Pressure Injuries

Question 0

Who identified DCS and in what year?

Answer 0

Paul Bert 1878

Question 1

DCS - decompression sickness

Answer 1

Bubbles in the tissues or vessels caused by a reduction in pressure

Question 2

S/Sx of DCS

Answer 2

Malaise, anorexia, fatigue out of line of preceding activity. If no other Sx, consider it a warning.

Question 3

Sx of skin bends

Answer 3

Itching after exposure to compressed air environment, not after immersion.

Question 4

Sx of cutis marmorata

Answer 4

Blotchy red or purple rash, usually over the upper trunk, blanches under direct pressure.

Question 5

Lymphatic DCS Sx

Answer 5

Thought to be caused by blockage of the lymphatics and glands. “Peau d’orange” caused by edema, usually seen in the limbs, parotid, or mammary regions.

Question 6

The “bends” Sx

Answer 6

Most widely occurring form of DCS. Common sites are knees and shoulders. Pain can be mild to severe. Bubbles have formed in the tissues/joints causing pain.

Question 7

Neurological DCS Sx

Answer 7

Any neurological Sx or deficit after exposure to higher pressure: loss of consciousness, “plegias”, vertigo, deafness, tingling, diminished vibratory sense, loss of anal sphincter tone.

Question 8

Sx of the “chokes”

Answer 8

Retrosternal pain which limits deep inspiration, dry cough, shallow/rapid inspirations, theorized to be due to venous gas emboli

Question 9

3 types of DCS

Answer 9

Type 1 - constitutional, skin, pain only
Type 2 - serious neurological sx (Vestibular, sensory, spinal cord, brain)
Type 3 - DCS associated with AGE or VGE (cardiopulmonary Sx - retrosternal pain; dry cough; shallow, rapid respirations - the chokes)

Question 10

Treatment table for type 1 DCS

Answer 10

Treatment table 5

Question 11

Treatment for type 2 or 3 DCS

Answer 11

Treatment table 6

Question 12

AGE

Answer 12

Symptomatic bubbles in the circulatory system or vessels.

Question 13

Causes of AGE

Answer 13

Caused by pulmonary barotrauma during free ascent after breathing compressed air at depth. (Alveolar tear introduces air into pulmonary capillaries. Air is transported by circulation to the brain.)

Also can be caused by lung pathology, penetrating chest trauma.

Question 14

Iatrogenic (nosocomial) methods of AGE formation

Answer 14

Heart/lung machines, cardiac cath, mechanical ventilation, chest tube placement, bronchoscopy, IV air injection, hemodialysis, central venous catheter placement.

Question 15

S/Sx of AGE

Answer 15

Depends on where the bubbles land.

Arterial bubbles that end up in cerebral circulation (CAGE) manifest like a stroke, loss of consciousness, confusion, vertigo, visual deficit, etc. Can end up elsewhere: cardiac arrest.

Question 16

VGE s/Sx

Answer 16

Form same as AGE, but end up in venous system and usually removed without complication.

Massive amounts of bubbles in venous system = chokes.

Question 17

How do VGE get into arterial system?

Answer 17

Patent foramen ovals - opening in the wall between the right atrium (de-oxygenated side) and the left atrium (oxygenated side)

Question 18

Treatment for AGE/VGE

Answer 18

Treatment table 6

Question 19

Pneumothorax - what is it and what causes it

Answer 19

Hole in the lung that allows air to go where it doesn’t belong.

Caused by pulmonary over pressure (Holding breath during ascent-Boyle’s law)

Also caused by trauma, central line insertion or removal.

May occur spontaneously.

Sx- pain in chest, difficulty breathing, increased heart rate, increased ventilator peak pressure if intubated

Question 20

Tension pneumothorax - what is it, s/sx

Answer 20

Enough pressure between the pleura and the lung tissue to cause the lung to collapse - a worse pneumo

Will cause trachea and heart to shift away from the collapsed side. Will cause circulatory blockage to the heart.

No breath sounds on affected side

Question 21

Treatment for pneumothorax

Answer 21

Chest tube or large bore needle insertion. This allows collapsed lung to reinflate and venous return to the heart to be unimpeded.

Question 22

HBO and pneumo

Answer 22

Any pt with chest trauma requires X-ray to confirm no pneumo or resolution of an existing pneumo prior to HBO

Chest tube pts must have Heimlich valve attached.

Any opening in chest needs covered with occlusive dressing - recently removed triple or double lumen IV, recently removed chest tube

Question 23

Pneumomediastinum

Answer 23

Air trapped behind the mediastinum. Comes from ruptured lung.

May be seen with subcutaneous emphysema - air trapped beneath the skin. Normally seen in the upper chest and neck. May cause pressure on the lungs, trachea, heart, great vessels, esophagus, vocal cords. Crepitus.

Question 24

Treatment for pnuemomediastinum and subcutaneous emphysema

Answer 24

100% oxygen at 1 ATA

Question 25

Most common barotrauma in HBO and scuba diving

Answer 25

Middle ear barotrauma

Caused by compressing the vol of gas in the middle ear (Boyle’s law)

Question 26

Ways to open Eustachian tubes

Answer 26

Valsalva, Toynbee, swallowing, or by creating an opening in the tympanic membrane. (Rupture, myringotomy, PE tubes)

Question 27

Patients most likely to have trouble equalizing

Answer 27

Anatomical abnormalities, cleft palate, upper respiratory infection, sinusitis, viral infections, otitis media, allergic rhinitis, radiation.

Pts not conscious or sedated will not be able to clear ears

Question 28

How to help pts with trouble clearing

Answer 28

Teaching, chamber manipulation, pre treat with decongestants, send to ENT for tx or tubes.

Question 29

What is reverse ear squeeze

Answer 29

Caused Eustachian tube dysfunction at end of tx. Can cause alternobaric vertigo.

Question 30

What can happen if a pt performs Valsalva maneuvers too vigorously?

Answer 30

Rupture of the round or oval window, which opens a channel between the inner and middle ear, potentially disturbing auditory function and balance.

Question 31

Sinus pain and HBOT

Answer 31

Blocked sinuses can cause pain on compression. Can be mistaken for tooth pain or barotrauma in upper teeth.

Pretreat with decongestants, nasal steroids.

Hold tx until Sx resolve

Question 32

GI pain prevention

Answer 32

Avoid gas-causing foods, avoid carbonated beverages, admin gas reducing meds, move around, sit up

Question 33

What is barodontalgia

Answer 33

Caused when small amount of trapped gas in a tooth expands on ascent, causing pain.

Happens in teeth with loose or new filings, or recent root canal.

No treatment. Send to dentist

Question 34

Ocular trauma

Answer 34

Occurs when air space in diving masks compresses during descent.

Causes damage to eye lids (edema, swelling, bruising) or conjunctival bleeding.

Potential for hard contact lenses to ocular barotrauma in chamber.