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A Case of Untreated Decompression Sickness

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A Case of Untreated Decompression Sickness

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    1. A Case of Untreated Decompression Sickness? Ian Mew

    2. Helicopter Admission GCS 3/15 Breathing

    11. 40 yr male Diving Instructor (Army) Normally fit & well

    12. 50m dive Total dive time 80~min Nitrox - partial re-breather All stops made on ascent Buddy was fine Correct treatment on boat & helicopter

    13. Airway Patent

    14. Breathing 40 min-1 Large tidal volumes Good air entry bilaterally SpO2 = 75%

    15. Circulation Well perfused Rate 120 min-1 BP 130/70 SR with some atrial ectopics BP well maintainedSR with some atrial ectopics BP well maintained

    16. Disability GCS of 3/15 (E1 V1 M1) Pupils 8mm & reactive Pupils noted to be pinpoint by coastguard on arrival at scene ? Occulogyric reaction prior to intubation in A+EPupils noted to be pinpoint by coastguard on arrival at scene ? Occulogyric reaction prior to intubation in A+E

    17. Blood Glucose 7.9mmol l-1 Temp 36.4 RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    19. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    20. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    21. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    22. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    23. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    24. Blood flow throughout the circle of Willis demonstrating no spasm of arteries No aneurysms seen Lateral C-spine = NADBlood flow throughout the circle of Willis demonstrating no spasm of arteries No aneurysms seen Lateral C-spine = NAD

    25. RSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art lineRSI propofol 100, sux 100, inline-intubation (II), Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr Radial art line

    26. Differential Diagnosis Decompression Sickness Aspiration Near Drowning Intra-cranial Event High PEEP 1st lung aspiration sent to micro ARDS net IV antibiotics with held until organism identified Steroids not givenHigh PEEP 1st lung aspiration sent to micro ARDS net IV antibiotics with held until organism identified Steroids not given

    27. Next 48hrs Treated as per latest guidelines for near drowning Head injury management High PEEP 1st lung aspiration sent to micro ARDS net IV antibiotics with held until organism identified Steroids not given Started on phenytoin after clonic movements seen in shoulderHigh PEEP 1st lung aspiration sent to micro ARDS net IV antibiotics with held until organism identified Steroids not given Started on phenytoin after clonic movements seen in shoulder

    28. Rapid resolution tends to suggest against aspirationRapid resolution tends to suggest against aspiration

    29. Loss of grey-white differentiation Cortical necrosis Absence of basal cysterns Sub arachnoid haemorrhageLoss of grey-white differentiation Cortical necrosis Absence of basal cysterns Sub arachnoid haemorrhage

    30. Effacement of ventricles Hypo-dense areas consistent with hypoxic injuryEffacement of ventricles Hypo-dense areas consistent with hypoxic injury

    31. Loss of gyri suggesting raised ICPLoss of gyri suggesting raised ICP

    32. Prognosis extremely poor Intra-cranial bolt insertion is not likely to change managementPrognosis extremely poor Intra-cranial bolt insertion is not likely to change management

    33. Day 3 Marked deterioration Respiratory Cardiovascular Diabetes Insipidus Pyrexial ? Hyperthalamic insult ? temp 40C DI as ?Na ?K & ? ? Urine output? Hyperthalamic insult ? temp 40C DI as ?Na ?K & ? ? Urine output

    34. Day 3 Further severe deterioration that night Treatment withdrawn ? Hyperthalamic insult ? temp 40C DI as ?Na ?K & ? ? Urine output? Hyperthalamic insult ? temp 40C DI as ?Na ?K & ? ? Urine output

    35. Post Mortem Initial arrhythmic event ? Pulmonary Oedema ? Hypoxic Brain Injury CNS Cerebral oedema & small L sided haemorrhagic pontine infarct RESP Severely congested & oedematous in keeping with acute pulmonary oedema CVS Concentric hypertrophy of L ventricle. No IHD. GI Congested liver & spleen otherwise normal CNS Cerebral oedema & small L sided haemorrhagic pontine infarct RESP Severely congested & oedematous in keeping with acute pulmonary oedema CVS Concentric hypertrophy of L ventricle. No IHD. GI Congested liver & spleen otherwise normal

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