Diving-related Arterial Gas Embolism
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Abstract
Diving-related Arterial Gas Embolism (AGE) is a life-threatening diving injury, often found to be the leading cause of fatalities among divers. The onset of symptoms associated with AGE occurs abruptly upon ascending to the surface or within minutes of being on the surface. The standard approach to managing AGE is recompression in a hyperbaric chamber. Thus, patients need accurate and rapid assessment, diagnosis, resuscitation, and initial treatment of AGE which is critical for optimal treatment outcomes. This review article aims to provide an overview of the pathophysiology, diagnosis, treatment, and prevention of diving-related AGE, with the objective of assisting medical practitioners to accurately diagnose and initially treat patients, as well as referring them for prompt recompression therapy as required.
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References
Bralow LM, Piehl M. Barotrauma and arterial gas embolism: a diving emergencies simulation case for emergency medicine residents. MedEdPORTAL 2018;14(1):1-6.
Casadesús JM, Nieto-Moragas J, Serrando MT, Boadas-Vaello P, Carrera A, Aguirre F, et al. Pulmonary barotrauma in SCUBA diving-related fatalities: a histological and histomorphometric analysis. Forensic Sci Med Pathol 2023 Jan 27. doi: 10.1007/s12024-022-00567-1.
Edgar M, Franco MA, Dainer HM. Case series of arterial gas embolism incidents in U.S. Navy Pressurized Submarine Escape Training from 2018 to 2019. Mil Med 2021;186(5-6):e613-8.
Moon RE. Hyperbaric treatment of air or gas embolism: current recommendations. Undersea Hyperb Med 2019;46(5):673-83.
Beevor H, Frawley G. Iatrogenic cerebral gas embolism: analysis of the presentation, management and outcomes of patients referred to The Alfred Hospital Hyperbaric Unit. Diving Hyperb Med 2016;46(1):15-21.
Balldin UI, Pilmanis AA, Webb JT. Central nervous system decompression sickness and venous gas emboli in hypobaric conditions. Aviat Space Environ Med 2004;75(11):969-72.
Tom S. Neuman AOB. Arterial gas embolism and pulmonary barotrauma. In: Brubakk A, Neuman T. Bennett and Elliott's physiology and medicine of diving. 5th ed. Cornwall: Saunders; 2003. p. 557-73.
lliott DH HJ, Barnard EEP. Clinical and radiological features of 88 cases of decompression baro- trauma. Federation of American Societies for Experimental Biology 1978;6:527-35.
Smith RM, Van Hoesen KB, Neuman TS. Arterial gas embolism and hemoconcentration. J Emerg Med 1994;12(2):147-53.
Lindblom U, Tosterud C. Pulmonary barotrauma with cerebral arterial gas embolism from a depth of 0.75-1.2 metres of fresh water or less: a case report. Diving Hyperb Med 2021;51(2):224-6.
Hampson NB, Moon RE. Arterial gas embolism breathing compressed air in 1.2 metres of water. Diving Hyperb Med 2020;50(3):292-94.
Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet 2011;377(9760):153-64.
Weiss LD, Van Meter KW. Cerebral air embolism in asthmatic scuba divers in a swimming pool. Chest 1995;107(6):1653-4.
Mitchell SJ, Bennett MH, Moon RE. Decompression sickness and arterial gas embolism. N Engl J Med 2022;386(13):1254-64.
U.S. Navy. U.S. Navy diving manual revision 7A. Washington, D.C: Government Printing Office; 2018.
Sadler C, Latham E, Hollidge M, Boni B, Brett K. Delayed hyperbaric oxygen therapy for severe arterial gas embolism following scuba diving: a case report. Undersea Hyperb Med 2019;46(2):197-202.
Leitch DR, Green RD. Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism. Aviat Space Environ Med 1986;57(10 Pt 1):931-8.
Thanasawat C. Underwater medicine: principles and practice. Bangkok: Netikul Press; 2022. p. 630. (in Thai).
Risberg J. Pulmonary barotrauma after helicopter underwater escape training. Diving Hyperb Med 2021;51(4):384-5.
Hayden SR, Buford KC, Castillo EM. Accuracy of a SET of screening parameters developed for the diagnosis of arterial gas embolism: the SANDHOG criteria. J Emerg Med 2015;49(5):792-8.
Stephenson J. Pathophysiology, treatment and aeromedical retrieval of SCUBA – related DCI. JMVH 2009;17(3):10-9.
Rusoke-Dierich O. Diving medicine. Switzerland: Springer; 2018. p. 215.
Satreerat K, Thanasawat C. Diving related neurapraxia. Royal Thai Navy Medical Journal 2022;49(1):212-22.
Smith RM, Neuman TS. Elevation of serum creatine kinase in divers with arterial gas embolization. N Engl J Med 1994;330(1):19-24.
Ozdoba C, Weis J, Plattner T, Dirnhofer R, Yen K. Fatal scuba diving incident with massive gas embolism in cerebral and spinal arteries. Neuroradiology 2005;47(6):411-6.
Moon RE. Hyperbaric oxygen therapy indication. 14th ed. Florida: Best Publishing; 2019.
Alexander AM, Martin N. Arterial gas embolism. Treasure Island (FL): StatPearls Publishing; 2022.
Casadesús JM, Aguirre F, Carrera A, Boadas-Vaello P, Serrando MT, Reina F. Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases. Forensic Sci Med Pathol 2018;14(1):18-25.
Andre S, Lehot H, Morin J, Louge P, de Maistre S, Roffi R, et al. Influence of prehospital management on the outcome of spinal cord decompression sickness in scuba divers. Emerg Med J 2022;39(10):747-52.
Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ. First aid normobaric oxygen for the treatment of recreational diving injuries. Undersea Hyperb Med 2007;34(1):43-9.
Oh SH, Kang HD, Jung SK, Choi S. Implementation of targeted temperature management in a patient with cerebral arterial gas embolism. Ther Hypothermia Temp Manag 2018;8(3):176-80.
Edmonds C, Bennett M, Lippmann J, Mitchell S. Diving and subaquatic medicine. 5th ed. Florida: CRC Press; 2016.
Trytko BE, Bennett MH. Arterial gas embolism: a review of cases at Prince of Wales Hospital, Sydney, 1996 to 2006. Anaesth Intensive Care 2008;36(1):60-4.
Malik N, Claus PL, Illman JE, Kligerman SJ, Moynagh MR, Levin DL, et al. Air embolism: diagnosis and management. Future Cardiol 2017;13(4):365-78.
Midlands Diving Chamber. Royal Navy treatment table 62. [Internet]. [cited 2023 March 18]. Available from: https://midlandsdivingchamber.co.uk/index.php?id=theory&page=2.
Bennett MH, Mitchell SJ, Young D, King D. The use of deep tables in the treatment of decompression illness: the Hyperbaric Technicians and Nurses Association 2011 workshop. Diving Hyperb Med 2012;42(3):171-80.
Clarke R. Monoplace chamber treatment of decompression illness: review and commentary. Diving Hyperb Med 2020;50(3):264-72.
Denoble PJ, Bird N, Chimiak J, editors. Treatment of decompression illness in recreational diving. [Internet]. [cited 2023 March 18]. Available from: https://world.dan.org/wp-content/uploads/2021/08/2019-pre-course-proceedings-web.pdf.
Undersea and Hyperbaric Medical Society. UHMS best practice guidelines prevention and treatment of decompression sickness and arterial gas embolism. 2011. [Internet]. [cited 2023 March 18]. Available from: https://www.uhms.org/images/DCS-AGE-Committee/dcsandage_prevandmgt_uhms-fi.pdf.
Moon RE. Adjunctive therapy for decompression illness: a review and update. Diving Hyperb Med 2009;39(2):81-7.
Perez MF, Perez JVO, Serrano AR, Andal MP, Aldover MC. Delayed hyperbaric intervention in life-threatening decompression illness. Diving Hyperb Med 2017;47(4):257-9.
Rattanawiwatpong P. Case report: an accidental finding of arterial gas embolism in rescue diver for six month delay. Thai Underwater Medicine Journal 2011;5(2):18-20. (in Thai)
Steffensmeier D, Albrecht R, Wendling J, Melliger R, Spahn DR, Stein P, et al. Specialist advice may improve patient selection for decompression therapy following diving accidents: a retrospective observational study. Scand J Trauma Resusc Emerg Med 2017;25(1):101.
The Diving Medical Advisory Committee. Fitness to return to diving after decompression illness. [Internet]. [cited 2023 January 24]. Available from: https://www.dmac-diving.org/guidance/DMAC13.pdf.
Manual of the Medical Department (MANMED). Physical examinations and standards article 15-102. U.S. [Internet]. [cited 2023 March 18]. Available from: https://www.med.navy.mil/Directives/MANMED/.
Treatment of Decompression Illness in Recreational Diving: Differences in Current Treatment Practices and Possible Reconciliation. [Internet]. [cited 2023 March 18]. Available from: https://world.dan.org/wp-content/uploads/2021/08/2019-pre-course-proceedings-web.pdf.
South Pacific Underwater Medicine Society (SPUMS). Guidelines on medical risk assessment for recreational diving. 5th ed. Melbourne: SPUMS; 2020.
Poolpol P, Sithisarankul P. Effect of hyperbaric environment on pulmonary function in professional divers. Royal Thai Navy Medical Journal 2018;45(3):632-44. (in Thai)