REPORT OF THE DECOMPRESSION ILLNESS ADJUNCTIVE THERAPY COMMITTEE OF THE UNDERSEA AND HYPERBARIC MEDICAL SOCIETY Including Proceedings of the Fifty-Third Workshop of the Undersea and Hyperbaric Medical Society Chaired by Richard E. Moon, MD Editor Richard E. Moon, MD Copyright ©2003 Undersea and Hyperbaric Medical Society, Inc. 10531 Metropolitan Avenue Kensington, MD 20895, USA ISBN 0-930406-22-2 The views, opinions, and findings contained herein are those of the author(s) and should not be construed as an official Agency position, policy, or decision unless so designated by other official documentation. Authors Richard D. Vann, Ph.D. Assistant Research Professor of Anesthesiology Duke University Medical Center Director of Research, Divers Alert Network Durham, NC 27710 Edward D. Thalmann, M.D. Assistant Clinical Professor of Anesthesiology Assistant Clinical Professor of Occupational and Environmental Medicine Duke University Medical Center Assistant Medical Director, Divers Alert Network Durham, NC 27710 John M. Hardman, M.D. Professor and Chairman Dept. of Pathology John A. Burns School of Medicine University of Hawaii Honolulu, HI 96822 Ward Reed, M.D., M.P.H. Fellow in Undersea and Hyperbaric Medicine Duke University Medical Center Durham, NC 27710 W. Dalton Dietrich, Ph.D. Departments of Neurological Surgery and Neurology The Miami Project to Cure Paralysis University of Miami School of Medicine Miami, FL 33101 Frank Butler, CAPT, MC, USN Biomedical Research Director Naval Special Warfare Command Pensacola, FL Richard E. Moon, M.D. Professor of Anesthesiology Associate Professor of Medicine Medical Director, Center for Hyperbaric Medicine and Environmental Physiology Duke University Medical Center Medical Director, Divers Alert Network Durham, NC 27710 2 Joseph Dervay, M.D., M.M.S., F.A.C.E.P Flight Surgeon Medical Operations and Crew Systems NASA Johnson Space Center Houston, TX 77058 David S. Warner, M.D. Professor of Anesthesiology Professor of Neurobiology Duke University Medical Center Medical Director, Divers Alert Network Durham, NC 27710 Zhong-jin Yang, M.D. Instructor in Anesthesiology Upstate Medical University Syracuse, NY 13210 Enrico M. Camporesi, M.D. Professor and Chairman Dept. of Anesthesiology Professor of Physiology Upstate Medical University Syracuse, NY 13210 Gary W. Latson, CDR, MC, USNR Senior Medical Officer Submarine Development Squadron Five San Diego, CA 92106-3597 Simon J. Mitchell, M.B. Ch.B., Dip. D.H.M, Ph.D. Dept. of Anaesthetics and Intensive Care Prince of Wales Hospital Sydney, Australia 3 Table of Contents Authors ……………………………………………………………………………………… 2 Acknowledgements …………………………………………………………………………. 5 History of the Decompression Illness Adjunctive Therapy Committee …………………….. 6 Pathophysiological Basis of Decompression Sickness (Richard Vann) …………………….. 9 Decompression Illness and Stroke: Similarities and Differences: A Diving Medical Officer’s Perspective (Ed Thalmann)……………………………………………………21 Discussion 1………………………………………………………………………………… 27 Experimental Decompression Illness: An Animal Model of Focal Brain Injury (John M. Hardman)……………………………………………………………………………….. 31 Discussion 2………………………………………………………………………………… 34 Outcome After Recompression Therapy (Ward Reed)……………………………………...41 Discussion 3………………………………………………………………………………… 50 Pathophysiology of CNS Injury: New Concepts Regarding Treatment (W. Dalton ……… 55 Dietrich) Discussion 4………………………………………………………………………………… 64 Adjunctive Treatment Standards for Decompression Sickness and Gas Embolism: The Special Operations Perspective (Frank Butler)……………………………………. 71 Requirement for Adjunctive Therapy in Recreational Diving (Richard E. Moon)……….... 75 Spaceflight Decompression Sickness Contingency Plan (Joseph Dervay)………………… 79 Discussion 5………………………………………………………………………………… 84 Principles of Physiologic Resuscitation in CNS Injury (David S. Warner)………………... 91 Discussion 6 ……………………………………………………………………………... 104 Protective Role of Propofol in Cerebral Ischemic Injury (Zhong-jin Yang and Enrico M. Camporesi) ………………………………………………………………... 111 Discussion 7.………………………………………………………………………………. 117 Fluid Resuscitation, Plasma Glucose and Body Temperature Control (Richard E. Moon)…………………………………………………………………….. 119 Discussion 8 ………………………………………………………………………………. 122 Use of 100% Surface Oxygen in Treatment of DCI (E.D. Thalmann) …………………… 129 Discussion 9.………………………………………………………………………………. 131 Anticoagulants in Decompression Illness (DCI) (Richard E. Moon).…………………….. 133 Discussion 10 ……………………………………………………………………………... 138 Intravenous Perfluorocarbon Emulsions in the Treatment of Decompression Sickness And Arterial Gas Embolism – A Review of Evidence of Therapeutic Benefit (Gary W. Latson).…………………………………………………………..…….. 145 Discussion 11 ……………………………………………………………………………... 157 Lidocaine (Lignocaine) (Simon J. Mitchell) ……………………………………………... 161 Discussion 12 ……………………………………………………………………………... 172 Corticosteroids in DCI (Richard E. Moon).……………………………………………….. 174 Discussion 13 ……………………………………………………………………………... 176 American Heart Association Guidelines for Clinical Efficacy …………………………… 184 UHMS Guidelines for Adjunctive Therapy of Decompression Illness …………………... 185 Research Priorities for Investigation of Decompression Illness.………………………….. 191 Index ……………………………………………………………………………………… 193 4 Acknowledgements The Undersea and Hyperbaric Medical Society is grateful to the following institutions and individuals: US Special Operations Command and the USSOCOM Biomedical Initiatives Steering Committee for making this project possible. The Center for Hyperbaric Medicine and Environmental Physiology, Duke University Medical Center for hosting the workshop. Ms. Lori Merritt for her considerable help in organizing the workshop and preparing the manuscript. Ms. Carmen Hurst for copy editing Mr. Rick Melvin of the Divers Alert Network for his design work. 5 History of the Decompression Illness Adjunctive Therapy Committee: The Adjunctive Therapy ad hoc Subcommittee was formed in 1998 to investigate and review therapies that could be used in addition to or in lieu of recompression therapy. In 2000 the subcommittee was formally changed to a UHMS standing committee. A grant application had been submitted by Don Chandler on behalf of the UHMS to the US Special Operations Command to (a) Form a standing UHMS committee to review the available literature on treatment of decompression sickness and gas embolism and make recommendations for therapy based on the best clinical series, case reports, and animal studies available; (b) Place special emphasis in this review on the pre-recompression phase of treatment, which may be prolonged in Special Operations; and (c) Make recommendations for specific animal trials that will study the most promising new treatment modalities or otherwise enhance our ability to treat dysbaric disorders. In line with its mission, a workshop was held at Duke University on January 23 and 24, 2002 to discuss current knowledge about decompression illness in humans, animal models, adjunctive therapies and possibilities for research. Participants are listed below: Dr. Peter Bennett (Duke University, Divers Alert Network) Dr. Fred Bove (Temple University) Dr. Frank Butler (BISC USSOCOM) Dr. Jim Chimiak (USN) Mr. Don Chandler (Undersea and Hyperbaric Medical Society) Dr. Joe Dervay (NASA) Dr. Dalton Dietrich (University of Miami) Dr. Rocky Farr (USASOC) Dr. Ed Flynn (USN) Dr. Jake Freiberger (Duke University) Dr. Clay Goodman (Baylor University) Dr. John Hardman (University of Hawaii) Dr. Christian Lambertsen (University of Pennsylvania) Dr. Gary Latson (USN) Dr. Wayne Massey (Duke University) Dr. Simon Mitchell (Wesley Hospital, Brisbane, Australia) Dr. Dale Molé (BUMED) Dr. Richard Moon (Duke University) Dr. Rob Perkins (Duke University and USN) Dr. Claude Piantadosi (Duke University) Dr. Ward Reed (Duke University and USN) Dr. David Southerland (USN) Dr. Ed Thalmann (Duke University) Dr. Richard Vann (Duke University) Dr. David Warner (Duke University) 6 Front Row (left to right): Dr. Gary Latson (US Navy), Dr. Claude Piantadosi (Duke University), Dr. Ed Thalmann (Duke University), Dr. Dale Molé (US Navy), Dr. Frank Butler (US Navy), Dr. Warner “Rocky” Farr (US Army), Dr. Richard Moon (Duke University), Dr. Ward Reed (US Navy and Duke University), Dr. Fred Bove (Temple University), Dr. Rob Perkins (US Navy and Duke University), Mr. Don Chandler (Undersea and Hyperbaric Medical Society), Dr. Jake Freiberger (Duke University), Dr. Richard Vann (Duke University) Back Row (left to right): Dr. Simon Mitchell (Wesley Hospital, Brisbane, Australia), Dr. Ed Flynn (US Navy), Dr. Jim Chimiak (US Navy), Dr. David Southerland (US Navy), Dr. Joe Dervay (NASA), Dr. John Hardman (University of Hawaii), Dr. Dalton Dietrich (University of Miami), Dr. Clay Goodman (Baylor University), Dr. Wayne Massey (Duke University), Dr. Joe Farmer (Duke University), Dr. Guy Dear (Duke University), Dr. Enrico Camporesi (State University of New York at Syracuse), Dr. David Warner (Duke University) Another meeting was held on June 30th, 2002 in La Jolla, CA to further discuss practical recommendations. The following possible interventions were discussed. Preliminary recommendations using the American Heart Association Criteria were also discussed. The guidelines finalized in December 2002 are appended to this proceedings. 7 8 PATHOPHYSIOLOGICAL BASIS OF DECOMPRESSION SICKNESS Richard D Vann Bubbles are implicated as the initiating factor in decompression sickness (DCS), but the disease has many forms and may occur secondary to