hyperbaric medicine

Ian Gawthrope

Hospital Grand Round Program

16/10/2015

Hyperbaric medicine

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Fremantle Hyperbaric Unit

Fiona Stanley Hyperbaric Unit

Multiplace chambers

Monoplace chambers

Critical care patients

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History of Hyperbaric Medicine1928 Cunningham built a 64 foot diameter steel hyperbaric ball with five floors at Cleveland Ohio USAPatients lived inside chamber at 2ATA

Scrapped for metal during World War II

Hyperbaric Medicine Unit

Mild Hyperbaric

13http://www.naturalhealthperth.com/hyperbaric-therapy.html

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Burns received when his hair caught fire from fireworks during the making of a Pepsi commercial in 1984. Treated with HBO and eventually bought his own chamber.

Michael Jackson and HBO

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Recognised Indications for Hyperbaric Oxygen• Dysbaric (Bubble) Injury• Decompression Illness• Acute Ischaemic Conditions• Compromised Flaps and Grafts• Crush Injury• Compartment Syndrome• Reperfusion Injury• Infective Conditions• Necrotising Fasciitis• Malignant Otitis Externa• Refractory Osteomyelitis• Refractory Mycoses

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Recognised Indications for Hyperbaric Oxygen

• Delayed Radiation Injury• Osteoradionecrosis• Soft Tissue Radionecrosis• Problem Wounds• Diabetic Ulcers• Venous Ulcers• Decubitus Ulcers• Frostbite• Toxic Gas Poisoning• Carbon Monoxide

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HBO - MECHANISMS OF ACTION

Fiona Stanley Hyperbaric Unitnumber of patient treatments 2532

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Fiona Stanley Hyperbaric Unit

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http://en.wikipedia.org/wiki/Radiation_therapy

Delayed Radiation Injury

The Role of HBO in Delayed Radiation Injury

Lag phase

Angiogenic phase

Plateau phase

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HBO and Delayed Radiation Injury

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Soft tissue radionecrosis• Wound spontaneously broke down 20

years after radiotherapy• Wound healed after 30 HBO and

wound care

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HBO in Wound Healing

Treatment tables

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Side Effects of HBOT• Barotrauma (4% of treatments)

– Middle ear, sinus squeeze• Oxygen toxicity seizures (1 in 1,650)• Pulmonary oxygen toxicity• Temporary worsening of short-

sightedness• Worsening of known cataracts• Claustrophobia• Fire

Fire risk!

Decompression Illness

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Definition

• Decompression illness arises in compressed gas divers, aviators, and astronauts when bubbles form in blood and / or in tissues, during or after a decrease in environmental pressure

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The Gas Law’s

• Boyle’s law: The volume of a gas is inversely proportional to the pressure provided the temperature and mass are constant

• Henry’s law: The amount of any given gas that will dissolve in a liquid at a given temperature is a function of the partial pressure of that gas in contact with the liquid.

History of DCI

• First noted in Caisson workers around 1845 - “Caisson’s Disease”

• Term “Bends” adopted during construction of Brooklyn Bridge in reference to “Grecian Bend” of women

• In 1889 25% of workers on Hudson river tunnel died of DCI. A recompression chamber reduced this to 1.7%

Mechanisms of bubble

formation

Two mechanisms of bubble formation

BUBBLE FORMATION

Dissolved gas Pulmonary barotrauma

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Pulmonary barotrauma

Divers ascend head firstCAGE is primary concern

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Arterial bubbles and the brainMuth CM, Shank ES. New Eng J Med 2000;347:476-82

WBCs

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Presentation of CAGE

• Rapid onset of neurological symptoms– often immediately at surface– unconsciousness in 50%– hemiparesis, monoparesis, sensory changes, visual change,

dysphasia, disorientation, dissociation

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Natural history of CAGE

• 5 - 10% die early• 30% static• 60% spontaneous recovery

• clinical correlate of bubble redistribution

• 50% of those recovering suffer progressive relapse

• clinical correlate of inflammatory events

Two mechanisms of bubble formation

BUBBLE FORMATION

Dissolved gas Pulmonary barotrauma

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Symptoms of DCI

Symptom

% of patients

Symptom

% of patients

Pain 67 Dyspnoea 13

Fatigue 54 Itch 10

Tingling 46 Visual disturbance 8

Headache 46 Rash 7

Numbness 35 Loss of consciousness 5

Weakness 26 Cough 3

Cognitive difficulty 25 Urinary dysfunction 1

Dizziness 20 Other 13

Ataxia 17

Two mechanisms of bubble formation – with a twist!

BUBBLE FORMATION

Dissolved gas Pulmonary barotrauma

Venous blood Arterial blood Tissues

Patent foramen ovale + other shunts

Treatment tables for DCI

Treatment tables for DCI

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Case History 1

• 27 year old male• Recreational diver• Spear fishing on surface supply hookah• 15 metres depth for 15 mins• Rapid ascent whilst reloading spear gun

– Loss of buoyancy• Two further attempts with rapid ascents!

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Case History 1

• Third uncontrolled ascent – on surface confused, with blurred vision and felt unable to move limbs

• Rescued to the boat• Kept supine• Transferred to Busselton ED

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Case History 1

• In ED – no neurological symptoms and felt well

• Complained of chest pain – CT Thorax was normal

• Creatinine 120 • Self discharged

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Case History 1

• Returned 9 hours later• Diffuse abdominal pain• Lactate 10.8• Treated with IV fluids and oxygen after

consulting Hyperbaric team• Lactate normalised• Creatinine 987

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Case History 1

• Transferred to Fremantle Hospital• Diagnosed with ATN• High fractional urinary excretion of 5.5%• Elevated LDH 468 (125-250)• MAG3 scan in keeping with ATN

• No myglobinuria, CK 893 – Rhabdomyolysis induced ATN unlikely

Case History 1Creatinine peaked at 1210

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Case History 1

• Treated with daily Hyperbaric oxygen for seven days

• Creatinine normalised

• Returned to diving• Full recovery

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Take home message

• Don’t hold your breath!• In a diver with any unexplained

symptoms – is diving related until proven otherwise!

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Case History 2

• 57 year old female retired hairdresser• Presented to SCGH ED with 2 day

history of nausea and vomiting, abdominal pain and confusion following a flight home from Malaysia

• PMH - IDDM

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Case History 2

• 2 days prior to her admission– Mixed up hair perming solution in a plastic

water bottle to give to her sister– Forgot it was there and after celebrating

Chinese New Year rushed to the airport– Reminded at airport security about the

bottle– Took a “big gulp”!

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Case History 2

• Didn’t want to miss her plane!• Ignored the burning sensation in her

chest and abdomen• On take-off began to vomit “frothy”

bubbles• Felt confused and couldn’t get to toilet

unaided

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Case History 2

• Medical related person on the flight diagnosed her with gastroenteritis

• Symptoms improved on the descent• Refused the awaiting ambulance

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Case History 2

• Symptoms persisted– Generally confused– Poor balance– Abdominal pain and diarrhoea– Unable to eat and drink

• Admitted for BSL control and ?endoscopy

• CT abdomen - normal

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Case History 2

• Day 3 seen by Clinical toxicology• Transferred for Hyperbaric Oxygen for

presumed CAGE– Flat affect– Unable to stand unaided– Patchy neurological signs

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Case History 2

• Treated with HBO to 2.8ATA• Miracle improvement!!• Walked unaided from chamber after

treatment• Further follow up treatment• Symptom free by end of treatment

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Hydrogen Peroxide Ingestion

• Dissociates on contact with mucosal surfaces to oxygen and water

• 20ml of 35% hydrogen peroxide produces approx 3L of oxygen– Passes into the portal system– Gas can overwhelm the pulmonary filter– Arterial gas emboli

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Take home message

• Don’t always do what airport security say!

• Delayed Hyperbaric treatment can often be helpful

• Consider delayed transfer if flying H2O2 ingestions

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Fiona Stanley Hyperbaric Unit

• 24/7 on call state wide service• Consultant and Registrar• Out of hours – mobile through

switchboard• In hours - contact department on

– 6152 5222

Questions?