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Below is a summary comparison of the signs and symptoms of DCI arising from its two components: "Decompression Sickness" and "Arterial Gas Embolism". Many signs and symptoms are common to both maladies, and it may be difficult to diagnose the actual problem. The dive history can be useful to distinguish which is more probable, but it is possible for both components to manifest at the same time following some dive profiles.
A more detailed account of the signs and symptoms of Decompression Sickness can be found here.
The term dysbarism encompasses decompression sickness, arterial gas embolism, and barotrauma, whereas decompression sickness and arterial gas embolism are commonly classified together as decompression illness when a precise diagnosis cannot be made. DCS and arterial gas embolism are treated very similarly because they are both the result of gas bubbles in the body. The U.S. Navy prescribes identical treatment for Type II DCS and arterial gas embolism. Their spectra of symptoms also overlap, although those from arterial gas embolism are generally more severe because they often arise from an infarction (blockage of blood supply and tissue death).
DCS is classified by symptoms. The earliest descriptions of DCS used the terms: "bends" for joint or skeletal pain; "chokes" for breathing problems; and "staggers" for neurological problems. In 1960, Golding "et al." introduced a simpler classification using the term "Type I ('simple')" for symptoms involving only the skin, musculoskeletal system, or lymphatic system, and "Type II ('serious')" for symptoms where other organs (such as the central nervous system) are involved. Type II DCS is considered more serious and usually has worse outcomes. This system, with minor modifications, may still be used today. Following changes to treatment methods, this classification is now much less useful in diagnosis, since neurological symptoms may develop after the initial presentation, and both Type I and Type II DCS have the same initial management.
Decompression sickness, also called caisson workers' disease and the bends, is the most well-known complication of scuba diving. It occurs as divers ascend, and often from ascending too fast or without doing decompression stops. Bubbles are large enough and numerous enough to cause physical injury. It is quite possible that all divers have microbubbles in their blood to some extent, but that most of the time these bubbles are so few and so small that they cause no harm. When DCS occurs, bubbles disrupt tissues in the joints, brain, spinal cord, lungs, and other organs. Symptoms vary enormously. DCS may be as subtle as unusual tiredness after a dive, or an aching elbow, or a mottled skin rash. Or, it may present dramatically, with unconsciousness, seizures, paralysis, shortness of breath, or death. Paraplegia is not uncommon.
Decompression Illness (DCI) describes a range of symptoms arising from decompression of the body.
DCI can be caused by two different mechanisms, which result in overlapping sets of symptoms. The two mechanisms are:
- Decompression sickness (DCS), which results from metabolically inert gas dissolved in body tissue under pressure precipitating out of solution and forming bubbles during decompression. It typically afflicts underwater divers on poorly managed ascent from depth or aviators flying in inadequately pressurised aircraft.
- Arterial gas embolism (AGE), which is gas bubbles in the bloodstream. In the context of DCI these may form either as a result of bubble nucleation and growth by dissolved gas into the blood on depressurisation, which is a subset of DCS above, or by gas entering the blood mechanically as a result of pulmonary barotrauma. Pulmonary barotrauma is a rupturing of lung tissue by expansion of breathing gas held in the lungs during depressurisation. This may typically be caused by an underwater diver ascending while holding the breath after breathing at ambient pressure, ambient pressure escape from a submerged submarine without adequate exhalation during the ascent, or the explosive decompression of an aircraft cabin or other pressurised environment.
In any situation which could cause decompression sickness, there is also potentially a risk of arterial gas embolism, and as many of the symptoms are common to both conditions, it may be difficult to distinguish between the two in the field, and first aid treatment is the same for both mechanisms.
Dysbarism refers to medical conditions resulting from changes in ambient pressure. Various activities are associated with pressure changes. underwater diving is the most frequently cited example, but pressure changes also affect people who work in other pressurized environments (for example, caisson workers), and people who move between different altitudes.
Symptoms of arterial gas embolism include:
- Loss of consciousness
- Cessation of breathing
- Vertigo
- Convulsions
- Tremors
- Loss of coordination
- Loss of control of bodily functions
- Numbness
- Paralysis
- Extreme fatigue
- Weakness in the extremities
- Areas of abnormal sensation
- Visual abnormalities
- Hearing abnormalities
- Personality changes
- Cognitive impairment
- Nausea or vomiting
- Bloody sputum
- Symptoms of other consequences of lung overexpansion such as pneumothorax, subcutaneous or mediastinal emphysema may also be present.
Small amounts of air often get into the blood circulation accidentally during surgery and other medical procedures (for example, a bubble entering an intravenous fluid line), but most of these air emboli enter the veins and are stopped at the lungs, and thus a venous air embolism that shows any symptoms is very rare.
Diving disorders, or diving related medical conditions, are conditions associated with underwater diving, and include both conditions unique to underwater diving, and those that also occur during other activities. This second group further divides into conditions caused by exposure to ambient pressures significantly different from surface atmospheric pressure, and a range of conditions caused by general environment and equipment associated with diving activities.
Barotrauma can affect the external, middle, or inner ear. Middle ear barotrauma (MEBT) is the most common being experienced by between 10% and 30% of divers and is due to insufficient equilibration of the middle ear. External ear barotrauma may occur on ascent if high pressure air is trapped in the external auditory canal either by tight fitting diving equipment or ear wax. Inner ear barotrauma (IEBT), though much less common than MEBT, shares a similar mechanism. Mechanical trauma to the inner ear can lead to varying degrees of conductive and sensorineural hearing loss as well as vertigo. It is also common for conditions affecting the inner ear to result in auditory hypersensitivity.
The sinuses similar to other air-filled cavities are susceptible to barotrauma if their openings become obstructed. This can result in pain as well as epistaxis (nosebleed).
Many diving accidents or illnesses are related to the effect of pressure on gases in the body;
Barotrauma is physical injury to body tissues caused by a difference in pressure between a gas space inside or in contact with the body, and the surroundings .
Barotrauma occurs when the difference in pressure between the surroundings and the gas space makes the gas expand in volume, distorting adjacent tissues enough to rupture cells or damage tissue by deformation. A special case, where pressure in tissue is reduced to the level that causes dissolved gas to come out of solution as bubbles, is called "decompression sickness", "the bends", or "caisson disease".
Several organs are susceptible to barotrauma, however the cause is well understood and procedures for avoidance are clear. Nevertheless, barotrauma occurs and can be life-threatening, and procedures for first aid and further treatment are an important part of diving medicine.
- Barotraumas of descent (squeezes)
- Barotraumas of ascent (overexpansion injuries)
Taravana is a disease often found among Polynesian island natives who habitually dive deep without breathing apparatus many times in close succession, usually for food or pearls. These free-divers may make 40 to 60 dives a day, each of 30 or 40 metres (100 to 140 feet).
Taravana seems to be decompression sickness. The usual symptoms are vertigo, nausea, lethargy, paralysis and death. The word "taravana" is Tuamotu Polynesian for "to fall crazily".
Taravana is also used to describe someone who is "crazy because of the sea".
The first symptom of compartment syndrome is pain. Loss of function and decreased pulses or pulselessness, however, are late signs. According to Shears, paresthesia in the distribution of the nerves transversing the affected compartment has also been described as relatively early sign of compartment syndrome, and later is followed by anesthesia (Shears, 2006).
- Pain is often reported early and almost universally. The description is usually of deep, constant, and poorly localized pain out of proportion with the findings on physical examination (often incorrectly described as pain out of proportion to the injury). The pain is aggravated by passively stretching the muscle group within the compartment or actively flexing it (though this finding is not specific to compartment syndrome alone) and is not relieved by analgesia up to and including morphine.
- Paresthesia (altered sensation e.g., "pins & needles") in the cutaneous nerves of the affected compartment is another typical sign.
- Paralysis of the limb is usually a late finding. The compartment may also feel very tense and firm (pressure). Some find that their feet and even legs fall asleep. This is because compartment syndrome prevents adequate blood flow to the rest of the leg.
- A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures and pulse is only affected if the relevant artery is contained within the affected compartment.
- Tense and swollen shiny skin, sometimes with obvious bruising of the skin.
- Congestion of the digits with prolonged capillary refill time.
A number of heat illnesses exist including:
- Heat stroke - Defined by a body temperature of greater than due to environmental heat exposure with lack of thermoregulation. Symptoms include dry skin, rapid, strong pulse and dizziness.
- Heat exhaustion - Can be a precursor of heatstroke; the symptoms include heavy sweating, rapid breathing and a fast, weak pulse.
- Heat syncope - Fainting or dizziness as a result of overheating.
- Heat edema
- Heat cramps - Muscle pains that happen during heavy exercise in hot weather.
- Heat rash - Skin irritation from excessive sweating.
- Heat tetany - Usually results from short periods of stress in intense heat. Symptoms may include hyperventilation, respiratory problems, numbness or tingling, or muscle spasms.
Heat illness or heat-related illness is a spectrum of disorders due to environmental exposure to heat. It includes minor conditions such as heat cramps, heat syncope, and heat exhaustion as well as the more severe condition known as heat stroke.
The symptoms of chronic exertional compartment syndrome (CECS) are brought on by exercise and consist of a sensation of extreme tightness in the affected muscles followed by a painful burning sensation if exercise is continued. After exercise is ceased, the pressure in the compartment will decrease within a few minutes, relieving painful symptoms. Symptoms will occur at a certain threshold of exercise which varies from person to person but is rather consistent for a given individual and can range anywhere from 30 seconds of running to about 10–15 minutes of running. CECS most commonly occurs in the lower leg, with the anterior compartment being the most frequently affected compartment. Foot drop is a common symptom of CECS.
Although multiple definitions exist, a tension pneumothorax is generally considered to be present when a pneumothorax (primary spontaneous, secondary spontaneous, or traumatic) leads to significant impairment of respiration and/or blood circulation. Tension pneumothorax tends to occur in clinical situations such as ventilation, resuscitation, trauma, or in patients with lung disease.
The most common findings in people with tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia) and rapid breathing (tachypnea) in the initial stages. Other findings may include quieter breath sounds on one side of the chest, low oxygen levels and blood pressure, and displacement of the trachea away from the affected side. Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of consciousness, a hyperresonant percussion note on examination of the affected side with reduced expansion and decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex beat (heart impulse), and resonant sound when tapping the sternum. This is a medical emergency and may require immediate treatment without further investigations (see below).
Tension pneumothorax may also occur in someone who is receiving mechanical ventilation, in which case it may be difficult to spot as the person is typically receiving sedation; it is often noted because of a sudden deterioration in condition. Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Deviation of the trachea to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as clinical signs.
A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems, and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. People who are affected by PSPs are often unaware of potential danger and may wait several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric pressure, explaining to some extent why episodes of pneumothorax may happen in clusters. It is rare for PSPs to cause tension pneumothoraces.
Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs. Hypoxemia (decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and – if very severe – may result in comas. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax.
Traumatic pneumothorax most commonly occurs when the chest wall is pierced, such as when a stab wound or gunshot wound allows air to enter the pleural space, or because some other mechanical injury to the lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma, with only rib fractures being more common in this group. The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge - particularly if mechanical ventilation is required. They are also encountered in patients already receiving mechanical ventilation for some other reason.
Upon physical examination, breath sounds (heard with a stethoscope) may be diminished on the affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal vibrations to the surface of the chest may be altered. Percussion of the chest may be perceived as hyperresonant (like a booming drum), and vocal resonance and tactile fremitus can both be noticeably decreased. Importantly, the volume of the pneumothorax can show limited correlation with the intensity of the symptoms experienced by the victim, and physical signs may not be apparent if the pneumothorax is relatively small.
A catastrophic illness is a severe illness requiring prolonged hospitalization or recovery. Examples would include coma, cancer, leukemia, heart attack or stroke. These illnesses usually involve high costs for hospitals, doctors and medicines and may incapacitate the person from working, creating a financial hardship. They are the type intended to be covered by high-deductible health plans. Research indicates that the unusual economic environment of the delivery of catastrophic illness care encourages the use of innovative therapies. Medicare contains a benefit for catastrophic illness.
The diagnosis is made by x-ray/MRI appearance and has five juxta-articular classifications and forehead, neck, and shaft classifications indicating early radiological signs.
Early on there is flattening of articular surfaces, thinning of cartilage with osteophyte (spur) formation. In juxta-articular lesions without symptoms, there is dead bone and marrow separated from living bone by a line of dense collagen. Microscopic cysts form, fill with necrotic material and there is massive necrosis with replacement by cancellous bone with collapse of the lesions.
The lesion begins as a random finding on x-ray without symptoms. Symptomatic lesions usually involve joint surfaces, and fracture with attempted healing occurs. This process takes place over months to years and eventually causes disabling arthritis, particularly of the femoral head (hip).
The following staging system is sometimes useful when managing lesions.
- Stage 0 - Intravascular coagulation
- Stage 1 - Dead Bone without repair
- Stage 2 - Dead Bone with repair but without collapse
- Stage 3 - Dead Bone with repair and with collapse
- Stage 4 - Secondary degenerative arthritis
In a study of bone lesions in 281 compressed air workers done by Walder in 1969, 29% of the lesions were in the humeral head (shoulder), 16% in the femoral head (hip), 40% in the lower end of the femur (lower thigh at the knee) and 15% in the upper tibia (knee below the knee cap).
Worsening of the condition from continued decompression in an asymptomatic x-ray finding may occur.
Chronic critical illness is a disease state which affects intensive care patients who have survived an initial insult but remain dependent on intensive care for a protracted period, neither dying nor recovering. The most characteristic clinical feature is a prolonged requirement for mechanical ventilation. Other features include profound weakness associated with critical illness polyneuropathy, increased susceptibility to infection, metabolic changes and hormonal changes. There may be protracted or permanent delirium, or other marked cognitive impairment. The physical and psychological symptoms of the disease are very severe, including a propensity to develop post traumatic stress syndrome.
Strict definitions of chronic critical illness vary. One definition is the requirement for mechanical ventilation for 21 days or more. It is estimated that 5-10% of patients who require mechanical ventilation as part of their initial illness will go on to develop chronic critical illness. Overall prevalence has been estimated at 34.4 per 100 000 of the population. Most adult patients do not survive chronic critical illness, and furthermore even those who are discharged from hospital frequently die soon after discharge. One-year mortality in adults is 48-68%. However, children fare better with two-thirds surviving to 5 years or beyond.
Dysbaric osteonecrosis or DON is a form of avascular necrosis where there is death of a portion of the bone that is thought to be caused by nitrogen embolism (blockage of the blood vessels by a bubble of nitrogen coming out of solution) in divers. Although the definitive pathologic process is poorly understood, there are several hypotheses:
- Intra- or extravascular nitrogen in bones, "nitrogen embolism".
- Osmotic gas effects due to intramedullary pressure effects.
- fat embolism
- hemoconcentration and increased coagulability.
Claudication is a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms. The word "claudication" comes from the Latin "claudicare" meaning 'to limp'.
Claudication that appears after a short amount of walking may sometimes be described by US medical professionals by the number of typical city street blocks that the patient can walk before the onset of claudication. Thus, "one-block claudication" appears after walking one block, "two-block claudication" appears after walking two blocks, etc. The term "block" would be understood more exactly locally but is on the order of 100 metres.
Intermittent vascular (or arterial) claudication (Latin: "claudicatio intermittens") most often refers to cramping pains in the buttock or leg muscles, especially the calves. It is caused by poor circulation of the blood to the affected area, called Peripheral artery disease. The poor blood flow is often a result of atherosclerotic blockages more proximal to the affected area; individuals with intermittent claudication may have diabetes — often undiagnosed. Another cause, or exacerbating factor, is excessive sitting (several hours), especially in the absence of reasonable breaks, along with a general lack of walking or other exercise that stimulates the legs.