decompression sickness pathophysiology of diving accidents€¦ · venous dcs bubbles &...
TRANSCRIPT
Dr. Wilhelm Welslau
Consultant for Diving and Hyperbaric Medicine
German Diving and Hyperbaric Medical Society
Decompression sickness
- Pathophysiology
of diving accidents
Decompression sickness
- Pathophysiology
of diving accidents
Diving accidents
DCS (Decompression sickness)
after long and deep dives
AGE (Arterial gas embolism)
after rapid ascents to the surface
DCI (Decompression injuries)
© Dr. Wilhelm Welslau – www.taucherarzt.at
DCS
Decompressionsickness
© Dr. Wilhelm Welslau – www.taucherarzt.at
Henry‘s gas law„Gases solve in liquids proportional to pressure“
© Dr. Wilhelm Welslau – www.taucherarzt.at
Henry‘s gas law„Gases solve in liquids proportional to pressure“
pressure elevation
saturation
time at
elevated pressure
saturation
pressure reduction
desaturation
time at
atmospheric pressure
desaturation
© Dr. Wilhelm Welslau – www.taucherarzt.at
Saturationtissues load up
with nitrogen (N2)
air
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
Desaturationtissues get rid
of nitrogen (N2)
air
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
SaturationDifferent tissues need different time to load nitrogen (N2)
240min.
120min.
60min.
30min.
© Dr. Wilhelm Welslau – www.taucherarzt.at
DesaturationDifferent tissues need different time get rid of nitrogen (N2)
240min.
120min.
60min.
30min.
© Dr. Wilhelm Welslau – www.taucherarzt.at
Decompression tables & computersCalculation of safe decompression procedures
© Dr. Wilhelm Welslau – www.taucherarzt.at
Bubble formationin venous blood
during & after decompression
blood
blood vessel wall
bubble
nucleus
supersaturated tissue
bubble
air
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
Bubble growthas long as venous blood is over-saturated with nitrogen (N2)
air
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
Venous bubbles• may stop local circulation• cause tissue hypoxia
air
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
Venous bubbles• may stop local circulation• cause tissue hypoxia• cause cellular death
air
alveola
CNS
skin
muscles
joints
bones
Courtesy of UHMS
lung
lungshuntlung
circuit
bodycircuit
brain
spinal cord
kidney
muscle
fatty tissue
PFOshunt
Shuntsallow venous blood• with dissolved nitrogen• with nitrogen bubblesto arterialize
© Dr. Wilhelm Welslau – www.taucherarzt.at
Blood shuntingin the lung
when venous gasbubbles occludelung capillaries
lung artery
lung vein
arterioles
capillariesair
alveola
CNS
skin
muscles
joints
bones
© Dr. Wilhelm Welslau – www.taucherarzt.at
PFOPatent foramen
ovale (~30%)
R-L Shunt possiblewhen right atrium
pressure increases
blood pressure
lung vein
lung arthery
body vein
right
atrium
left
atrium
oval window
(scared over)
body artery
blood pressure
right
chamberleft
chamber
cardial septum
© Dr. Wilhelm Welslau – www.taucherarzt.at
lung
lungshuntlung
circuit
bodycircuit
brain
spinal cord
kidney
muscle
fatty tissue
PFOshunt
Shuntsallow venous blood• with dissolved nitrogen• with nitrogen bubblesto arterialize
© Dr. Wilhelm Welslau – www.taucherarzt.at
Shuntsallow venous blood with nitrogen bubbles to arterialize
From: Z. Dujic in: The future of diving: 100 years of Haldane and beyond (2009)
Bubbles in functional terminal arteries
From: Muth CM & Shank ES. NEJM 2000;342:476-482
• endothelial irritation• inflamation• edema• circulation stop• tissue hypoxia• cellular death
Bubbles inneurological tissues
cause loss of function
according to affected region
© Dr. Wilhelm Welslau – www.taucherarzt.at
Possible symptoms
of nitrogen bubbles
• Discolouration and alteration of the skin• Pain• Tingling• Physical weakness• Numbness
• Paralysis• Breathing difficulties• Vision, hearing or speech disturbance
• Vertigo• Nausea
• Impaired consciousness
• Discolouration and alteration of the skin• Pain• Tingling• Physical weakness• Numbness
• Paralysis• Breathing difficulties• Vision, hearing or speech disturbance
• Vertigo• Nausea
• Impaired consciousness
© Dr. Wilhelm Welslau – www.taucherarzt.at
AGE
Arterial GasEmbolism
© Dr. Wilhelm Welslau – www.taucherarzt.at
Boyle‘s
gas lawpressure p volume V
© Dr. Wilhelm Welslau – www.taucherarzt.at
Depth
Residual
volume
Total
capacity
Barotrauma
of the
lungs
Risk factors:
• obstructivelung diseases
• bullae• tuberculosis
No risk:• < 2 m depth
© Dr. Wilhelm Welslau – www.taucherarzt.at
Barotrauma of the lungsRisk factor: bullae
© Dr. Wilhelm Welslau – www.taucherarzt.at
Barotrauma
of the
lungs
resulting in:
pneumothorax
© Dr. Wilhelm Welslau – www.taucherarzt.at
alveola
Barotrauma
of the
lungs
resulting in:
mediastinalemphysema
© Dr. Wilhelm Welslau – www.taucherarzt.at
alveola
Barotrauma
of the
lungs
resulting in:
arterial gasembolism
© Dr. Wilhelm Welslau – www.taucherarzt.at
alveola
Arterial gasembolism
• endothelial irritation• inflamation• edema• circulation stop• tissue hypoxia• cellular death
© Dr. Wilhelm Welslau – www.taucherarzt.at
Venous DCS bubbles
& arterialised DCS bubbles
& AGE bubbles
may cause similar problems
• Discolouration and alteration of the skin• Pain• Tingling• Physical weakness• Numbness
• Paralysis• Breathing difficulties• Vision, hearing or speech disturbance
• Vertigo• Nausea
• Impaired consciousness
• Discolouration and alteration of the skin• Pain• Tingling• Physical weakness• Numbness• Paralysis• Breathing difficulties
• Vision, hearing or speech disturbance• Vertigo• Nausea• Impaired consciousness
© Dr. Wilhelm Welslau – www.taucherarzt.at
Venous DCS bubbles
& arterialised DCS bubbles
& AGE bubbles
may be treated similarly
DCI
AGE Pneumo-thorax
Mediastinalemphysema
Pulmonary barotrauma
Shuntmecha-nisms
Inert gasbubbles
DCS
From: Guideline‚Diving Accident‘www.gtuem.org
© Dr. Wilhelm Welslau – www.taucherarzt.at
DSC + AGE = DCI
DecompressionInjury
© Dr. Wilhelm Welslau – www.taucherarzt.at
Thank youfor your attention
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