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LINES A Hartford Hospital publication addressing articles Vol. XII No. 4, Spring 2004 of interest to emergency and critical care personnel standing of each of these gas laws is needed to needed to allow nitrogen to be reabsorbed. If Case Study: dive safely and to treat injuries should they the diver ascends to the surface too rapidly, AIR GAS EMBOLISM occur. nitrogen can bubble out of the blood stream and By Steven Haemmerle, RRT, EMT-P Boyle’s law states that at constant tempera- become lodged in tissues and in the vasculature, ture, the relationship between pressure and resulting in decompression sickness Type I, also n June 8, 2003, the Stonington Fire volume are inversely related. In other words, air known as “the bends.” Divers experiencing DCS Department was dispatched to Ston- within the lungs and sinuses will shrink when a Type I may complain of a slowly progressing Oington Harbor to aid 53 year old diver descends underwater and expand upon pain or numbness in the limbs. Joint pain or pain Stephen Grady, who was found unresponsive and in severe respiratory distress after an early morning scuba dive. Stephen, an experienced commercial diver, was performing a routine salt- water dive at a depth of no greater than ten feet. Immediately following ascent, fellow divers found him apneic, cyanotic and unconscious. Rescue breathing was initiated. Stephen soon became conscious and resumed spontaneous but labored respirations. An air gas embolism (AGE) was suspected and LIFE STAR was requested to transport this patient to Norwalk Hospital for hyperbaric treatment. LIFE STAR physical exam revealed an alert male in moderate respiratory distress. Wheezing was noted in all lung fields and an albuterol neb- ulizer treatment was started. He denied any chest pain or aches in his joints, ears or back. No subcutaneous emphysema was noted. He moved all extremities equally and had no evidence of facial asymmetry. y Hyperbaric Chamber at Hartford Hospital During preparations for flight, Stephen in the muscles or back that worsens with move- suddenly became anxious, combative, air hun- ascent. While breathing compressed gas at ment can also be present. Mild symptoms such gry, cyanotic and dyspneic. He was promptly depth, a diver should never hold his breath as these are not life threatening but may require medicated and intubated, with improved aera- while ascending to the surface because the vol- treatment. DCS Type I may be potentiated by tion to all lung fields resulting. A 12-lead EKG ume of air trapped in the lungs will expand, air travel soon after a dive, or by multiple dives completed during transport showed no acute resulting in a pneumothorax, pneumomedi- per day. ischemic changes. astinum or air gas embolism (AGE). AGE A more severe form of decompression sick- Stephen was ultimately transported to Nor- formation will quickly evolve into unresponsive- ness (DCS Type II) occurs when nitrogen walk Hospital for hyperbaric therapy. His ness or cardiovascular collapse immediately bubbles out of the blood stream and affects the treatment included three “dives” in the hyper- upon ascent. These complications can be avoid- nervous or cardiopulmonary systems. The bub- baric chamber, in addition to comprehensive ed simply by exhaling while slowly ascending to bles can travel to the heart causing cardiac care. He was discharged home several days later the surface. arrest, to the pulmonary vasculature causing res- and has completely recovered from this injury. Henry’s Law describes the ability of a gas to piratory distress or arrest, or to the brain to dissolve into a solution when increased atmos- cause a stroke. Dyspnea, chest pain, severe Discussion: pheric pressure is exerted on the gas and liquid. headache, altered mental status and shock may An example of this is an unopened bottle of occur. Since the formation of these gas bubbles Breathing compressed gas above ambient pres- soda. Few, if any, bubbles are visible before the is related to the time spent underwater and the sure potentially exposes all divers to an array of bottle is opened because the carbonation has depth of the dive, strict adherence to dive table life-threatening injuries including air gas been added to the liquid under pressure. Once depth and time ratios is crucial. embolism (AGE), pneumomediastinum, pneu- the cap is opened, pressure is released and the A thorough history regarding the dive and mothorax, and decompression sickness. The gas bubbles quickly come out of the solution. the relationship to the onset of symptoms is key genesis for each of these types of dive injuries is As a diver breathes compressed gas at in diagnosing a potential dive injury. Important directly related to the physics described by depth, nitrogen becomes dissolved in the blood information to obtain includes: the depth of the Boyle’s and Henry’s gas laws. A thorough under- (Henry’s Law). A slow ascent to the surface is dive; bottom time; decompression stops; past Continued on page 2 A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel 2 Embolism continued from page 1 Another Airway Adjunct: THE BOUGIE diving accidents and past medical history. Phys- ical findings such as hemodynamic instability, By Steven Neher, RN, CEN, EMT-P ficult airway. To use the bougie, laryngoscopy subcutaneous emphysema, decreased function must reveal at least a view of the epiglottis. Once of extremities, difficulty breathing, or altered Poor vocal cord visualization due to debris, the epiglottis is identified, a well-lubricated mental status strongly suggest a life-threatening soft tissue swelling or anatomic variants can make bougie is advanced past this structure with the dive injury and should be addressed during the intubation difficult. Further complicating matters, angled tip pointing anteriorly and midline, allow- primary survey. Abdominal pain, joint pain and patients may be in compromising positions on ing the device to pass through the glottic paralysis are also common signs of this type of scene, neck movement may be contraindicated or opening even when the vocal cords are injury. Although physical exam and history can lighting may be inade- not visible. be highly suggestive of dive injury, differential quate. The LIFE STAR Bougie placement into the trachea is sug- diagnoses such as hypoglycemia and head team has added use of a gested when a washboard or clicking sensation is injury must be considered. gum elastic bougie felt as the bougie tip moves over the tracheal Timely recompression in a hyperbaric (pronounced ‘boo-jee’) rings, or resistance is met as the device encoun- chamber is the only definitive treatment for a to facilitate intubation ters the carina. The bougie should be advanced serious dive injury. Pre-chamber treatment goals when laryngoscopy until the lips fall between the two black parallel are aimed at rapid patient transport to a hyper- provides a less than lines found proximally on the device. At this baric medicine center and supportive care. LIFE optimal view of the depth, the distal tip is beyond the cords and there STAR is often used to meet these goals for crit- glottic opening. is enough length proximally to use the bougie as ical patients. The altitude changes occurring The bougie is a an introducer. Once in proper position, an endo- during typical LIFE STAR transport are not sig- disposable, low cost device made of latex-free tracheal tube is threaded over the bougie and nificant enough to negatively impact a patient polyethylene. Measuring 5 mm in diameter and advanced to an appropriate depth. The bougie is with a dive injury. 60 cm in length, it is a semi-rigid plastic rod that then removed and endotracheal tube placement The Diver’s Alert Network (DAN), is a has a 36 degree angled tip and a rounded end to must be confirmed and secured. tremendous resource for anyone who suspects prevent airway trauma. The small diameter, shape Although not commonly used in the pre- they may have a dive injury, or for health care and elasticity of this device may allow it to pass hospital environment, the bougie has easily providers with acute questions regarding the through the vocal cords more easily than an transitioned into LIFE STAR practice. treatment of dive injured patients. The 24-hour endotracheal tube. Our team has used this lightweight, inexpen- DAN Hotline number is 1-919-684-4326, and The bougie, first described by Macintosh in sive tool on several occasions to secure emergency collect calls are accepted. More 1949, is widely accepted by anesthetists as an a difficult airway. A continued improvement in information about the Diver’s Alert Network alternate method to achieve intubation of the dif- difficult intubation success rates is anticipated. can be found at www.diversalertnetwork.org. Today, hyperbaric medicine is used to treat many different diseases including AGE, DCS, The LIFE STAR Communications Center carbon monoxide poisoning, gas gangrene, crush injuries, wounds resistant healing, blood By John Grenier, Communications Specialist STAR crew. Map books, aviation sectionals, and loss anemia, intracranial abcess, necrotizing soft Delorme Street Atlas Software are all on hand. tissue infections, osteomyelitis, delayed radia- Located in the Emergency Department at The Yeoman, an electronic marine navigation tion injury, compromised skin grafts and Hartford Hospital, the dimly lit LIFE STAR plotter that utilizes various area maps to immedi- thermal burns. In Connecticut, only Norwalk Communications Center buzzes 24 hours a day. ately identify latitudes, longitudes, headings and Hospital and Hartford Hospital offer hyperbar- As the coordination point for two full-time rotor distances, offers quick directional precision. A ic therapy. Norwalk Hospital has offered wing aircraft, 125 Security and Fire Safety Connecticut grid map (a state DOT tourism map hyperbaric care in its mono-place chamber for Department personnel, and the Connecticut printed with a grid overlay) may also be used to years.

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