2017 June;47(2)
Diving Hyperb Med. 2017 June;47(2):75-81. doi: 10.28920/dhm47.2.75-81. PMID: 28641319. PMCID: PMC6147232.
Understanding scuba diving fatalities: carbon dioxide concentrations in intra-cardiac gas
Vincent Varlet1, Alejandro Dominguez2, Marc Augsburger1, Maisy Lossois3, Coraline Egger2,3, Cristian Palmiere3, Raquel Vilarino2,3, Silke Grabherr2,3
1 Forensic Chemistry and Toxicology Unit, University Centre of Legal Medicine Lausanne – Geneva, Switzerland
2 Forensic Imaging Unit, University Centre of Legal Medicine Lausanne – Geneva, Switzerland
3 Forensic Medicine Unit, University Center of Legal Medicine Lausanne – Geneva, Switzerland
Corresponding author: Vincent Varlet, Forensic Chemistry and Toxicology Unit, University Centre of Legal Medicine Lausanne – Geneva, CH-1011 Lausanne, Switzerland
Key words
Gases; Diving deaths; Drowning; Decompression sickness; Air embolism; Arterial gas embolism
Abstract
(Varlet V, Dominguez A, Augsburger M, Lossois M, Egger C, Palmiere C, Vilarino R, Grabherr S. Understanding scuba diving fatalities: carbon dioxide concentrations in intra-cardiac gas. Diving and Hyperbaric Medicine. 2017 June;47(2):75-81. doi: 10.28920/dhm47.2.75-81. PMID: 28641319. PMCID: PMC6147232.)
Introduction: Important developments in the diagnosis of scuba diving fatalities have been made thanks to forensic imaging tool improvements. Multi-detector computed tomography (MDCT) permits reliable interpretation of the overall gaseous distribution in the cadaver. However, due to post-mortem delay, the radiological interpretation is often doubtful because the distinction between gas related to the dive and post-mortem decomposition artifactual gases becomes less obvious.
Methods: We present six cases of fatal scuba diving showing gas in the heart and other vasculature. Carbon dioxide (CO2) in cardiac gas measured by gas chromatography coupled to thermal conductivity detection were employed to distinguish decomposition from embolism based on the detection of decomposition gases (hydrogen, hydrogen sulfide and methane) and to confirm arterial gas embolism (AGE) or post-mortem offgasing diagnoses. A Radiological Alteration Index (RAI) was calculated from the scan.
Results: Based on the dive history, the intra-cadaveric gas was diagnosed as deriving from decomposition (one case, minimal RAI of 61), post-mortem decompression artifacts (two cases, intermediate RAI between 60 and 85) and barotrauma/AGE (three cases, maximal RAI between 85 and 100), illustrating a large distribution inside the bodies.
Conclusion: MDCT scans should be interpreted simultaneously with compositional analysis of intra-cadaveric gases. Intracadaveric gas sampling and analysis may become useful tools for understanding and diagnosing scuba diving fatalities. In cases with short post-mortem delays, the CO2 concentration of the cardiac gas provides relevant information about the circumstances and cause of death when this parameter is interpreted in combination with the diving profile.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Original article
Full article available here.
Diving Hyperb Med. 2017 June;47(2):82-87. doi: 10.28920/dhm47.2.82-87. PMID: 28641320. PMCID: PMC6147223.
Transcutaneous oximetry measurements of the leg: comparing different measuring equipment and establishing values in healthy young adults
Tobias P Trinks1, Denise F Blake2, Derelle A Young3, Ken Thistlethwaite1, Venkat N Vangaveti4
1 Hyperbaric Medicine Unit, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
2 Emergency Department, The Townsville Hospital, Townsville, Queensland and College of Marine and Environmental Sciences, James Cook University, Townsville, Queensland, Australia
3 Hyperbaric Medicine Unit, The Townsville Hospital
4 College of Medicine and Dentistry, James Cook University, Queensland, Australia
Corresponding author: Tobias Trinks, Hyperbaric Medicine Unit, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, Queensland 4006, Australia
Key words
Patient monitoring; Standards; Wounds; Hyperbaric oxygen therapy
Abstract
(Trinks TP, Blake DF, Young DA, Thistlethwaite K, Vangaveti VN. Transcutaneous oximetry measurements of the leg: comparing different measuring equipment and establishing values in healthy young adults. Diving and Hyperbaric Medicine. 2017 June;47(2):82-87. doi: 10.28920/dhm47.2.82-87. PMID: 28641320. PMCID: PMC6147223.)
Introduction: Transcutaneous oximetry measurement (TCOM) is a non-invasive method of determining oxygen tension at the skin level using heated electrodes.
Aim: To compare TCOM values generated by different machines and to establish lower limb TCOM values in a cohort of healthy individuals younger than 40 years of age.
Method: Sixteen healthy, non-smoking volunteers aged 18 to 39 years were recruited. TCOM was obtained at six locations on the lower leg and foot using three different Radiometer machines. Measurements were taken with subjects lying supine, breathing air.
Results: Except for one sensor site, there were no statistical differences in measurements obtained by the different TCOM machines. There was no statistical difference in measurements comparing left and right legs. Room air TCOM values for the different lower leg sites were (mean (SD) in mmHg): lateral leg 61.5 (9.2); lateral ankle 61.1 (9.7); medial ankle 59.1 (10.8); foot, first and second toe 63.4 (10.6); foot, fifth toe 59.9 (13.2) and plantar foot 74.1 (8.8). The overall mean TCOM value for the lower limb was 61 (10.8; 95% confidence intervals 60.05–62.0) mmHg.
Conclusion: Lower-leg TCOM measurements using different Radiometer TCOM machines were comparable. Hypoxia has been defined as lower-leg TCOM values of less than 40 mmHg in non-diabetic patients and this is supported by our measurements. The majority (96.9%) of the lower leg TCOM values in healthy young adults are above the hypoxic threshold.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Original article
Diving Hyperb Med. 2017 June;47(2):88-96. doi: 10.28920/dhm47.2.88-96. PMID: 28641321. PMCID: PMC6147228.
Identifying and acting on potentially inappropriate care? Inadequacy of current hospital coding for this task
P David Cooper, David R Smart
Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
Corresponding author: Dr David Cooper, Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, GPO Box 1061L, Hobart, Tasmania 7001, Australia
Key words
Clinical coding; Data; Economics; Evidence; Health; Hyperbaric oxygen therapy; Policy
Abstract
(Cooper PD, Smart DR. Identifying and acting on potentially inappropriate care? Inadequacy of current hospital coding for this task. Diving and Hyperbaric Medicine. Diving and Hyperbaric Medicine. 2017 March;47(2):88-96. doi: 10.28920/dhm47.2.88-96. PMID: 28641321. PMCID: PMC6147228.)
Introduction: Recent Australian attempts to facilitate disinvestment in healthcare, by identifying instances of ‘inappropriate’ care from large Government datasets, are subject to significant methodological flaws. Amongst other criticisms has been the fact that the Government datasets utilized for this purpose correlate poorly with datasets collected by relevant professional bodies. Government data derive from official hospital coding, collected retrospectively by clerical personnel, whilst professional body data derive from unit-specific databases, collected contemporaneously with care by clinical personnel.
Aim: Assessment of accuracy of official hospital coding data for hyperbaric services in a tertiary referral hospital.
Methods: All official hyperbaric-relevant coding data submitted to the relevant Australian Government agencies by the Royal Hobart Hospital, Tasmania, Australia for financial year 2010−2011 were reviewed and compared against actual hyperbaric unit activity as determined by reference to original source documents.
Results: Hospital coding data contained one or more errors in diagnoses and/or procedures in 70% of patients treated with hyperbaric oxygen that year. Multiple discrete error types were identified, including (but not limited to): missing patients; missing treatments; ‘additional’ treatments; ‘additional’ patients; incorrect procedure codes and incorrect diagnostic codes. Incidental observations of errors in surgical, anaesthetic and intensive care coding within this cohort suggest that the problems are not restricted to the specialty of hyperbaric medicine alone. Publications from other centres indicate that these problems are not unique to this institution or State.
Conclusions: Current Government datasets are irretrievably compromised and not fit for purpose. Attempting to inform the healthcare policy debate by reference to these datasets is inappropriate. Urgent clinical engagement with hospital coding departments is warranted.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Original article
Full article available here.
Diving Hyperb Med. 2017 June;47(2):97-109. doi: 10.28920/dhm47.2.97-109. PMID: 28641322. PMCID: PMC6147252.
Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care
Devon M Livingstone, Kristine A Smith, Beth Lange
Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, University of Calgary, Alberta, Canada
Corresponding author: Devon Livingstone MD, Division of Otolaryngology – Head and Neck Surgery, Department of Surgery, University of Calgary, 7th floor, 4448 Front Street SE, Calgary, Alberta, Canada, T3M 1M4
Key words
Head and neck; ENT; Injuries; Medical conditions and problems; Barotrauma; Decompression sickness; Review article
Abstract
(Livingstone DM, Smith KA, Lange B. Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care. Diving and Hyperbaric Medicine. 2017 June;47(2):97-109. doi: 10.28920/dhm47.2.97-109. PMID: 28641322. PMCID: PMC6147252.)
Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver’s hearing and balance systems. The majority of diverelated injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Review article
Full article available here.
Diving Hyperb Med. 2017 June;47(2):110-117. doi: 10.28920/dhm47.2.110-117. PMID: 28641323. PMCID: PMC6147229.
Ischaemia-reperfusion injury and hyperbaric oxygen pathways: a review of cellular mechanisms
Ashish Francis, Richard Baynosa
Division of Plastic Surgery, Department of Surgery, University of Nevada School of Medicine, Las Vegas, USA
Corresponding author: Ashish Francis, Division of Plastic Surgery, Department of Surgery, University of Nevada School of Medicine, 1701 W Charleston Blvd, Suite 400, Las Vegas, NV 89102, USA
Key words
Hypoxia; Hyperoxia; Reperfusion injury; Free radicals; Nitric oxide; Ischaemic preconditioning; Review article
Abstract
(Francis A, Baynosa R. Ischaemia-reperfusion injury and hyperbaric oxygen pathways: a review of cellular mechanisms. Diving and Hyperbaric Medicine. 2017 June;47(2):110-117. doi: 10.28920/dhm47.2.110-117. PMID: 28641323. PMCID: PMC6147229.)
Ischaemia-induced tissue injury has wide-ranging clinical implications including myocardial infarction, stroke, compartment syndrome, ischaemic renal failure and replantation and revascularization. However, the restoration of blood flow produces a ‘second hit’ phenomenon, the effect of which is greater than the initial ischaemic event and characterizes ischaemiareperfusion (IR) injury. Some examples of potential settings of IR injury include: following thrombolytic therapy for stroke, invasive cardiovascular procedures, solid organ transplantation, and major trauma resuscitation. Pathophysiological events of IR injury are the result of reactive oxygen species (ROS) production, microvascular vasoconstriction, and ultimately endothelial cell-neutrophil adhesion with subsequent neutrophil infiltration of the affected tissue. Initially thought to increase the amount of free radical oxygen in the system, hyperbaric oxygen (HBO) has demonstrated a protective effect on tissues by influencing the same mechanisms responsible for IR injury. Consequently, HBO has tremendous therapeutic value. We review the biochemical mechanisms of ischaemia-reperfusion injury and the effects of HBO following ischaemia-reperfusion.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Review article
Full article available here.
Diving Hyperb Med. 2017 June;47(2):118-122. doi: 10.28920/dhm47.2.118-122. PMID: 28641324. PMCID: PMC6147224.
Treatment preferences for decompression illness amongst Singapore dive physicians
Valerie Huali Tan1, Kenneth Chin2, Aravin Kumar3, Jeremiah Chng4, Chai Rick Soh5
1 National University Health System, Singapore
2 Diagnostic Radiology, Singapore General Hospital, Singapore
3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
4 Hyperbaric Medicine Section, Navy Medical Service, Republic of Singapore Navy, Singapore
5 Surgical Intensive Care Unit, Hyperbaric and Diving Medicine Centre, Singapore General Hospital
Corresponding author: Valerie H Tan, Hyperbaric and Diving Medicine Centre, c/o 16 College Road, Block 4 Level 1, Singapore General Hospital, Singapore 169854
Key words
Decompression sickness; Cerebral arterial gas embolism (CAGE); Hyperbaric medicine; Hyperbaric oxygen therapy; Recompression; Survey
Abstract
(Tan VH, Chin K, Kumar AA, Chng J, Soh CR. Treatment preferences for decompression illness amongst Singapore dive physicians. Diving and Hyperbaric Medicine. 2017 June;47(2):118-122. doi: 10.28920/dhm47.2.118-122. PMID: 28641324. PMCID: PMC6147224.)
Introduction: Owing to the scarcity of randomized controlled trials to guide treatment for decompression illness (DCI), there are many unanswered questions about its management. Apart from reviews and expert opinion, surveys that report practice patterns provide information about useful management strategies. Hence, this study aimed to identify current treatment preferences for DCI amongst diving physicians in Singapore.
Methods: An anonymous web-based questionnaire was sent to known diving physicians in Singapore. The demographics of the respondents were captured. Respondents were asked about their preferred management for five different DCI scenarios.
Results: The response rate was 74% (17 of 23 responses). All respondents chose to recompress patients described in the five scenarios. Regarding the number of recompression sessions, “one additional session after no further improvement in signs and symptoms” was the most common end point of treatment across all the scenarios (47 of 85 responses). Analgesics would be used by five physicians, three would use lidocaine and two steroids as adjuvant therapies.
Conclusions: Apart from the general agreement that recompression is indicated for DCI, there was no strong consensus regarding other aspects of management. This survey reinforces the need for robust RCTs to validate the existing recommendations for DCI treatment.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: The world as it is
Full article available here.
Diving Hyperb Med. 2017 June;47(2):123-126. doi: 10.28920/dhm47.2.123-126. PMID: 28641325. PMCID: PMC6147222.
Superior canal dehiscence syndrome associated with scuba diving
Naoharu Kitajima1,2, Akemi Sugita-Kitajima1,3, Seiji Kitajima1
1 Kitajima ENT Clinic, Tokyo, Japan
2 Department of Otolaryngology, Tokyo Medical University, Tokyo, Japan
3 Department of Otolaryngology, St. Marianna University School of Medicine, Kanagawa, Japan
Corresponding author: Naoharu Kitajima, Kitajima ENT Clinic, 1-15-15 Tagara Nerima-ku, Tokyo 179-0073, Japan
Key words
ENT; Scuba diving; Injuries; Inner ear; Ear barotrauma; Radiological imaging, Valsalva manoeuvre; Case report
Abstract
(Kitajima N, Sugita- Kitajima A, Kitajima S. Superior canal dehiscence syndrome associated with scuba diving. Diving and Hyperbaric Medicine. 2017 June;47(2):123-126. doi: 10.28920/dhm47.2.123-126. PMID: 28641325. PMCID: PMC6147222.)
A 28-year-old female diver presented with dizziness and difficulty clearing her left ear whilst scuba diving. Her pure-tone audiometry and tympanometry were normal. Testing of Eustachian tube function revealed tubal stenosis. Video-oculography revealed a predominantly torsional nystagmus while the patient was in the lordotic position. Fistula signs were positive. High-resolution computed tomography (HRCT) of the temporal bone revealed a diagnosis of bilateral superior semicircular canal dehiscence (SCDS). Cervical vestibular-evoked myogenic potential (cVEMP) testing showed that the amplitude of the cVEMP measured from her left ear was larger than that from the right. In electronystagmography (ENG), nosepinched Valsalva manoeuvres caused eye movements to be mainly directed counterclockwise with a vertical component. Tullio phenomenon was also positive for both ears. SCDS patients tend to be misdiagnosed and misunderstood; common misdiagnoses in these cases are alternobaric vertigo (AV), inner ear barotrauma, and inner-ear decompression sickness. It is difficult to diagnose vertigo attacks after scuba diving as SCDS; however, when the patient develops sound- and/or pressure-induced vertical-torsional nystagmus, HRCT should be conducted to confirm a diagnosis of SCDS.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Case report
Full article available here.
Diving Hyperb Med. 2017 June;47(2):127-130. doi: 10.28920/dhm47.2.127-130. PMID: 28641326. PMCID: PMC6147225.
A technical diving-related burns case: treatment in a remote location
Fiona C Sharp1, Martin DJ Sayer2
1 Fiona Stanley Hospital, Murdoch, Western Australia
2 West Scotland Centre for Diving and Hyperbaric Medicine, Scottish Association for Marine Science, Dunbeg, Oban, Argyll, Scotland
Corresponding author: Fiona C Sharp, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA 6150, Australia
Key words
Burns; Fire or explosion; First aid; Medical kits; Rebreathers/closed circuit; Remote locations; Case reports
Abstract
(Sharp FC, Sayer MDJ. A technical diving-related burns case: treatment in a remote location. Diving and Hyperbaric Medicine. 2017 June;47(2):127-130. doi: 10.28920/dhm47.2.127-130. PMID: 28641326. PMCID: PMC6147225.)
Injuries suffered as a result of a rebreather oxygen explosion and fire occurred to a diver on vacation in the island state of Chuuk, Micronesia. The medical and logistical management of the diver in a remote location are described. The mechanism of both the fire and the subsequent blast and burn injuries are discussed. Prevention of and preparation for such incidents are discussed in the context of the increasing frequency of dive and adventure travel to remote areas.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Case report
Full article available here.
Diving Hyperb Med. 2017 June;47(2):131-132. doi: 10.28920/dhm47.2.131-132. PMID: 28641327. PMCID: PMC6147755.
Correction to Mathieu D, Marroni A, Kot J: Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving Hyperb Med. 2017 Mar;47(1):24-32.
Daniel Mathieu1, Alessandro Marroni2, Jacek Kot3
1 European Committee for Hyperbaric Medicine: President, Professor of Critical Care Medicine, Critical care Department, Medical University and Hospital of Lille, France
2 European Committee for Hyperbaric Medicine: Vice-President, DAN Europe Research Division, Roseto degli Abruzzi, Italy
3 European Committee for Hyperbaric Medicine: Secretary General, Head of the National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland
Key words
European Committee for Hyperbaric Medicine; Retraction
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Correction
Diving Hyperb Med. 2017 June;47(2):133. doi: 10.28920/dhm47.2.133. PMID: 28641328. PMCID: PMC8349731.
ECHM Consensus Conference and levels of evidence
Susannah Sherlock
Department of Anaesthesia and Department of Hyperbaric Services, Royal Brisbane and Women’s Hospital and University of Queensland
Key words
Hyperbaric oxygen therapy; Medical conditions and problems; Evidence; European Committee for Hyperbaric Medicine; Letters
(to the Editor)
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Letter to the Editor
Full article available here.
Diving Hyperb Med. 2017 June;47(2):134. doi: 10.28920/dhm47.2.134. PMID: 28641329. PMCID: PMC8349730.
Reply: ECHM Consensus Conference and levels of evidence
Daniel Mathieu1, Alessandro Marroni2, Jacek Kot3
1 European Committee for Hyperbaric Medicineand Department of Critical Care, Medical University and Hospital of Lille, France
2 European Committee for Hyperbaric Medicine and DAN Europe Research Division, Roseto degli Abruzzi, Italy
3 European Committee for Hyperbaric Medicine and National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland
Key words
Hyperbaric oxygen therapy; Medical conditions and problems; Evidence; European Committee for Hyperbaric Medicine; Letters
(to the Editor)
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.
Publication Type: Letter to the Editor