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Emergency And Acute Medicine-Hyperbaric Oxygen Therapy
Basics
Description Hyperbaric oxygen therapy (HBOT) involves administration of 100% oxygen at pressures greater than 1 atmosphere (typically 2–3 atm). It increases oxygen delivery at the cellular level; at 3 atm, dissolved oxygen alone can support life without hemoglobin. HBOT also reduces the size of intravascular gas bubbles, making it effective for air embolism and decompression sickness. Two chamber types are used. Monoplace chambers accommodate a single supine patient, are pressurized with 100% oxygen, and monitored externally. Multiplace chambers treat multiple patients simultaneously, allow attendants inside, use air pressurization with oxygen delivered via mask, hood, or endotracheal tube, and permit transfer of equipment through airlocks.
Diagnosis
Indications Primary emergency indications include arterial gas embolism, decompression sickness, and carbon monoxide poisoning. Other indications include clostridial myonecrosis, necrotizing fasciitis, refractory osteomyelitis, chronic nonhealing wounds, radiation-induced tissue injury, crush injuries, thermal burns, and compromised skin grafts or flaps.
Alert In emergency medicine, focus should be on arterial gas embolism, decompression sickness, and carbon monoxide toxicity.
Essential workup Determine whether the clinical condition meets criteria for HBOT. Perform a thorough physical examination to establish a pretreatment baseline and identify contraindications. Absolute contraindication is untreated pneumothorax due to risk of tension pneumothorax. Relative contraindications include cardiovascular instability; unstable patients cannot be treated in monoplace chambers and may only be treated in multiplace chambers if benefit outweighs risk.
Diagnosis tests and interpretation
Laboratory Arterial blood gas to assess hypoxia when clinically indicated.
Imaging Chest radiograph to evaluate for occult pneumothorax prior to therapy.
Treatment
Initial stabilization/therapy Manage airway, breathing, and circulation. Establish IV access, administer 100% oxygen, and apply cardiac monitoring when appropriate.
Emergency department management Confirm indication for HBOT. Fill all balloon-containing devices (e.g., Foley catheters, endotracheal tube cuffs) with fluid to prevent rupture during pressurization. Pretreat patients with sinus congestion using decongestants. Place myringotomy tubes in obtunded or mechanically ventilated patients and in those with middle ear pathology.
Alert Complications include sinus or ear pain, barotrauma (ruptured tympanic membranes, tension pneumothorax), oxygen-toxicity–induced seizures, decompression sickness from rapid decompression, and limited access to unstable patients in monoplace chambers.
Follow-up and disposition
Admission criteria Arterial gas embolism, decompression sickness, and significant carbon monoxide toxicity.
Discharge criteria Stable patients with resolved symptoms after treatment.
Issues for referral Transfer may be required to a facility with hyperbaric capability; risks and benefits must be weighed carefully in unstable patients. The Divers Alert Network provides 24-hour consultation for dive-related injuries (919-684-9111).
Follow-up recommendations Arrange hyperbaric follow-up for repeat recompression therapy if indicated.
Key points Always exclude occult pneumothorax before therapy. Fill balloon-containing devices with fluid prior to pressurization. Emergency use of HBOT is most critical for gas embolism, decompression sickness, and carbon monoxide poisoning.
Basics
Description Hyperbaric oxygen therapy (HBOT) involves administration of 100% oxygen at pressures greater than 1 atmosphere (typically 2–3 atm). It increases oxygen delivery at the cellular level; at 3 atm, dissolved oxygen alone can support life without hemoglobin. HBOT also reduces the size of intravascular gas bubbles, making it effective for air embolism and decompression sickness. Two chamber types are used. Monoplace chambers accommodate a single supine patient, are pressurized with 100% oxygen, and monitored externally. Multiplace chambers treat multiple patients simultaneously, allow attendants inside, use air pressurization with oxygen delivered via mask, hood, or endotracheal tube, and permit transfer of equipment through airlocks.
Diagnosis
Indications Primary emergency indications include arterial gas embolism, decompression sickness, and carbon monoxide poisoning. Other indications include clostridial myonecrosis, necrotizing fasciitis, refractory osteomyelitis, chronic nonhealing wounds, radiation-induced tissue injury, crush injuries, thermal burns, and compromised skin grafts or flaps.
Alert In emergency medicine, focus should be on arterial gas embolism, decompression sickness, and carbon monoxide toxicity.
Essential workup Determine whether the clinical condition meets criteria for HBOT. Perform a thorough physical examination to establish a pretreatment baseline and identify contraindications. Absolute contraindication is untreated pneumothorax due to risk of tension pneumothorax. Relative contraindications include cardiovascular instability; unstable patients cannot be treated in monoplace chambers and may only be treated in multiplace chambers if benefit outweighs risk.
Diagnosis tests and interpretation
Laboratory Arterial blood gas to assess hypoxia when clinically indicated.
Imaging Chest radiograph to evaluate for occult pneumothorax prior to therapy.
Treatment
Initial stabilization/therapy Manage airway, breathing, and circulation. Establish IV access, administer 100% oxygen, and apply cardiac monitoring when appropriate.
Emergency department management Confirm indication for HBOT. Fill all balloon-containing devices (e.g., Foley catheters, endotracheal tube cuffs) with fluid to prevent rupture during pressurization. Pretreat patients with sinus congestion using decongestants. Place myringotomy tubes in obtunded or mechanically ventilated patients and in those with middle ear pathology.
Alert Complications include sinus or ear pain, barotrauma (ruptured tympanic membranes, tension pneumothorax), oxygen-toxicity–induced seizures, decompression sickness from rapid decompression, and limited access to unstable patients in monoplace chambers.
Follow-up and disposition
Admission criteria Arterial gas embolism, decompression sickness, and significant carbon monoxide toxicity.
Discharge criteria Stable patients with resolved symptoms after treatment.
Issues for referral Transfer may be required to a facility with hyperbaric capability; risks and benefits must be weighed carefully in unstable patients. The Divers Alert Network provides 24-hour consultation for dive-related injuries (919-684-9111).
Follow-up recommendations Arrange hyperbaric follow-up for repeat recompression therapy if indicated.
Key points Always exclude occult pneumothorax before therapy. Fill balloon-containing devices with fluid prior to pressurization. Emergency use of HBOT is most critical for gas embolism, decompression sickness, and carbon monoxide poisoning.
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