Basics
Description
- Administration of 100% oxygen at >1 atm (typically 2 " “3 atm)
- Mechanisms of action:
- Increases oxygen availability at the cellular level:
- Breathing 100% oxygen at 3 atm supplies enough dissolved oxygen to support life without hemoglobin.
- Compresses formed gas bubbles (in cases of air embolism or decompression sickness)
- 2 types of hyperbaric oxygen chambers:
- Monoplace:
- Accommodates 1 supine patient
- Technician outside the chamber for monitoring
- Compressed with 100% oxygen
- Multiplace:
- Holds multiple patients
- Holds attendants who "dive " ¯ with the patients
- Airlocks available for medication/equipment transfer outside of the chamber
- Compressed with air " ”patients breath oxygen by face mask, endotracheal tube, or face hood.
Diagnosis
Signs and Symptoms
Indications for hyperbaric oxygen therapy: ‚
- Arterial gas embolism
- Decompression sickness
- Carbon monoxide toxicity
- Soft tissue infections:
- Clostridial myonecrosis
- Necrotizing fasciitis
- Refractory osteomyelitis
- Chronic nonhealing wounds
- Wound care:
- Radiation-induced tissue injury
- Crush injuries
- Thermal burns
- Compromised skin grafts and flaps
The ED physician should focus on arterial embolism, decompression sickness, and carbon monoxide toxicity as uses for hyperbaric oxygen. ‚
Essential Workup
- Determine need for hyperbaric oxygen therapy as described above.
- Perform a comprehensive physical exam to screen for contraindications to therapy and to establish a pretreatment baseline exam.
- Contraindications to therapy:
- Untreated pneumothorax is the absolute contraindication:
- May convert to a tension pneumothorax
- Cardiovascular instability:
- Unstable patient cannot be treated in a monoplace chamber.
- Such a patient may be treated in multiplace chamber if benefit outweighs risk.
Diagnosis Tests & Interpretation
Lab
Arterial blood gas: ‚
- To evaluate for hypoxia in appropriate cases
Imaging
Chest radiography: ‚
- To evaluate for occult pneumothorax
Treatment
Initial Stabilization/Therapy
- Manage ABCs
- Establish IV access.
- 100% oxygen
- Cardiac monitor (when appropriate)
Ed Treatment/Procedures
- Determine need for hyperbaric oxygen therapy.
- Fill any devices with balloons (Foley catheters, endotracheal tubes) with fluid to avoid rupture during therapy.
- Pretreat patients with any sinus complaints with decongestants.
- Place myringotomy tubes in obtunded or mechanically ventilated patients or in patients with middle ear pathology (e.g., otitis media).
Complications of hyperbaric oxygen therapy: ‚
- Sinus/ear pain
- Barotrauma:
- Ruptured tympanic membranes
- Tension pneumothorax
- Seizures:
- May be a result of oxygen toxicity
- Decompression sickness:
- When decompression is too rapid
- Inability to access an unstable patient when using a monoplace chamber
Follow-Up
Disposition
Admission Criteria
- Arterial gas embolism
- Decompression sickness
- Significant carbon monoxide toxicity
Discharge Criteria
Stable patient with resolved symptoms ‚
Issues for Referral
- May need to transfer to a facility that has a hyperbaric oxygen chamber
- Evaluate risks and benefits when considering the transfer of a potentially unstable patient.
- Divers Alert Network:
- 24 hr emergency hotline for consultation of dive-related injuries
- Referral source for hyperbaric oxygen chambers
- Telephone number:
- Website:
- www.diversalertnetwork.org
Followup Recommendations
Hyperbaric follow-up for repeat recompression therapy. ‚
Pearls and Pitfalls
- Fill any devices with balloons (Foley catheters, endotracheal tubes) with fluid to avoid rupture during therapy.
- Check for occult pneumothorax.
Additional Reading
- Buckley ‚ NA,
Juurlink ‚ DN, Isbister
‚ G, et al. Hyperbaric oxygen for carbon monoxide poisoning.
Cochrane Database Syst Rev.
2011;(4):CD002041. - Guzman, ‚ JA. Carbon monoxide poisoning. Crit Care Clin. 2012;28(4):537 " “548.
- Weaver ‚ LK. Carbon monoxide poisoning. N Engl J Med. 2009;360:1217 " “1225.
See Also (Topic, Algorithm, Electronic Media Element)
- Carbon Monoxide Toxicity
- Decompression Sickness
Codes
ICD9
- 958.0 Air embolism
- 986 Toxic effect of carbon monoxide
- 993.3 Caisson disease
ICD10
- T58.94XA Toxic effect of carb monx from unsp source, undet, init
- T70.3XXA Caisson disease [decompression sickness], initial encounter
- T79.0XXA Air embolism (traumatic), initial encounter
SNOMED
- 18678000 hyperbaric oxygen therapy (procedure)
- 89684003 Bends
- 17383000 Toxic effect of carbon monoxide (disorder)
- 271376002 Air embolism (disorder)