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1. A Case of Untreated Decompression Sickness? Ian Mew
2.
Helicopter Admission
GCS 3/15
Breathing
11. 40 yr male
Diving Instructor (Army)
Normally fit & well
12. 50m dive
Total dive time 80~min
Nitrox - partial re-breather
All stops made on ascent
Buddy was fine
Correct treatment on boat & helicopter
13. Airway
Patent
14. Breathing 40 min-1
Large tidal volumes
Good air entry bilaterally
SpO2 = 75%
15. Circulation
Well perfused
Rate 120 min-1
BP 130/70 SR with some atrial ectopics
BP well maintainedSR with some atrial ectopics
BP well maintained
16. Disability GCS of 3/15 (E1 V1 M1)
Pupils 8mm & reactive
Pupils noted to be pinpoint by coastguard on arrival at scene
? Occulogyric reaction prior to intubation in A+EPupils noted to be pinpoint by coastguard on arrival at scene
? Occulogyric reaction prior to intubation in A+E
17. Blood Glucose 7.9mmol l-1
Temp 36.4
RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
19. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
20. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
21. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
22. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
23. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
24. Blood flow throughout the circle of Willis demonstrating no spasm of arteries
No aneurysms seen
Lateral C-spine = NADBlood flow throughout the circle of Willis demonstrating no spasm of arteries
No aneurysms seen
Lateral C-spine = NAD
25. RSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art lineRSI propofol 100, sux 100, inline-intubation (II),
Vecuronium 10mg, Midazolam 10mg, IVI propofol 20ml/hr
Radial art line
26. Differential Diagnosis Decompression Sickness
Aspiration
Near Drowning
Intra-cranial Event High PEEP
1st lung aspiration sent to micro
ARDS net
IV antibiotics with held until organism identified
Steroids not givenHigh PEEP
1st lung aspiration sent to micro
ARDS net
IV antibiotics with held until organism identified
Steroids not given
27. Next 48hrs Treated as per latest guidelines for near drowning
Head injury management High PEEP
1st lung aspiration sent to micro
ARDS net
IV antibiotics with held until organism identified
Steroids not given
Started on phenytoin after clonic movements seen in shoulderHigh PEEP
1st lung aspiration sent to micro
ARDS net
IV antibiotics with held until organism identified
Steroids not given
Started on phenytoin after clonic movements seen in shoulder
28. Rapid resolution tends to suggest against aspirationRapid resolution tends to suggest against aspiration
29. Loss of grey-white differentiation
Cortical necrosis
Absence of basal cysterns
Sub arachnoid haemorrhageLoss of grey-white differentiation
Cortical necrosis
Absence of basal cysterns
Sub arachnoid haemorrhage
30. Effacement of ventricles
Hypo-dense areas consistent with hypoxic injuryEffacement of ventricles
Hypo-dense areas consistent with hypoxic injury
31. Loss of gyri suggesting raised ICPLoss of gyri suggesting raised ICP
32. Prognosis extremely poor
Intra-cranial bolt insertion is not likely to change managementPrognosis extremely poor
Intra-cranial bolt insertion is not likely to change management
33. Day 3 Marked deterioration
Respiratory
Cardiovascular
Diabetes Insipidus
Pyrexial ? Hyperthalamic insult ? temp 40C
DI as ?Na ?K & ? ? Urine output? Hyperthalamic insult ? temp 40C
DI as ?Na ?K & ? ? Urine output
34. Day 3 Further severe deterioration that night
Treatment withdrawn ? Hyperthalamic insult ? temp 40C
DI as ?Na ?K & ? ? Urine output? Hyperthalamic insult ? temp 40C
DI as ?Na ?K & ? ? Urine output
35. Post Mortem Initial arrhythmic event
?
Pulmonary Oedema
?
Hypoxic Brain Injury CNS Cerebral oedema & small L sided haemorrhagic pontine infarct
RESP Severely congested & oedematous in keeping with acute pulmonary oedema
CVS Concentric hypertrophy of L ventricle. No IHD.
GI Congested liver & spleen otherwise normal
CNS Cerebral oedema & small L sided haemorrhagic pontine infarct
RESP Severely congested & oedematous in keeping with acute pulmonary oedema
CVS Concentric hypertrophy of L ventricle. No IHD.
GI Congested liver & spleen otherwise normal