to the decompression illness

was also reported. They conclude that 18 year olds were not capable of having this kind of illness than older workers.

Twenty five construction workers of Tamar

bridge

have

cases

of

decompression sickness. This study was conducted by Littleton wherein he 1855

conclude that decompression sickness is due to the release of air occasioning pressure

to

the

brain,

and

he

recommended that the step-by-step reduction and application of pressure must done.

1857

Sudden release of intravascular gas may cause death - (Hoppe-Seyler)

Bucquoy

advised

a

slow

decompression and he was able to 1861

publish a report on the hazards of working in compressed air.

Recompression as a “true specific” 1863

treatment to decompression sickness. This thoughts was recommended by Foley.

The

major

advancement

in

diving

activity starts when Rouquayrol and 1865

Denayrouze

was

constructed

their

demand valve and diving rig. This aims to

increase

the

diver’s

mobility

underwater.

A report was published by Bauer wherein twenty five caisson workers 1870

were paralyzed and four of them were died. The rest of them were recovered after 4 weeks .

Thirty

of

three

hundred

fifty

two

compressed air employees of St. Louis Eades bridge project were injured and 1871

12 of them were died. Dr. Alphonse Jaminet, a physician, described his own experience in decompression sickness. His description was first recorded.

Gal’s 1872

description

on

neurological

decompression sickness in divers was published.

An ENT surgeon, Andrew Smith was the physician in charge in the Brooklyn bridge project and he was the first to use the term “caisson disease”. The 1873

said project employed 600 workers, 119 cases of decompression were observe by Dr. Smith. Fourteen of them were died. The

surgeon

did

not

used

recompression as treatment for caisson disease because he thought that it is a heroic mode of treatment.

The acute oxygen toxicity or the Paul Bret Effect was established by Paul Bret and his “La Pression Barometique” was published. He used his pet (dog) to 1878

describe

the

association

between

obesity and an increased susceptibility to decompression illness. His dog survives pressure exposure while its body is thin, but when it became obese the

dog

died

in

same

pressure

exposure.

Frog used in experiment to study 1900

decompression caused bubbles and to explain the process of recompression.

Haldane was 1905

Admiralty

appointed by British

to

make

a

safe

decompression procedures.

The risk of permanency of disability of decompression 1912

increasing

sickness

number

of

and death

its was

emphasized by Hill.

1913

L. Brauer was the first to use the term “arterial gas embolism”.

1915

The United States Navy (USN) Diving table were first issued.

The RN and US Department of Mines 1919

used air decompression schedules that results

in

high

incidence

decompression sickness.

of

Hyperbaric air was used by Dr. O. 1921

Cunningham in treating diabetes and several type of illness.

1924

Standard recompression procedures was first issued by the USN.

1929

Davis decompression chamber was created.

USN 1930’s

Submarine

escape

was

discovered that arterial gas embolism and decompression sickness are not the same disorder.

Gagnan and J. Cousteau invented the 1943

“aqua lung”. This device was evaluated by Gagnan to use in gas powered cars.

Decompression 1955

illness

in

divers,

caisson workers and aviators were identical. This study was issued by Haymaker et al.

Decompression sickness was divided into two categories; type I (mild pain) 1960

and type II (serious). This classification was done by Golding et al. and it was supported by USN.

USN printed 1985

a procedure

for the

analysis of the Central Nervous System in its Diving Manual.

This compilation of significant event in the study of decompression sickness was collected in several references. The evolution of the knowledge in this illness is chronologically arranged in order to emphasize the progress in the investigation of DCS.

II.

EPIDEMIOLOGY The occurrence of Decompression sickness (DCS) is very rare and the total

number of worldwide active diver is unknown. According to South Pacific Underwater Medicine Society (SPUMS) and the European Underwater and Baromedical Society in their recently issued Diving and Hyperbaric Medicine, the estimated rate of having decompression sickness is about 2.8 cases out of 10,000 dives. They noticed that the incidence in cave divers is lower than the expected number of cases. Appropriate diving practice and training must be consider for the prevention of DCS.

In the research of Jersey SL et al. they explained a near-fatal case of neurological decompression sickness happened throughout the combat mission. The pilot suffered a severe brain injury during the flight and it was nearly fatal that leads to a permanent mental disability. Decompression sickness in divers and aviators are not comparable. DCS in divers are commonly damaged the spinal cord, while DCS in aviators the brain is normally injured. General risk factors such as higher altitude, longer exposure, greater in flight activity and lack of pre-oxygenation may increase the predisposition to aviation DCS. Every year, Divers Alert Network or DAN is publishing an annual diving report. This report is a compilation of surveys and cases such as divers’ injuries and deaths. Recently, DAN receives a report about an old man. This 58 year old diver was diagnosed a cardiovascular disease and he decided to give up is diving career, but after his valve replacement surgery he resumed to cave diving. He emerged from a dive to 56 mfw. As a result, he suffered symptoms similar to decompression sickness. The diver was tried to cure in a hyperbaric chamber but, he died.

Another incidence of death was recorded in annual diving report of DAN but, the cause of the death is still unexplained. This experienced diver and instructor is a 29 year old male that has a medical history of asthma. He completed his dive without any symptoms however, he complained of nausea and prickly limbs. He also experienced 30 seconds of seizures, shortness of breath and dizziness, then he was admitted to local emergency room and shifted to a hyperbaric chamber for treatment but, suddenly he died. Severe decompression sickness was also recorded in 64 year old professional diver. The cause of his death is DCS and AGE.

III.

Classification

Decompression sickness in diving occurs when a nitrogen gas accumulates in body tissues in a positive pressure environment and after subsequent reduction of the ambient pressure that escapes into the body fluids and will form buubles (Vann et al. 2011).

a) Type I decompression sickness (less severe/the bends) Type I DCS is the less severe type or mild form of the illness and it’s commonly produces pain that usually occurs in the joint such as arms, legs, back, or muscles. It is categorized by one or a mixture of musculoskeletal DCS or bends, skin DCS or creeps and lymphatic DCS. This mild pain starts within 10 minutes after surfacing though, other textbooks says it starts within 15 minutes. This tooth ache like of pain usually in joint and tissue but sometimes, it is hard to locate where pain occurs.

At first, victim with DCS type I will be experiencing slightly pain however, this mild pain gently become an intense pain. The shoulders, wrist, elbow, hand, knee and ankle are the most frequent site of mild pains according to Dr. S. Pulley a clinical professor of Department of Emergency Medicine.

b) Type II decompression sickness (more severe)

Type II DCS is the more severe type of the illness and may lead to neurological problems, paraplegia, blindness and sometimes death. It is categorized according to the symptoms; the spinal cord and peripheral nervous system DCS, inner ear DCS wherein it is commonly occurred in helium – oxygen diving, and pulmonary DCS

that may develop due to the blockage of lung circulation. The common site affected by this type is the spinal cord. Victims with DCS type II may experience shortness of breath or chokes, chest pain, severe head ache, and altered mental status. Severe cases on this type that are rare may result in shock and death.

IV.

Cause of Decompression sickness During decompression the gas bubbles form into tissues and when the

difference between the inert gas pressure in tissues and also the ambient pressure exceeds tolerable limits. Different rates of blood supply to the organs and corresponding times of exposure is multiply by the varying half valve. This two event may cause an autochtonous gas bubbles in the various organs. Blow up of decompression needs a high pressure exposure and this will result in an explosive decompression where in the gas bubbles will simultaneously combines in the arterial blood and in the tissues. The combination of arterial gas embolism and autochtonous gas bubbles that will cause DCS. (Bulmann 1984).

Its symptomatology is recognized by the organ that is affected by the capillary obstruction. Increase in volume of the gas bubbles is a relevant event in developing of decompression sickness. Further, there are secondary factors such as platelets aggregation, intravasal coagulation and also the perifocal edema with hemorrhage and displacement of fluid located in extravasal space. (Bulmann 1984).

DCS may also cause by many factors. One of these, is the formation of bubbles in blood or tissue throughout or after a decrease in environmental pressure. Working in compressed air area can also lead to decompression sickness. According to Naval Safety Center written by Ms. Kelsey Leo, dive time such as diving too long and diving too quickly can trigger this ailment. One of the major reason of rapid ascent is

maybe due to panic. The controlled ascent must not more than 10 meters per minute to avoid DCS. When surfacing too quickly, it can result to high pressure then nitrogen bubbles formed in blood. After the formation of nitrogen bubbles from the blood will expand and gather into joints, tissues and other parts of the body. Bubbles may block the circulation of blood that will cause death.

Therefore, the sign and symptoms of DCS will immediately begin.

V.

Sign and Symptoms Signs of this condition are numbness of the limbs, mild pain in joint or

muscle, Symptoms of Decompression sickness are depending on what type of DCS is, and generates symptoms related to the effect of bubble formation ...