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Hyperbaric Oxygen Therapy, Emergency Medicine

Basics

Description

- 2 types of hyperbaric oxygen chambers: - Monoplace: - Accommodates 1 supine patient - Technician outside the chamber for monitoring - Compressed with 100% oxygen

- Wound care: - Radiation-induced tissue injury - Crush injuries - Thermal burns - Compromised skin grafts and flaps

- Decompression sickness: - When decompression is too rapid - Inability to access an unstable patient when using a monoplace chamber

  • 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 patientTechnician outside the chamber for monitoringCompressed with 100% oxygenMultiplace:Holds multiple patientsHolds attendants who "dive " ¯ with the patientsAirlocks available for medication/equipment transfer outside of the chamberCompressed 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 myonecrosisNecrotizing fasciitisRefractory osteomyelitisChronic nonhealing wounds
  • Wound care:Radiation-induced tissue injuryCrush injuriesThermal burnsCompromised 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 pneumothoraxCardiovascular 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 membranesTension pneumothorax
  • Seizures:May be a result of oxygen toxicity
  • Decompression sickness:When decompression is too rapidInability 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 injuriesReferral source for hyperbaric oxygen chambersTelephone 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)