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"Gas and fat embolic syndrome" involving a mass stranding of beaked whales (family Ziphiidae) exposed to anthropogenic sonar signals.

A study of the lesions of beaked whales (BWs) in a recent mass stranding in the Canary Islands following naval exercises provides a possible explanation of the relationship between anthropogenic, acoustic (sonar) activities and the stranding and death of marine mammals. Fourteen BWs were stranded in the Canary Islands close to the site of an international naval exercise (Neo-Tapon 2002) held on 24 September 2002. Strandings began about 4 hours after the onset of midfrequency sonar activity. Eight Cuvier's BWs (Ziphius cavirostris), one Blainville's BW (Mesoplodon densirostris), and one Gervais' BW (Mesoplodon europaeus) were examined postmortem and studied histopathologically. No inflammatory or neoplastic processes were noted, and no pathogens were identified. Macroscopically, whales had severe, diffuse congestion and hemorrhage, especially around the acoustic jaw fat, ears, brain, and kidneys. Gas bubble-associated lesions and fat embolism were observed in the vessels and parenchyma of vital organs. In vivo bubble formation associated with sonar exposure that may have been exacerbated by modified diving behavior caused nitrogen supersaturation above a threshold value normally tolerated by the tissues (as occurs in decompression sickness). Alternatively, the effect that sonar has on tissues that have been supersaturated with nitrogen gas could be such that it lowers the threshold for the expansion of in vivo bubble precursors (gas nuclei). Exclusively or in combination, these mechanisms may enhance and maintain bubble growth or initiate embolism. Severely injured whales died or became stranded and died due to cardiovascular collapse during beaching. The present study demonstrates a new pathologic entity in cetaceans. The syndrome is apparently induced by exposure to mid-frequency sonar signals and particularly affects deep, long-duration, repetitive-diving species like BWs.

Animals↗

Evidence for gas nuclei in decompressed rats.

In vitro and in vivo studies have shown that pressure treatment before decompression reduces bubble formation. This has been interpreted as evidence that bubbles originate from pre-existing gas nuclei. The present experiments were conducted to determine if pressure treatment during air or liquid breathing before a 2-h air dive would reduce the decompression sickness (DCS) indicence for rats. Control dives, preceded by liquid breathing with 17 and 24 rats to 135- and 150-fsw had DCS incidences of 35% and 29%. Liquid-breathing pressure treatment at 1347 fsw before 135 fsw dive (11 rats) or at 1796 fsw before the 150-fsw dive (24 rats) reduced the incidences to 0% and 8%. In the air-breathing experiments, a 240-fsw control dive with 200 rats gave an 83% incidence. Pressure treatment at 600 fsw (195 rats) or 100 fsw (153 rats) reduced the DCS incidence to 74% and 64%. These experiments suggest that the bubbles responsible for DCS in the rat originate from gas nuclei.

Air↗

The pathophysiologic role of fat in dysbaric osteonecrosis.

Dysbaric osteonecrosis (DON) can occur in humans and sheep after a single hyperbaric air exposure with inadequate decompression. The authors hypothesize that DON does not result from primary embolic or compressive effects of nitrogen bubbles on the osseous vasculature, but by secondary injury to the marrow adipose tissue by rapidly expanding nitrogen gas that triggers local, and possibly systemic, intravascular coagulation. A 28-year-old scallop diver remained at a depth of 92 feet in sea water for 4.5 hours on surface-supplied compressed air. Decompression sickness occurred after a no-stop ascent to the surface, and he died 70 minutes later. Autopsy showed multiple gas bubbles, not only within the great vessels, but in the fatty marrow of his femoral and humeral heads. Lipid and platelet aggregates were found on the surface of marrow bubbles. Fibrin-platelet thrombi were detected within dilated venous sinusoids adjacent to bubbles, and in veins, capillaries, and arterioles. Since pulmonary, renal, and intraosseous (subchondral) fat embolism and fibrin thromboses were observed, it is suggested that injured marrow adipocytes can release liquid fat, thromboplastin, and other vasoactive substances, which conceivably can also play a systemic procoagulant role in triggering disseminated intravascular coagulation and additional DON.

Adipose Tissue↗

[The value of ultrasonic detection of circulating bubbles in animal and man--the contribution to physiopathogenesis of a decompression accident].

The appearance of bubbles in the organism induces events which may lead to the symptom of decompression sickness. In order to detecting these bubbles and to attain a better understanding of their role, we investigated these problems in the mini-pork by using a measuring device based on the Doppler effect. The results show that any hyperbaric stress which oversteps a certain time or depth limit, gives rise to circulating bubbles in the venous system. We therefore developed a portable detector for humans, as well as a quotation method (KM code) for quantifying the different bubble loads. We thus could show that the appearance time for bubbles can be exceedingly long and that intra- and interindividual variability is very high. Bubbles detection is of predictive value and this factor has to be taken into account for possible neurologic injuries.

Animals↗

Rationale for a hyperbaric treatment capability at a Lunar Station.

Missions to establish a permanent presence on the Moon will include a significant amount of extravehicular activity (EVA), which carries the risk of decompression sickness (DCS). Factors which will influence that risk include: cabin and space suit pressure environments, frequency of an activity level during EVA, and the possibility of a loss-of-pressure mishap. These factors were considered for Space Station Freedom (SSF), resulting in the decision to include a hyperbaric airlock capable of treating DCS. Using concepts from operational medicine, the need for such a capability is determined by its influence on mission risk. In comparison to SSF, a Lunar Station will have gravity, a higher EVA rate, physically more DCS provocative EVA, and little, if any, capacity for medical evacuation. Therefore, unless Lunar mission planners can provide pressure environments that offer near zero risk of DCS for nominal operations, a hyperbaric treatment capability should be included.

Aerospace Medicine↗

Cerebral perfusion deficits in dysbaric illness.

Decompression sickness (DCS) is usually categorised as type I (mild; peripheral pain, non-neurological) or type II (serious; neurological). Type II is regarded as predominantly a spinal cord disease with infrequent cerebral involvement. Cerebral perfusion was studied by injection of 99Tcm-hexamethylpropyleneamine oxime and single photon emission tomography in 28 divers with confirmed incidents of DCS and cerebral arterial gas embolism (CAGE). Cerebral perfusion deficits were present in all 23 cases of type II DCS and in all 4 cases of CAGE. No deficits were present in the single case of type I DCS. Type II DCS should be recognised as a diffuse, multifocal, central nervous system disease.

Adolescent↗

Comparisons of performance effectiveness among divers.

Using a criterion of performance effectiveness derived from actual dives made under operational conditions, comparisons were made between U.S. Navy divers identified as high and low in performance effectiveness. Comparison measures included intelligence, anxiety, disciplinary problems, and incidence of decompression sickness (DCS). As expected, the most effective divers made more frequent and more hazardous dives than the least effective divers. In addition they had fewer diving accidents and a lower incidence of DCS. While the most effective divers had lower intelligence scores than the least effective group, both groups were substantially above the Navy average. These findings indicate that intelligence appears to be a critical variable in the career retention of divers, as well as the frequency and types of dives to which divers are exposed. The higher incidence of diving accidents and complications, especially DCS, found among the least effective divers may also have been involved in the lower frequency of diving observed among the members of this group.

Accident Proneness↗

Hematology and blood chemistry in saturation diving: II. Open-sea vs. hyperbaric chamber.

Hematograms, platelet function, and blood-enzyme chemistry were compared in two similar saturation-excursion dives, one conducted in a hyperbaric chamber and the other in the open sea. The chamber dive was more stressful in that it was preceded by a series of bounce decompression dives (one of which produced a 100% incidence of cutaneous pruritus in four subjects) and in that the excursions from saturation depth (60 fsw or 2.818 ATA) were longer and deeper (producing one case of O2 convulsions, one of confirmed decompression sickness, and several of Doppler-detected vascular bubbles). The chamber dive was associated with a marked and significant reduction in circulating platelet count; significant increases in plasma enzyme activities in the victim of O2 toxicity (LDH, CPK) and in one subject with Doppler bubbles and questionable bends symptoms (LDH, GOT, GPT) but not in another; and mild but significant anemia. In the open-water dive, one subject, who developed symptoms of gastroenteritis, showed moderate elevation of LDH, GOT, and GPT activity. No significant change in platelet counts occurred. Both dives were associated with elevated white-cell counts, apparently as a result of numerous minor infections, and reduced sensitivity of platelets of ADP-induced aggregation.

Alanine Transaminase↗

Influence of occupational diving upon the nervous system: an epidemiological study.

Neurological signs and symptoms were recorded from 156 air and saturation divers and 100 controls. Fifty one (33%) of the divers had had symptoms from the central nervous system during decompression. Also, 22 (14%) had been unconscious while diving. In total 79 (51%) had had decompression sickness (DCS). Twelve (8%) of the divers and no controls had had specific neurological symptoms (vision disturbances, vertigo, reduced skin sensitivity) in non-diving situations, and six (4%) of the divers (no controls) had had episodes of cerebral dysfunction (seizures, transient cerebral ischaemia, transient amnesia). The divers had significantly more general symptoms from the nervous system and more abnormal neurological findings than the controls. The most prominent symptoms were difficulties in concentration and problems with long and short term memory. The most prominent abnormal findings in the divers were compatible with dysfunction in the distal spinal cord or nerve roots, and polyneuropathy. The general neurological symptoms and findings were independently significantly correlated with diving exposure, prevalence of DCS, and age.

Adult↗

[Results of aromatherapeutic rehabilitation of women after extended exposure in altitude chamber for recompression treatment].

In recent years recreational diving has gained popularity among women. Occasional decompression sickness and pulmonary barotraumata are cured with the use of recompression tables. To evaluate factors in therapeutic recompression, experiment Rusalka-2004 (Mermaid) was performed with participation of a female crew "descended" at air pressure of 70 m H2O and maintained in hyperoxic (pO2 = 0.45-0.5 kgs/cm2) heliox at 40-0 m H2O for four days. On "ascent" the crew was given a course of aroma rehabilitation. To assess effects of this therapy, entries in a dedicated questionnaire were made and the Spilberger-Khanin SAM (self-appraisal-activity-mood) test and a modification of the Dembau--Rubinshtein self-appraisal method were fulfilled on the daily basis. The best result was achieved in the subjects who were particularly favourable to this sensory stimulation and made own choice of scents of 100% natural essences.

Adult↗

The transportable recompression rescue chamber as an alternative to delayed treatment in serious diving accidents.

This report summarizes experience in the use of a Transportable Recompression Rescue Chamber (TRRC) for one man in the rapid initiation of treatment and evacuation in severe scuba diving accidents. An evacuation system is described which incorporates the centralized management of all diving accidents and standardized TRRCs capable of interlocking under pressure with the stationary medical chamber. Oxygen breathing capability in the TRRC allows the use of up-to-date U.S. Navy oxygen treatment tables. Included are 19 cases of Type II decompression sickness and pulmonary barotrauma with neurological manifestations, most of which occurred at remote diving sites with no nearby walk-in chambers. Case analysis includes distance and means of evacuation, delay in initiating therapy, time spent in TRRC, and initial and final outcome. Together, TRRCs and airborne evacuation to a stationary medical chamber insures a minimal delay between the onset of symptoms and the start of recompression therapy. The use of the TRRC is a prime factor in minimizing delay. No complications associated with the use of TRRCs have been encountered. Ideally, evacuation should be made in a pressurized two-compartment (for a victim and an attendant) chamber. However, if this is not available we strongly advocate the use of one-man pressurized TRRCs over unpressurized evacuation.

Barotrauma↗

Homogeneous nucleation of gas bubbles in vivo.

Several current theories of decompression sickness (DCS) presume the preexistence of gas bubble nuclei in tissue, because the de novo nucleation of gas bubbles in the body is thought to be theoretically impossible. Reexamination of nucleation theory reveals the overwhelming importance of two parameters: gas supersaturation and tissue surface tension (gamma). For the high gamma of pure water nucleation theoretically requires more than 1,000 ATA supersaturation. Lower values of gamma allow nucleation to occur with vastly smaller supersaturations. Application of homogeneous nucleation theory can provide reasonable fits to both rat and human pressure-reduction data with values of gamma within the range reported for biological fluids (below 5 dyn/cm). The initial bubble sizes predicted are 0.1 micron or less. The presence of heterogeneous sites, for example crevices and lipid surfaces, makes nucleation even more likely.

Decompression Sickness↗

Early stopping of aerospace medical trials: application of sequential principles.

A two-period, crossover trial was conducted in the hypobaric chamber on human subjects to compare the influence of inflight exercise (experimental) and restricted activity (control) on altitude decompression sickness (DCS) during simulated extravehicular activities. Out of 39 pairs (total of 78 exposures), 4 cases of DCS occurred under control and 5 occurred under experimental conditions. Analysis of the crossover results showed that the P values for differences in DCS occurrence was 0.56. Under these circumstances, it was necessary to decide whether additional information would be obtained by accruing more subjects. This problem was examined by using a skew sequential design in which the "stopping rule" was based on an alpha of 0.05 (one-sided) and power of 80%. The result of this analysis was in favor of the null hypothesis, and the trial was terminated. The authors recommend the use of similar stopping rules in aerospace trials to optimize sample size without compromising statistical validity.

Adult↗

The oxygen window and decompression bubbles: estimates and significance.

The "oxygen window" causes a partial pressure difference of inert gas between the inside and outside of decompression bubbles. Estimates of Po2 and Pco2 in tissue are necessary for O2 window calculations and any calculations about growth or decay of decompression sickness bubbles, but the estimates involve many uncertainties. Using simplifying assumptions, we estimated the O2 window over a broad range of environments for tissues having a wide range of O2 extractions. The results were as follows: a) the window increases with ambient pressure, but levels off at very high pressure; b) the window is only 1 or 2 kPa for air breathing at extreme altitudes, and 200 kPa or more in hyperbaric environments; c) when O2 is breathed instead of air, the window is as much as 50 times larger at altitude but only about 10 times larger in hyperbaric environments; d) changes in bubble size due to the window decrease as barometric pressure increases; and e) there are seven additional factors which may supplement or oppose the action of the oxygen window.

Altitude↗

The effects of various gases on cortical and spinal somatosensory evoked potentials at pressures up to 10 bar.

The development of dog electrophysiological models for studying the treatment of cerebral arterial air embolism and spinal cord decompression sickness, required that the effects of the treatment gases on spinal and cortical somatosensory evoked potentials (SEP and CEP) be known. We found an inverse linear relationship between CEP amplitude and air pressure to 230 ft. An asymptote was approached when pressure was increased to 300 ft. This effect was not seen with 20% oxy-helium. The waves representing local cord events were depressed to a lesser extent than were the CEPs. We were able to detect an equilibration time in the EP suppression comparable to estimated inert gas wash-in time for the brain. A small depression of CEPs that did not reach significance was seen with exposure to 2.8 bar of oxygen and continuous exposure for up to 120 min caused no further diminution in amplitude than would be caused by time alone.

Air↗

Spectral analysis of bubble sounds in decompressed guinea pigs.

Doppler ultrasonic monitoring was used to detect bubbles in sixteen guinea pigs subjected to a simulated air-dive profile of 9 ATA for 25 minutes. After completion of the decompression, eight subjects did not demonstrate any signs of decompression sickness (DCS), two developed paraplegia and six died. Under sedation, the Doppler ultrasonic bubble detector was placed precordially to record the bubble signals in both pre-dive and post-dive. The recorded signals were analyzed with a high resolution signal analyzer to compare changes between pre-dive and post-dive spectrograms. Bubble signals appeared in the frequency range between 0.64 +/- 0.02 KHz and 6.08 +/- 0.30 KHz. In terms of the net spectral level versus frequency areas (difference between pre-dive and post-dive spectrograms), the mean areas in the paraplegia group and the death group were significantly larger than those in the group without DCS. Therefore, we concluded that the spectral analysis may be an objective and quantitative adjunctive method to the interpretation of Doppler bubble signals.

Animals↗

Diving-related inner ear injuries.

Diving-related inner ear barotrauma (IEB) and inner ear decompression sickness (IEDS) most often result in permanent severe cochleovestibular deficits, unless immediate diagnosis is reached and the correct treatment is commenced early. Nine cases of sport-diving-induced inner ear injuries that were referred to the Israeli Naval Hyperbaric Institute between October 1987 and September 1989 are presented with regard to evaluation, treatment, and follow-up. The diagnosis was IEB in five divers and IEDS in four. Explorative tympanotomy was carried out with remarkable results in two patients with IEB, while the remaining three were relieved by bed rest alone. Three of the four IEDS patients were recompressed according to the extended US Navy Table 6 with good short-term results. The role of complete otoneurological evaluation in the decision-making process leading to the correct diagnosis and treatment is emphasized.

Adolescent↗

Patent foramen ovale: a review of associated conditions and the impact of physiological size.

Patent foramen ovale (PFO) is implicated in platypnea-orthodeoxia, stroke and decompression sickness (DCS) in divers and astronauts. However, PFO size in relation to clinical illness is largely unknown since few studies evaluate PFO, either functionally or anatomically. The autopsy incidence of PFO is approximately 27% and 6% for a large defect (0.6 cm to 1.0 cm). A PFO is often associated with atrial septal aneurysm and Chiari network, although these anatomic variations are uncommon. Methodologies for diagnosis and anatomic and functional sizing of a PFO include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and transcranial Doppler (TCD), with saline contrast. Saline injection via the right femoral vein appears to have a higher diagnostic yield for PFO than via the right antecubital vein. Saline contrast with TTE using native tissue harmonics or transmitral pulsed wave Doppler have quantitated PFO functional size, while TEE is presently the reference standard. The platypnea-orthodeoxia syndrome is associated with a large resting PFO shunt. Transthoracic echocardiography, TEE and TCD have been used in an attempt to quantitate PFO in patients with cryptogenic stroke. The larger PFOs (approximately > or =4 mm size) or those with significant resting shunts appear to be clinically significant. Approximately two-thirds of divers with unexplained DCS have a PFO that may be responsible and may be related to PFO size. Limited data are available on the incidence of PFO in high altitude aviators with DCS, but there appears to be a relationship. A large decompression stress is associated with extra vehicular activity (EVA) from spacecraft. After four cases of serious DCS in EVA simulations, a resting PFO was detected by contrast TTE in three cases. Patent foramen ovales vary in both anatomical and functional size, and the clinical impact of a particular PFO in various situations (platypnea-orthodeoxia, thromboembolism, DCS in underwater divers, DCS in high-altitude aviators and astronauts) may be different.

Aerospace Medicine↗