What is a suitable case presentation title for decompression sickness?

Appropriate Case Presentation Title for Decompression Sickness

"Decompression Illness: Bubble Formation During Ascent Leading to Systemic Manifestations" is the most appropriate case presentation title for decompression sickness, reflecting the pathophysiology and clinical presentation of this potentially life-threatening condition 1.

Understanding Decompression Sickness

Decompression sickness (DCS) occurs as a result of bubble formation during or after ascent as inert gas (typically nitrogen) that was dissolved in the diver's tissues at depth comes out of solution 1. This condition typically manifests within 24 hours of a reduction in ambient pressure, most commonly in divers ascending from depths of at least 20 feet (6 meters) 2.

Pathophysiology

• Bubbles form in tissues and circulation during ascent when dissolved inert gas comes out of solution
• Bubbles can cause:
  • Mechanical tissue disruption
  • Occlusion of blood flow
  • Platelet activation
  • Endothelial dysfunction
  • Capillary leakage 2

Clinical Manifestations

Symptoms range in severity and may include:

1. Type I DCS (Less severe):

   • Joint pain ("the bends")
   • Skin manifestations (itching, rash, doughy swellings)
   • Generalized fatigue 3, 4

2. Type II DCS (More severe):

   • Neurological symptoms (motor weakness, ataxia, paresthesia)
   • Pulmonary symptoms ("the chokes" - chest tightness, cough, dyspnea)
   • Cardiovascular collapse
   • Death in severe cases 1, 3, 4

First Aid and Treatment

First Aid

The use of supplementary oxygen by first aid providers with specific training is reasonable for cases of decompression sickness (Class IIa, LOE C-LD) 1. High inspired concentration of oxygen is recommended as first aid for all cases 2.

Definitive Treatment

1. Recompression therapy: The only known and effective treatment is recompression in a hyperbaric chamber while breathing 100% oxygen 3, 5
2. Fluid administration: Isotonic, glucose-free fluids are recommended for prevention and treatment of hypovolemia 2
3. Prophylaxis against venous thromboembolism in paralyzed patients 3

Important Clinical Considerations

Risk Factors

• Rapid ascent
• Inadequate decompression stops
• Repetitive dives
• Exercise during or after diving
• Cold exposure
• Pre-existing pulmonary abnormalities (especially obstructive airway disease) 1

Complications

• Residual neurological deficits may remain even after treatment in serious cases 3
• Recurrent episodes of decompression sickness tend to be more severe than the original incident 1

Special Considerations

• Pulmonary circulation plays a major role in filtering bubbles
• Anatomical shunts (e.g., patent foramen ovale) increase risk of arterial gas embolism 1
• Pulmonary oedema associated with immersion can occur in divers and may present with cough, breathlessness, and hemoptysis 1

Pitfalls to Avoid

1. Delayed treatment: Early recompression significantly improves outcomes
2. Misdiagnosis: Consider DCS in patients with neurological symptoms or joint pain after diving, even if they report following proper decompression protocols 4
3. Factitious DCS: Be aware that some patients may present with factitious symptoms of DCS, though treatment should not be delayed if genuine DCS is suspected 6
4. Inadequate oxygen: First aid should always include 100% oxygen administration when available 2

Remember that decompression sickness requires prompt recognition and treatment to prevent long-term morbidity and mortality. The case presentation title should reflect both the pathophysiology and the systemic nature of this condition.