Delayed hyperbaric oxygen therapy for severe arterial gas embolism following scuba diving: a case report.

We present the case of a 42-year-old female who was critically ill due to an arterial gas embolism (AGE) she experienced while diving in Maui, Hawaii. She presented with shortness of breath and dizziness shortly after surfacing from a scuba dive and then rapidly lost consciousness. The diver then had a complicated hospital course: persistent hypoxemia (likely secondary to aspiration) requiring intubation; markedly elevated creatine kinase; atrial fibrillation requiring cardioversion; and slow neurologic improvement. She had encountered significant delay in treatment due to lack of availability of local hyperbaric oxygen (HBO2) therapy. Our case illustrates many of the complications that can occur when a patient suffers a severe AGE. These cases may occur even without a history of rapid ascent or risk factors for pulmonary barotrauma, and it is imperative that they be recognized and treated as quickly as possible with HBO2. Unfortunately, our case also highlights the challenges in treating critically ill divers, particularly with the growing shortage of 24/7 hyperbaric chambers able to treat these ICU-level patients.

Recurrence of Neurological Deficits in an F/A-18D Pilot Following Loss of Cabin Pressure at Altitude.

INTRODUCTION: Supersonic, high altitude aviation places its pilots and aircrew in complex environments, which may lead to injury that is not easily diagnosed or simply treated. Decompression illness (either venous or arterial) and environmental conditions (e.g., abnormal gases and pressure) are the most likely adverse effects aircrew often face. Though symptomatic aircrew personnel may occasionally require hyperbaric oxygen treatment, it is rare to require more than one treatment before returning to baseline function. CASE REPORT: This challenging aviation case details the clinical course and discusses the salient physiological factors of an F/A-18D pilot who presented with neurological symptoms following loss of cabin pressure at altitude. DISCUSSION: Most crucial to this discussion was the requirement for multiple hyperbaric oxygen treatments over several days due to recurrence of symptoms. The likelihood of recurrence during and after future flights cannot be estimated with accuracy. This case illustrates a degree of recurrences for neurological symptoms in aviation (hypobaric exposure to hyperbaric baseline environment) that has not previously been described. Robinson T, Evangelista JS III, Latham E, Mukherjee ST, Pilmanis A. Recurrence of neurological deficits in an F/A-18D pilot following loss of cabin pressure at altitude. Aerosp Med Hum Perform. 2016; 87(8):740-744.

A favorable outcome despite a 39-hour treatment delay for arterial gas embolism: case report.

Cerebral arterial gas embolism (CAGE) occurs when gas enters the cerebral arterial vasculature. CAGE can occur during sitting craniotomies, cranial trauma or secondary to gas embolism from the heart. A far less common cause of CAGE is vascular entrainment of gas during endoscopic procedures. We present the case of a 49-year-old male who developed a CAGE following an esophagoduodenoscopy (EGD) biopsy. Due to a delay in diagnosis, the patient was not treated with hyperbaric oxygen (HBO2) therapy until 39 hours after the inciting event. Despite presenting to our institution non-responsive and with decorticate posturing, the patient was eventually discharged to a rehabilitation facility, with only mild left upper extremity weakness. This delay in HBO2 treatment represents the longest delay in treatment to our knowledge for a patient suffering from CAGE secondary to EGD. In addition to the clinical case report, we discuss the etiology of CAGE and the evidence supporting early HBO2 treatment, as well as the data demonstrating efficacy even after considerable treatment delay.

Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor.

BACKGROUND: Electronic cigarettes (e-cigarettes) are a technology that has been touted as a safe and effective alternative to traditional cigarettes. There is, however, a paucity of literature showing the adverse outcomes of e-cigarettes and a correlation with acute eosinophilic pneumonia (AEP). OBJECTIVE: To present a possible association between e-cigarettes and AEP. CASE REPORT: A 20-year-old previously healthy man was found to develop AEP after smoking an e-cigarette. He was treated with antibiotics and steroids and his symptoms improved. CONCLUSION: Though an alternative to traditional cigarettes, e-cigarettes can have unpredictable and potentially serious adverse effects. More research needs to be conducted to determine their safety. If seeing a patient in the ED with pulmonary symptoms after use of e-cigarettes, AEP should be considered in the differential.

Differential diagnosis considerations of sickness after rapid pressure changes at altitude.

INTRODUCTION: Aviation has undergone significant advancement over time; despite our best practices, injuries can still occur. Occasionally aviators will suffer from injuries of barotrauma, decompression sickness, or arterial gas embolism. The history and physical examination are important when evaluating the injury and its subsequent treatment. This article will help readers identify key components of the history and physical examination in a patient to recognize decompression sickness and arterial gas embolism. CASE REPORT: This case report is of a Naval F/A-18C pilot who demonstrated acute and delayed neurologic symptoms when his cockpit underwent four rapid decompression cycles from 11,000 to 29,000 ft (3353 to 8839 m) in a 20-s period. He was subsequently treated with hyperbaric oxygen via a standard U.S. Navy TreatmentTable 6 with complete neurological recovery as determined by his improved neurological abilities. DISCUSSION: Naval aviators are exposed to multiple stresses during flight. When injuries occur it is important to obtain a careful history and physical examination. A broad differential diagnosis, including decompression sickness, hypoxia, and arterial gas embolism, should be considered to ensure prompt and appropriate evaluation and treatment. In this case report, the pilot had acute neurological injuries concerning for arterial gas embolism or an hypoxic episode, as well as a delayed recurrence of symptoms consistent with decompression sickness.

Diplopia due to mask barotrauma.

BACKGROUND: Scuba diving is a very popular and safe sport. Occasionally divers will suffer an injury from barotrauma, decompression sickness or an arterial gas embolism. The history and physical examination are important when determining the etiology of the injury and its subsequent treatment. OBJECTIVES: This article will help readers identify key components of the history and physical examination in a patient to help differentiate between and injury caused by barotrauma or arterial gas embolism. CASE REPORT: This is a case of a diver that was initially felt to have an arterial gas embolism after scuba diving. After obtaining further history and performing a detailed physical exam it was determined that his diplopia was due to barotrauma from his mask. This was confirmed by an orbital computed tomography (CT) scan. SUMMARY: Scuba diving is a very safe sport. When injuries occur it is important to obtain a careful history and physical examination to determine the exact cause of the injury because treatments vary according to the type of injury. In this case, the history and physical examination showed that the only neurologic sign the patient had was diplopia, which is not consistent with a diagnosis of arterial gas embolism. The CT scan helped with the diagnosis because it proved the patient had an orbital hematoma causing his proptosis and double vision.