Thoughts on untreated DCS

[doctormike]

Not to speak for Mike, but he probably meant clinically significant venous bubbles.

You can speak for me any time.

And yes, that's correct....

---------- Post added November 23rd, 2012 at 10:11 PM ----------

Hi Mike,

Perhaps I’ve misunderstood you, but there is a long, substantial and consistent history of published literature showing that some degree of venous gas phase formation/VGEs are echosonographically demonstrable in virtually any decompression, including ascents from very shallow depths and on short bounce dives. While admittedly the vast majority of this venous activity involves small bubble grades that remain asymptomatic (although their effects over a lifetime of diving are subject to some debate), to the best of my knowledge it is not “relatively rare.” Am I missing something?

True dat, but from what I understand (corresponding with people who actually do this for a living), venous bubbles aren't the source of injury in most cases of DCI (that is, DCS or AGE). Remember, I'm an ear-wax-ologist, and my only knowledge of hyperbaric medicine comes from my friends in this forum and from my own injury.

In order for the venous bubbles to be clinically significant, they would have to be large enough to either cause a pulmonary venous emboli or to enter the arterial circulation through some sort of right to left shunt. And if they did enter the left heart, they would more likely cause the stroke-like clinical scenario such as you might see with an AGE, and not necessarily DCS (although as we noted, there is some overlap of symptoms). Again, there are better people than me to go over this with if you want more than my simple understanding of the relevant physiology.

Indeed this is another way to sustain AGE, but it doesn’t exhaust the possibilities. Intrapulmonary anatomical shunts have been reported in healthy humans and widening of the alveolar-to-arterial oxygen gradient with crossover has been reported following mild-to-moderate physical exertion while diving. What think you?

Regards,

Doc

Right - poor phrasing on my part. A PFO is one class of a shunt, which includes other atrial septal defects, intrapulmonary shunts, etc... And you are correct that there can be asymptomatic pulmonary vascular anomalies that result in venous blood bypassing the alveolar capillary beds, which may be exacerbated in some situations. But my understanding is (and I certainly could be wrong!) that divers who sustain an AGE as an actual injury commonly have pulmonary barotrauma.

But again, pretty far from my wheelhouse. DDM? TSandM?

 

[Akimbo]

The evidence is very weak. We don't use it. Sometimes we'll give ibuprofen for residual pain at the end of a treatment once we've determined the diver's response to the treatment.

Questions

1. What are your thoughts on taking aspirin or ibuprofen after diving for what we think is probably muscle pain, but could possibly be DCS?
2. Should we wait X-time before taking one of them to see if more definable DCS symptoms develop?
3. If the pain does not subside after taking one to the degree “we normally expect”, should we be more suspicious of DCS?
4. Aside from potentially masking mild symptoms, is there a downside to taking either OTC medication from a DCS treatment perspective?
5. Do you see any downside for divers that take 1 aspirin/day prophylactically?

 

[Duke Dive Medicine]

Questions

1. What are your thoughts on taking aspirin or ibuprofen after diving for what we think is probably muscle pain, but could possibly be DCS?
2. Should we wait X-time before taking one of them to see if more definable DCS symptoms develop?
3. If the pain does not subside after taking one to the degree “we normally expect”, should we be more suspicious of DCS?
4. Aside from potentially masking mild symptoms, is there a downside to taking either OTC medication from a DCS treatment perspective?
5. Do you see any downside for divers that take 1 aspirin/day prophylactically?

Hi Akimbo,

For 1-4, if DCS is in the differential at all, it's best to be evaluated by a diving physician or, in your sphere, the diver medic. If he/she suspects DCS, hyperbaric treatment would be the priority. Analgesics before or during treatment usually are not indicated because then it's difficult to tell which is working, the hyperbaric oxygen or the medication, and response to hyperbaric treatment is one way to confirm a diagnosis of DCS. For 5, there's no evidence that prophylactic aspirin has any effect on DCS outcomes. Here's a paper on rats, which admittedly are not divers though some would argue that the sets intersect Pharmacological interventions to dec... [Aviat Space Environ Med. 2008] - PubMed - NCBI

Best,
DDM

 

[DocVikingo]

Hey Mike,

November 23, 2012 07.25AM

Hi Mike, Perhaps I’ve misunderstood you, but there is a long, substantial and consistent history of published literature showing that some degree of venous gas phase formation/VGEs are echosonographically demonstrable in virtually any decompression, including ascents from very shallow depths and on short bounce dives. While admittedly the vast majority of this venous activity involves small bubble grades that remain asymptomatic (although their effects over a lifetime of diving are subject to some debate), to the best of my knowledge it is not “relatively rare.”

November 23, 2012 06.50PM

Tru dat, but from what I understand (corresponding with people who actually do this for a living), venous bubbles aren't the source of injury in most cases of DCI (that is, DCS or AGE). Remember, I'm an ear-wax-ologist, and my only knowledge of hyperbaric medicine comes from my friends in this forum and from my own injury.

Now that you’ve made the not unimportant clarification that you meant “clinically significant venous bubbles,” it seems we are entirely in agreement on the issue.

Thanks,

Doc

---------- Post added November 26th, 2012 at 09:28 AM ----------

....Do you see any downside for divers that take 1 aspirin/day prophylactically?

Hi Akimbo,

I've discussed this general topic in a number of earlier inquiries, including in post #37 (January 10th, 2011) of this thread --> http://www.scubaboard.com/forums/diving-medicine/256344-aspirin-diving-4.html. It cites the then brand new study suggesting that aspirin has no prophylactic activity against DCS. There is a piece out there suggesting that another particular NASAID may have beneficial effects on such recompression variables as the number of hyperbaric sessions needed to achieve discharge status, but overall the literature does not support the use of antiplatelet or anti-inflammatory agents as adjuncts in the treatment of routine DCI.

Despite the published science, it is interesting that in some countries, for example France, the majority of recompression facilities do routinely include aspirin in the treatment regimen.

As for any downside to daily aspirin, taken by healthy persons in small to modest doses with food it usually is well-tolerated. However, in a small number of individuals it indeed can and does have adverse effects on a wide variety of body systems --> Aspirin Side Effects | Drugs.com

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[Joe_MB]

Thanks to everyone who replied to my original post.

In the end after consulting with the diving doctor I took two rides on a table 6 (ten very dull hours) which seemed to improve the pain somewhat. However after a few days the pain has returned. I'm going to give it a little while and hope it goes away (if it was just some strange muscle strain that I didn't notice at the time) but if nothing changes then I shall head back to the UK to get me properly checked out.

Cheers

Joe