Rabu, 06 Juli 2011
Selasa, 05 Juli 2011
SCUBA Medicine: A First-Responder's Guide to Diving Injuries
Author Information
Kaiser Permanente, Harbor City, CA
Address for correspondence: Evan Stuart Bass, MD, Kaiser Permanente, 25965 S. Normandie Ave., Harbor City, CA (E-mail: esbass@aol.com).
Abstract
Self-contained underwater breathing apparatus (SCUBA) diving is an ever-growing sport, and despite a myriad of technological advances to improve safety, it remains dangerous. Providers of medical care for SCUBA divers must have an understanding of diving physiology and potential medical problems that can occur. SCUBA diving also can take participants to remote areas, so being properly prepared for potential emergencies can make a significant difference. The following is a review of diving physiology and the medical problems that can occur in SCUBA divers, along with some suggestions as to how to prepare for a SCUBA excursion.
Introduction
Self-contained underwater breathing apparatus (SCUBA) has become more accessible to the public, with more than five million Americans now diving. Opportunities to learn about diving can vary from a brief course at a hotel resort to a full certification course. Certification courses can be completed in as few as 3 d and also are offered online to divers as young as 12 yr old. Training courses focus on the dynamics of underwater physiology and the inherent risks of diving.
SCUBA medicine is a developing specialty, and physicians should be aware of the serious medical conditions that can occur. This article discusses the physiology behind various diving injuries and medical supplies that may come in handy. It is important that you, as a physician, can recognize a diving injury and be able to treat the patient whether on a tropical vacation or when a patient arrives in the clinic after a recent dive.
Case: While on vacation at the Bikini Atoll, an isolated SCUBA-haven in the Pacific Ocean, a tourist runs up and asks for medical help. As the only physician nearby, you run to the water's edge and discover a SCUBA diver lying on her back, appearing to have a seizure. What do you do?
After contacting an emergency hotline, you realize that the only medical intervention this SCUBA diver has in the next few hours is you. What do you think is affecting this diver? What can you do to stabilize her, and are there any tools at your disposal that can increase her chances of survival?
We will discuss this life-threatening scenario as well as other commonly seen diving injuries as we delve into SCUBA medicine from the perspective of a medical professional and discuss what items should be included in a medical dive bag.
History of Scuba
Since the time of renowned oceanographer Jacques Cousteau, SCUBA diving has become a pastime of millions of Americans. What began with ancient divers using hollow reeds to breath air while underwater later developed into others using metal helmets and bodysuits connected by tubing to oxygen (9).
Diving continued to evolve, battling high underwater pressures and oxygen toxicity, until 1942, when Cousteau and Emile Gagnan invented the modern demand regulator. Their open-circuit device allowed divers to inhale compressed air from a tank and exhale it into the water (9). SCUBA equipment has since become more fine-tuned and now is more readily accessible to the public (10).
Physiology
Recreational SCUBA uses compressed, normal sea-level air for respiration with a composition of approximately 21% oxygen, 78% nitrogen, and 1% other gases. Pure oxygen is not used due to potential toxicity and safety issues (5).
Two important laws regarding gas principles assist the physician in diagnosis and treatment of SCUBA injuries, as well as determining fitness to pursue diving:
1. Henry's Law. The amount of gas that enters a solvent is directly proportional to the partial pressure of that gas. Significance: With increasing depth, the gases present in air dissolve in greater amounts into the tissues of the body. Gases that are easily metabolized (e.g., oxygen) do not cause problems, but gases that are slowly metabolized (e.g., nitrogen) will tend to collect in the tissues (14).
2. Boyle's Law. The volume of gas is inversely proportional to its pressure. This is significant because the SCUBA system delivers air at increasing pressure as the diver goes deeper underwater. If air that is delivered underwater becomes trapped and cannot be released, the air will expand as the diver rises toward the surface (14).
The examining physician must be on the lookout for medical conditions that can trap air, such as Eustachian tube dysfunction, sinus disease, and chronic obstructive pulmonary disease (COPD). If the diver surfaces too quickly, trapped air increases in pressure and/or expands, creating potential barotraumatic damage to the affected area. Also, ascent from depth can cause dissolved gases to vaporize, form bubbles, and expand in the soft tissues. This is the basis of decompression sickness, the symptoms of which depend upon the size and location of these bubbles (14).
Adipose tissue tends to collect nitrogen more, so divers who are overweight should be alerted to their increased risk and need for strict adherence to time and depth limits. Women also have a greater predisposition toward development of decompression sickness for reasons that are not entirely clear (14).
Medical Clearance
The examination and clearance of the recreational SCUBA diver is a controversial subject with many medico-legal implications. Because research in this area is limited, much of the information and recommendations are based on speculation. The physician must have a clear understanding of diving physiology and refer any uncertain situations to an appropriate specialist. An excellent expert-reviewed resource for information regarding the preparticipation examination of the recreational scuba diver is the Guidelines for Recreational Scuba Diver's Physical Examination, created by the Recreational SCUBA Training Council. This document is available for free download at http://WRSTC.com/downloads.php (13).
A vital rule to remember: SCUBA diving has potentially fatal risks, and a distressed diver creates a significant risk for rescuers. The safety of other divers is at stake, so deviation from recommendations must not be tolerated. Instructors and physicians should be thorough and separate in their decisions to allow an individual to pursue diving (6,11).
A thorough predive history and physical should be undertaken with divers of all abilities. In addition to obtaining general past medical and surgical history, the evaluation should focus on several critical physiologic systems (Table 1). Other general considerations include:
1. Ability to breath. A history of emphysema or bullae can lead to pulmonary overinflation on ascent, which can cause air embolus or alveolar rupture.
2. Exercise tolerance. Diving equipment can weigh up to 40 lb, and the ability to both lift this weight and swim with it are important factors to consider prior to diving.
3. Mental status. Panic is a common response underwater; however, abnormal panic or anxiety can impact the diver's response time and course of action.
4. Medications. If certain medications (e.g., antiseizure or antiemetics) are not at therapeutic levels, the diver may lose consciousness, vomit (causing choking), or suffer other dire consequences.
5. Recent health concerns. An upper respiratory infection can lead to a ruptured tympanic membrane due to an inability to equalize pressure in the ears.
Relative contraindications to diving include a history of coronary artery disease (a stress test should be done before clearance), pregnancy (because of the unknown risk of fetal emboli), prior decompression sickness or diving-related injuries, and divers with pacemakers (should be interrogated to ensure the device can withstand increased pressure) (6,11).
Absolute contraindications include cardiac pathology such as hypertrophic cardiomyopathy, seizures or history of stroke, history of spontaneous pneumothorax, gastric outlet obstruction, certain ear/nose/throat disorders, and psychiatric conditions including claustrophobia or untreated panic disorder. All of these can lead to either sudden loss of consciousness, risk to other divers because of a potentially inappropriate response, or increased risk of barotraumas or decompression sickness (6,11).
Diving Injuries
Barotrauma
The most common diving injuries are a result of the pressure environment that divers are exposed to during their descent and ascent. Barotrauma occurs because of the compression or the expansion of air that results in several pathophysiologic changes. Specifically, damage occurs when tissue within a given space is unable to equalize to the pressure of the water (5). The most common barotrauma is related to the ears and sinuses, and the most serious is form is pulmonary barotrauma (8).
Barotrauma of Descent
Middle ear barotrauma, or "ear squeeze," occurs during descent when a diver fails to equalize the pressure between the air in the middle ear and the pressure of the water. As a diver descends, the pressure of the water increases and compresses the small spaces of the middle ear. The unequal pressures can cause pain, vertigo, tinnitus, and hearing loss, and severe cases can rupture the tympanic membrane. Predisposing factors for developing "ear squeeze" include mucosal congestion, mucosal polyps, or prior maxillofacial trauma. Divers should attempt to equalize the pressure on descent with a gentle Valsalva maneuver. Treatment for middle ear barotraumas includes decongestion and abstinence from diving until recovery. In cases of large tympanic membrane perforations, a referral to an ear, nose, and throat (ENT) specialist is appropriate, and antibiotics should be started if there is a rupture with purulent drainage (5,11).
Inner ear barotrauma is damage to the round or oval window, which is often caused by a too-vigorous Valsalva maneuver. This can cause permanent injury to the cochleovestibular system. Symptoms are similar to the "ear squeeze" with pain, vertigo, tinnitus, and hearing loss. The history usually is most helpful in diagnosing a middle ear barotrauma, which includes difficulty equalizing ears, use of forceful Valsalva, and symptoms that are noted immediately after the ascent. The treatment consists of bed rest with elevating head of bed, avoiding Valsalva maneuvers (nose blowing, using stool softeners), and referral to ENT. Early surgical intervention may be indicated for patients with severe hearing loss (5,11).
"Sinus squeeze" is barotrauma that commonly affects the maxillary and frontal sinuses. Patients may experience sinus pain, headache, and epistaxis. Sinus barotrauma is treated with decongestants and possibly antibiotics (5,11).
Barotrauma of Ascent
During a diver's ascent, the environmental pressure from the water is decreased; therefore, air inside the body expands, which causes the lungs to expand. Pulmonary barotrauma occurs when there is overinflation of the lung, which can lead to bursting of alveoli. A well-trained diver purposely exhales during their ascent to allow for the air in their lungs to escape. Patients with obstructive lung disease are at greater risk for lung barotrauma because air is exhaled slower. This type of barotrauma usually results in mediastinal or subcutaneous emphysema. A pneumomediastinum may be seen on chest x-ray but rarely requires specific treatment. Although uncommon, a pneumothorax also may develop, which may require a tube thoracostomy. Consider the diagnosis of a pneumothorax if a patient is complaining of shortness of breath or has diminished breath sounds or tracheal deviation (5,13).
An air embolism is the most severe and life-threatening form of pulmonary barotrauma. It often occurs during a rapid, uncontrolled ascent. In the event of an air embolism, arterial occlusion occurs when air bubbles leak through a ruptured pulmonary vein and enter into the systemic circulation. The brain is the most susceptible organ to an air embolism; therefore, neurological symptoms are the most common presenting sign. Signs of a cerebral arterial gas embolism develop very quickly upon surfacing from the dive (usually within 5 min). Possible symptoms include seizure, loss of consciousness, disorientation, or stroke-like symptoms with hemisensory or motor deficits. In about 4% of cases, immediate apnea and cardiac arrest occur (13).
The treatment for arterial gas embolism includes immediate recompression in a hyperbaric chamber. Outcomes are best if a patient is treated within 4 h of symptoms. Other measures include administering oxygen and intravenous fluids to increase tissue perfusion. If the diver is on a boat and waiting for an ambulance, he or she should be placed in a supine position or, if vomiting, placed in a left lateral decubitus to prevent aspiration. The Divers Alert Network (www.diversalertnetwork.org, 919-684-9111 begin_of_the_skype_highlighting 919-684-9111 end_of_the_skype_highlighting) can provide assistance to provide the location of the nearest decompression facility (4,13).
Decompression sickness, or "the bends," results from bubble formation in the blood and tissue. This occurs during ascent when normally dissolved nitrogen in the tissue forms bubbles. The symptoms can range from muscle aches and fatigue to spinal cord involvement, including weakness and paresthesia. Bubbles also may enter the arterial circulation, which will produce symptoms similar to an air embolism. Decompression sickness is classified into two categories. Type I is nonsystemic or musculoskeletal and usually develops within 6 h. In this type, divers will complain of throbbing and aching joint pain, skin rash, and pruritis. Type II is systemic, which affects the neurologic, vestibular, and pulmonary functions. Patients develop symptoms within 1 h and include dizziness, weakness, and gait abnormalities. Treatment requires recompression in a hyperbaric oxygen chamber in order to decrease the bubbles' size. Supplemental oxygen and IV fluids also should be administered (5,12).
Marine Envenomations
The most common marine envenomation is from the organisms in the Cnidaria category. The Cnidaria are characterized by their stinging, venomous cells called nematocysts. Types include jellyfish, Portuguese man-of-war, box jellyfish, soft corals, and sea anemones. There are over 8,000 species, and about 100 are toxic to humans (1,3).
In the United States, true jellyfish are the most frequently encountered. The presentation is a painful, papular-urticarial eruption at the site of the sting. Treatment should focus on deactivating and removing the nematocysts. Vinegar is the treatment of choice, and the affected area should be immersed in vinegar and soaked for at least 10 min. Rubbing alcohol also has been shown effective, or irrigation with saltwater. Special care should be used when removing the nematocyst from the skin to avoid further venom release. Use a gloved hand to prevent further stings, and do not rub or scrape the area. To assist in nematocyst removal, tweezers and adhesive tape may be helpful. The anecdotal treatments, including alcohol, urine, and meat tenderizer, have not consistently shown success in treating symptoms. Freshwater rinsing is not recommended because it stimulates venomous release, and pressure bandages also are no longer recommended. Other treatment considerations should include basic first aid, pain control, tetanus prophylaxis protocol, and wound care. Prophylactic antibiotics are not required for most stings (1,2,7).
The Portuguese man-of-war is another frequently encountered envenomation. They tend to float at the surface of the ocean and reside in regions of the Pacific, Indian oceans, and the northern Atlantic Gulf stream. In the summer months of Australia, there are reported to be 10,000 human stings each year. The stings are very painful and create red welts on the skin that last for several days. In rare occasions, anaphylactic reaction can occur, which require immediate medical attention. For cutaneous cases, treatment should focus on carefully removing any remaining parts of the Portuguese man-of-war with gloved hands to avoid secondary stinging. Similarly to true jellyfish stings, fresh water can worsen the reaction and should be avoided. Salt water can be applied to the area, and vinegar is controversial in its effectiveness (2,7).
There are several toxic species in the Cnidaria group; however, the Cuboza or box jellyfish (Chironex fleckeri and Carukia barnesi) are some of the most deadly marine organisms. They are found in northern Australia waters but have not been reported in the North America region. The Chironex fleckeri is the most lethal jellyfish in the world, but many of the cases are limited to cutaneous symptoms because the toxin does not penetrate skin well. Skin findings include severe pain with dark reddish-brown whip-like areas. These areas can form blisters and become necrotic within 24 h and remain for over 2 wk. If systemic symptoms occur, they usually present within 20 min and include headache, fever, vomiting, muscle spasm, and respiratory distress (3,7).
The Carukia barnesi is another potentially fatal organism. The initial sting is described as moderate pain at the site of envenomation, but within 30 min, patients will develop systemic symptoms, referred to as the Irukandji Syndrome. This syndrome includes hypertension, tachycardia, agitation, abdominal cramping, nausea, vomiting, severe low-back pain, and possibly pulmonary edema (2).
Treatment for box jellyfish stings is similar to treatments for other Cnidaria, including basic first aid, careful removal of nematocysts, tetanus prophylaxis protocol, and wound care. However, when systemic symptoms occur, patients may require respiratory and cardiovascular support. There is an antivenom for Chironex fleckeri stings, and it is indicated in patients with cardiopulmonary arrest, hypotension, dysrhythmias, altered level of consciousness, difficulty swallowing, or speaking (2).
Another venomous creature a diver may encounter is a stingray. Humans are usually stung on their lower extremities because stingrays hide underneath the sand and will strike after humans accidentally step on them. Envenomation immediately causes severe pain. Rarely, the spine can break off into the wound and causes significant bleeding. Treatment involves irrigation and removal of any pieces of the spine. To help reverse the effects of the venom, the area should be placed in hot water for 30 to 90 min at temperatures as tolerated (up to 113°F). Basic first aid, pain control, tetanus prophylaxis protocol, and wound care also should be addressed (7).
Conclusion
While SCUBA diving remains a fascinating underwater adventure for most participants, physicians need to be aware of the risks of this potentially fatal endeavor. By discussing medical physiology, clearance issues, and common injuries, divers can be prepared for many possible scenarios.
In addition, most diving expeditions take place in exotic but small locales or on boats, far from any nearby advanced medical treatment centers. This quandary puts the onus of medical care on nearby physicians and other health care personnel.
Let's revisit the scenario that we presented in our introduction. You arrive at the edge of the water to discover a SCUBA diver lying down with apparent seizure activity. Your first step is standard first-aid - ABCs (Airway, Breathing, Circulation). While assessing the diver, her partner tells you that the afflicted diver had a rapid ascent from a deep underwater depth. You conclude that the diver is likely suffering from barotrauma causing a possible air embolism. You place the diver in the supine position and look into your medical dive bag (see Table 2 for a list of potentially beneficial supplies). You then administer oxygen and utilize your portable hyperbaric chamber while awaiting further medical help (4).
References
1. Bailey PM, Little M, Jelinek GA, et al. Jellyfish envenoming syndromes: unknown toxic mechanisms and unproven therapies. Med. J. Aust. 2003; 178:34-7.
2. Brush DE. Marine envenomations. In: Flomembaum N, Goldfrank LR, Howland MA, Lewin NA, Hoffman RS, Nelson LS, editors. Goldfrank's Toxicologic Emergencies. 8th ed. New York, NY: McGraw-Hill; 2006. p. 1629-42.
3. Daubert P. Cnidaria Envenomation. E Medicine [Internet]. [Accessed 2010 December 30]. Available from: http://emedicine.medscape.com/article/769538-overview.
4. Divers Alert Network [Internet]. [Accessed 2010 December 30]. Available from: www.diversalertnetwork.org/default.aspx.
5. Hardy K. Diving-related emergencies. Emerg. Med. Clin. N. Am. 1997; 15:223-40.
6. Harrison D, Lloyd-Smith R, Khazei A, et al. Controversies in the medical clearance of recreational SCUBA divers: updates on asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale. Curr. Sports Med. Rep. 2005; 4:275-81.
7. Isbister G, Caldicott D. Trauma and envenomations from marine fauna. In: Tintinalli J, Kelen G, Stapczyncki JS, editors. Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 2004. p. 1206-12.
8. Kaplan J, Eidenberg M. "Barotrauma" E Medicine [Internet]. [Accessed 2010 December 30]. Available from: http://emedicine.medscape.com/article/768618-overview.
9. Lynch J, Bove A. Diving medicine: a review of current evidence. J. Am. Board Fam. Med. 2009; 22:399-407.
10. Martin L. SCUBA Diving Explained - Questions and Answers on Physiology and Medical Aspects of SCUBA Diving. Flagstaff, AZ: Best Pub. Co.; 1997.
11. McMullin A. SCUBA Diving: What you and your patients need to know. Cleve. Clin. J. Med. 2006; 71:711-21.
12. Pulley S. Decompression sickness. E Medicine [Internet]. [Accessed 2010 December 30]. Available from: http://emedicine.medscape.com/article/769717-overview.
13. Recreational SCUBA Training Council. Guidelines for Recreational Scuba Diver's Physical Examination [Internet]. [Accessed 2011 March 14]. Available from: http://WRSTC.com/downloads.php.
14. Snyder B, Neuman T. Dysbarism and complications of diving. In: Tintinalli J, Kelen G, Stapczyncki JS, editors. Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 2004. p. 1213-7.
© 2011 American College of Sports Medicine
http://journals.lww.com/acsm-csmr/Fulltext/2011/05000/SCUBA_Medicine__A_First_Responder_s_Guide_to.8.aspx?WT.mc_id=EMxALLx20100222xxFRIEND
Senin, 04 Juli 2011
Treatment of Children's Epilepsy by Hyperbaric Oxygenation
Proceedings of the Eleventh International
Congress on Hyperbaric Medicine
President: Wen-ren Li, M.D., Fuzhou, People's Republic of China
Secretariat: Frederick S. Cramer, M.D., San Francisco, California, U.S.A.
Treatment of Children's Epilepsy by Hyperbaric Oxygenation:
Analysis of 100 Cases
Wong Qibiao, Wang Hongjun; Chen Linzheng, Zhao Cuiyun
Hyperbaric Oxygen Treatment Centre, Zhou Gulan, EEG Lab, Zhujiang
More than half of epilepsy patients are children. The treatment is difficult because of epilepsy itself and its therapy. In order to find an effective anticonvulsant treatment for children, we began a treatment using hyperbaric oxygen in 1987. The result was satisfactory.
MATERIALS
Sex and age: The whole group included 100 patients (72 males, 28 females), ages 4 days to 14 years. Eighty-four percent of them were between 1 month and 9 years old.
Causes of disease:
The causes in 23 patients were unknown (primary epilepsy), while others had the following established causes:
1. cerebral lesion due to birth injury in 55 patients;
2. encephalitis in 14 patients;
3. high fever in 2 pediatric patients;
4. anoxic cerebropathy in 4 children;
5. brain tumor in 1 child;
6. cerebrovascular malformation in 1 child.
Neuropsychiatric manifestation:
• intelligence was impaired in 68 patients:
• 45 children had mental symptom and personality change;
• local neurosystemic signs were detected in 47 patients.
Family history:
In this group, relatives (within three generations) of 4 patients had a history of epilepsy, while 12 had history of mental disorders. Seven children's parents had consanguineous marriages.
Table 1. Patterns of Seizures
Grand mal 32
Psychomotor seizures 12
Petit mal 10
Focal seizures 44
Autonomic symptoms 2
EEG examination:
All patients in this group had an EEG test. lt was found that
• 92 patients had abnormal EEG’s;
• 66 patients had focal sparkle or sharp wave;
• 10 patients had paroxysmal sparkle-slow wave and sharp-slow wave;
• 6 patients had paroxysmal cerebral dysrhythmias;
• 10 patients had confusing abnormal EEG’s;
• 3 patients had normal EEG’s;
• 5 other patients had boundary EEG’s.
CT and MRI scanning:
Seventy-six patients were proved abnormal, including ventricular enlargement due to atelencephalia, focal encephalatrophy, tumours and local low density pathy, skull fracture. The other 24 patients were normal.
Seizure frequency:
• 21 patients seizured every week;
• 18 patients did every month;
• 23 patients did every two months,
• the other 38 patients seizured more than twice a year.
TREATMENT
Anticonvulsant medication:
• 39 patients were treated systematically
• Twenty patients could be controlled by little diazepam and r-amino butyric acid
• Forty-one patients received no anticonvulsant because of their parents' objection, since they thought the children were too young
• Some individuals were controlled by luminal intramuscular injection on convulsion.
Hyperbaric oxygenation treatment:
The private hyperbaric oxygen chamber was manufactured by Ninpo Hyperbaric-Oxygen Chamber Factory. ln the chamber, the pure oxygen pressure is 1.7-2.0 atmospheres. The patients were treated for 80 minutes every day. A course was 15-30 days. Some patients had therefore been treated 35-45 times.
Curative effect:
• The treatment was found effective in 82 patients (82%), significantly effective ln 68 patients (68%). It showed that the seizures greatly diminished, and the EEG was improved.
• Forty-three patients had stopped anticonvulsant medication, while in other patients the amount of antiepileptic was decreased.
• After hyperbaric oxygenation treatment, 82 patients' intelligence, personality, and mentalities were improved; 51 children studied very well; 10 primary and 4 secondary epilepsy children had no change after being treated 30 times.
Electroencephalogram (EEG):
After hyperbaric oxygenation treatment, 45 patients had normal EEG’s; 28 patients had focal abnormal EEG’s; 3 patients had paroxysmal sharp-slow wave and another 20 patients' EEG’s were slightly abnormal, 4 patients had boundary EEG’s.
Follow-up:
Seventy-six patients had been observed for more than 3 years. Forty children had been completely free of anticonvulsants. Three children had 1 or 2 slight attacks every year. Twenty-five patients were administered a little anticonvulsants and their seizures diminished a lot. The attacks did not change in 11 children with systemic therapy.
DISCUSSION
Questions on pathogeny of children's epilepsy:
The causes of children's epilepsy are varied. Fifty-five of 77 patients (2/3) who had established causes were due to birth injury. How to prevent this is a complicated problem. For those fetuses which we guess are too big to labour normally, we suggest an operation as early as possible, so as to decrease the damage to the brain.
Mechanism of treatment of children's epilepsy with HBO:
Hyperbaric oxygenation could improve the cerebral circulation, provide the brain with more oxygen, and reduce edema. Hyperbaric oxygen could also promote the energy metabolism of cerebral cells and improve the recovery of epileptic foci.
Reduction of handicapped children due to epilepsy:
Epilepsy often impairs the children's intelligence and personality; hyperbaric oxygenation could not only control the attacks of epilepsy but also prevent the occurrence of intelligence impairment and abnormal personality, so as to diminish the ratio of handicapped children due to illness.
The way of gaining a good effect in the treatment:
The effect is good in the cases whose causes are known, especially those caused by brain damage due to birth injury. As to the period of treatment, most patients need 2-3 years. If the infants do not have high fever or respiratory inflammation, the treatment can begin from several days after birth. Fifteen to 20 days make a course, and 2 courses a year
fr: Proceedings of the Eleventh International Congress on Hyperbaric Medicine, diterbitkan ulang oleh dr.Erick Supondha (Hyperbaric & Diving Medicine Consultant) Jakarta, Indonesia
Congress on Hyperbaric Medicine
President: Wen-ren Li, M.D., Fuzhou, People's Republic of China
Secretariat: Frederick S. Cramer, M.D., San Francisco, California, U.S.A.
Treatment of Children's Epilepsy by Hyperbaric Oxygenation:
Analysis of 100 Cases
Wong Qibiao, Wang Hongjun; Chen Linzheng, Zhao Cuiyun
Hyperbaric Oxygen Treatment Centre, Zhou Gulan, EEG Lab, Zhujiang
More than half of epilepsy patients are children. The treatment is difficult because of epilepsy itself and its therapy. In order to find an effective anticonvulsant treatment for children, we began a treatment using hyperbaric oxygen in 1987. The result was satisfactory.
MATERIALS
Sex and age: The whole group included 100 patients (72 males, 28 females), ages 4 days to 14 years. Eighty-four percent of them were between 1 month and 9 years old.
Causes of disease:
The causes in 23 patients were unknown (primary epilepsy), while others had the following established causes:
1. cerebral lesion due to birth injury in 55 patients;
2. encephalitis in 14 patients;
3. high fever in 2 pediatric patients;
4. anoxic cerebropathy in 4 children;
5. brain tumor in 1 child;
6. cerebrovascular malformation in 1 child.
Neuropsychiatric manifestation:
• intelligence was impaired in 68 patients:
• 45 children had mental symptom and personality change;
• local neurosystemic signs were detected in 47 patients.
Family history:
In this group, relatives (within three generations) of 4 patients had a history of epilepsy, while 12 had history of mental disorders. Seven children's parents had consanguineous marriages.
Table 1. Patterns of Seizures
Grand mal 32
Psychomotor seizures 12
Petit mal 10
Focal seizures 44
Autonomic symptoms 2
EEG examination:
All patients in this group had an EEG test. lt was found that
• 92 patients had abnormal EEG’s;
• 66 patients had focal sparkle or sharp wave;
• 10 patients had paroxysmal sparkle-slow wave and sharp-slow wave;
• 6 patients had paroxysmal cerebral dysrhythmias;
• 10 patients had confusing abnormal EEG’s;
• 3 patients had normal EEG’s;
• 5 other patients had boundary EEG’s.
CT and MRI scanning:
Seventy-six patients were proved abnormal, including ventricular enlargement due to atelencephalia, focal encephalatrophy, tumours and local low density pathy, skull fracture. The other 24 patients were normal.
Seizure frequency:
• 21 patients seizured every week;
• 18 patients did every month;
• 23 patients did every two months,
• the other 38 patients seizured more than twice a year.
TREATMENT
Anticonvulsant medication:
• 39 patients were treated systematically
• Twenty patients could be controlled by little diazepam and r-amino butyric acid
• Forty-one patients received no anticonvulsant because of their parents' objection, since they thought the children were too young
• Some individuals were controlled by luminal intramuscular injection on convulsion.
Hyperbaric oxygenation treatment:
The private hyperbaric oxygen chamber was manufactured by Ninpo Hyperbaric-Oxygen Chamber Factory. ln the chamber, the pure oxygen pressure is 1.7-2.0 atmospheres. The patients were treated for 80 minutes every day. A course was 15-30 days. Some patients had therefore been treated 35-45 times.
Curative effect:
• The treatment was found effective in 82 patients (82%), significantly effective ln 68 patients (68%). It showed that the seizures greatly diminished, and the EEG was improved.
• Forty-three patients had stopped anticonvulsant medication, while in other patients the amount of antiepileptic was decreased.
• After hyperbaric oxygenation treatment, 82 patients' intelligence, personality, and mentalities were improved; 51 children studied very well; 10 primary and 4 secondary epilepsy children had no change after being treated 30 times.
Electroencephalogram (EEG):
After hyperbaric oxygenation treatment, 45 patients had normal EEG’s; 28 patients had focal abnormal EEG’s; 3 patients had paroxysmal sharp-slow wave and another 20 patients' EEG’s were slightly abnormal, 4 patients had boundary EEG’s.
Follow-up:
Seventy-six patients had been observed for more than 3 years. Forty children had been completely free of anticonvulsants. Three children had 1 or 2 slight attacks every year. Twenty-five patients were administered a little anticonvulsants and their seizures diminished a lot. The attacks did not change in 11 children with systemic therapy.
DISCUSSION
Questions on pathogeny of children's epilepsy:
The causes of children's epilepsy are varied. Fifty-five of 77 patients (2/3) who had established causes were due to birth injury. How to prevent this is a complicated problem. For those fetuses which we guess are too big to labour normally, we suggest an operation as early as possible, so as to decrease the damage to the brain.
Mechanism of treatment of children's epilepsy with HBO:
Hyperbaric oxygenation could improve the cerebral circulation, provide the brain with more oxygen, and reduce edema. Hyperbaric oxygen could also promote the energy metabolism of cerebral cells and improve the recovery of epileptic foci.
Reduction of handicapped children due to epilepsy:
Epilepsy often impairs the children's intelligence and personality; hyperbaric oxygenation could not only control the attacks of epilepsy but also prevent the occurrence of intelligence impairment and abnormal personality, so as to diminish the ratio of handicapped children due to illness.
The way of gaining a good effect in the treatment:
The effect is good in the cases whose causes are known, especially those caused by brain damage due to birth injury. As to the period of treatment, most patients need 2-3 years. If the infants do not have high fever or respiratory inflammation, the treatment can begin from several days after birth. Fifteen to 20 days make a course, and 2 courses a year
fr: Proceedings of the Eleventh International Congress on Hyperbaric Medicine, diterbitkan ulang oleh dr.Erick Supondha (Hyperbaric & Diving Medicine Consultant) Jakarta, Indonesia
Alat Hiperbarik oksigen terapi
Ruangan Hiperbarik berdasarkan klasifikasi dari National Fire protection Association (NFPA-99 Health care Facilities ) United states, dibagi
1.Kelas A - untuk Manusia, Multiplace chamber atau ruangan hiperbarik yang diperuntukan bagi manusia dengan jumlah lebih dari satu orang dimana ruangan tersebut terdiri dari lebih dari 1 ruangan bisa dua, tiga atau lebih, sehingga jika terjadi kendala atau masalah pada salah satu pasien atau peserta terapi dapat dilakukan penanganan dengan baik tanpa mengganggu pasien yang lain. Selain itu juga masalah kontaminasi penyakit maupun hal lain dapat dipisahkan dengan baik. alat hiperbarik seperti ini adalah yang terbaik jika akan melayani pasien lebih dari 1 orang dalam satu kali pelayanan, sehingga baik tenaga perawat yang menemani didalam maupun yang mengawasi diluar , baik paramedis maupun dokter ahli hiperbarik dapat memberikan bantuan langsung kedalam jika terjadi hal hal yang tidak di inginkan. sebaiknya pasien atau peserta hiperbarik menilai dan menganalisa alat hiperbarik yang baik, aman, dan benar sesuai dengan standar yang berlaku di dunia internasional tentang pelayanan hiperbarik. pikirkan seribu kali jika anda akan melakukan terapi hiperbarik secara bersama sama dalam pengertian dalam satu kali terapi ada lebih dari satu orang dalam satu ruangan secara bersamaan, pastikan apakah ruangan hiperbarik itu merupakan multiplace chamber yang memiliki ruangan lebih dari satu didalammnya, jika bukan pikirkan jika terjadi sesuatu di dalam terhadap salah satu pasien atau peserta terapi, apa yang bisa dilakukan. Hati hati pasien yang lain akan gagal terapi paling ringan resikonya. tp jk pasien yang mengalami itu memiliki masala serius bisa saja akan naik ke permukaan dan kita bisa terkena penyakit dekompresi. Sekali lagi pastikan jika anda melakukan terapi hiperbarik lebih dari satu orang maka ruangannya pun harus lebih dari satu ruangan didalamnya.
2.Kelas B manusia (monoplace chamber): ruangan hiperbarik seperti ini diperuntukan bagi manusia dengan kapasitas satu orang atau tunggal didalamnya. dan biasanya pasien sendiri didalam tidak ditemani oleh tenaga medis. tenaga edis hanya mengawasi dan memantau dari luar. semua instruksi, peralatan pendukung dan kendali ada diliuar.
3. Kelas C Binatang bukan untuk manusia.
Jadi ruangan hiperbarik itu ada 3 janis, pertama jenis multiple place berarti diperuntukan untuk lebih dari satu orang. hati hati jika ada ruangan hiperbarik atau alat hiperbarik yang hanya memiliki satu ruangan tetapi melayani pasien atau orang lebih dari 1 orang. pertimbangkan dengan baik dan bijaksana untuk keselamatan anda.
berikutnya ruangan hiperbarik monoplace untuk satu orang. jadi jika dialam ruangan hiperbarik hanya memiliki satu ruangan walaupun besar sebaiknya diperuntukan untuk satu orang. demi keselamatan pasien atau peserta hiperbarik.
berikutnya adlah ruangan hiperbarik untuk binatang.
Hal yang dijelaskan diatas baru satu asfek penting bagi kita jika ingin menjalankan terapi hiperbarik. hal lainnya yang sebaiknya para pasien atau peserta hiperbarik ketahui adalah :
I. Ketenagaan :
1. apakah unit hiperbarik ini di awasi dan dibimbing oleh dokter ahli hiperbarik
2. apakah perawat pelaksana yang mengendalikan dan menjadi pendamping merupakan perawat yang telah mendapat pendidikan di bidang hiperbarik atau hanya sekedar perawat yang tidak mendapatkan pelatihan hiperbarik. ( hati hati mereka hanya bisa menjalankan alat tanpa tahu maksud dan tujuannya, apa dan bagaimana yg terjadi jika mereka melakukan sesuatu mereka tidak mengerti, bahkan buat keselamatan diri mereka sendiri dan temannya pun mreka tidak tahu apa yg akan terjadi, beberapa kecelakaan terhadap para perawat seperti ini sudah beberapa kali terjadi di beberap fasilitas hiperbarik milik swasta).
3. apakah ada teknisi yang ahli dibidang hiperbarik yang selalu mengawasi jalannya peralatan hiperbarik. Beberapa ada yang tidak diawasi, beberapa lagi ada tp bukan teknisi hanya sekedar tenaga yg tidak berpendidikan atau mengerti tehnik ttg hiperbarik, yg duduk disana (banyak pada asilitas hiperbarik yang dikelola swasta).
II. Pengawasan atau pengendalian sebelum menjalankan terapi hiperbarik
1. apakah dilakukan pemeriksaan oleh dokter terhadap semua hal yang merupakan kontra indikasi untuk dapat melakuan terapi hiperbarik.
2. apakah dilakukan pemeriksaan foto rontgent dada sebagai seleksi terhadap seseorang apakah laya dan aman ntuk melakukan terapi hiperbarik
3. adakah panduan dari dokter atau paramedis tentang langah yang harus dilakukan dalam program terapinya. juga tentang penyakit penyakit dan obat obatan yang merupakan kontra indikasi untu terapi hiperbarik
hati hati jika tidak dilakukan hal hal seperti diatas, bukan kesehatan atau kesembuhan yang anda dapat tetapi fatality atau kecelakaan yg akan menimpa anda. Sebaiknya konsultasikan dengan rinci tentang penyakit yang anda derita tentang obat obatan yang anda konsumsi jangan sampai anda melakukan terapi hiperbarik tanpa pengawasan dokter maka masalah yang akan anda alami mungkin akan berakibat buruk buat anda. knosultasikanlah segalanya kepada dokter ahli hiperbarik apa yang boleh dan tidak boleh anda lakukan dan konsumsi selama anda menjalani terapi hiperbarik. dan berapa lama program yg dianjurkan oleh dokter ahli hiperbarik tersebut.( hati hati karena masih langkanya dokter hiperbarik banyak rumah sakit dan pengusaha hanya menyediakan dokter dokter umum yang tidak memiliki kompetensi di bidang hiperbarik yang akan melayani anda !!!!).
III. peralatan pendukung
jika bisa coba anda perhatikan peralatan pendukung apakah sudah memenuhi standar keamanan menurut anda. misalkan
1.katup katup yang dipakai sudah sesuai untuk peruntukannya, jangan sampai anda melakukan terapi hiperbarik dimana katup katup yang mengalirkan udara tekanan tinggi menggunakan katup yang biasa kita jumpai di matrial bangunan atau yang biasa dipakai untuk keperuan rumah tangga di kamar mandi. apakah oksigen yang dipakai betul oksigen 100%, oksigennya cair atau gas ( yg baik adalah oksigen cair, buat pengusaha oksigen cair boros dan mahal)
2.Kompresornya apakah sudah sesuai dengan kompresor untuk hiperbarik, anda gak sulit untuk mengetahuinya. jika kompresor itu anda belum pernah lihat bentuknya dan agak aneh biasanya kompresor itu sesuia standar, tp jika anda melihat kompresornya sering anda lihat di pnggir jalan, tukang cat pinggir jalan pakai, mereknya pun banyak di matrial atau toko bangunan, supermarket bangunan biasanya alat itu gak standar.
3. Masker yang anda pakai apakah standar, caranya gampang jika anda sering lihat bentuk masker seperti itu dan salurannya juga banyak dijual untuk peralatan rumah tangga hati hati biasanya tidak standar. tp jika maskernya seperti pilot pesawat kemungkinan masker tersebut sesuai standar. (biasa dipakai di RSAL maskr spt ini)
4. alat pendukung medis
apakah alat pendukung medis tersedia di dalam dan diluar ruangan hiperbarik. jika tidak ada, anda harus berhati hati terhadap faslitas hiperbarik seperti ini. keamanan anda yang lebih utama. cari tahu dan konsultasikan dengan ahlinya.
IV. Keluhan yg dialami
1. selesai terapi hiperbarik pusing, mual, nyeri telinga, hati hati terhadap kualitas alat hiperbariknya.
sedikit berbagi demi keselamatan kita bersama. kita perlu hati hati bukan berarti mencugiai. waspada terhadap keselamatan diri sendiri berdasarkan analisa anda dari informasi para ahli bukan dari pedagang merupakan hal penting yg perlu dilakukan.
selamat melakukan terapi hiperbarik dan hati hati !!!!!!
fr. dr. Erick Supondha
Hyperbaric & Diving Medicine Consultant
1.Kelas A - untuk Manusia, Multiplace chamber atau ruangan hiperbarik yang diperuntukan bagi manusia dengan jumlah lebih dari satu orang dimana ruangan tersebut terdiri dari lebih dari 1 ruangan bisa dua, tiga atau lebih, sehingga jika terjadi kendala atau masalah pada salah satu pasien atau peserta terapi dapat dilakukan penanganan dengan baik tanpa mengganggu pasien yang lain. Selain itu juga masalah kontaminasi penyakit maupun hal lain dapat dipisahkan dengan baik. alat hiperbarik seperti ini adalah yang terbaik jika akan melayani pasien lebih dari 1 orang dalam satu kali pelayanan, sehingga baik tenaga perawat yang menemani didalam maupun yang mengawasi diluar , baik paramedis maupun dokter ahli hiperbarik dapat memberikan bantuan langsung kedalam jika terjadi hal hal yang tidak di inginkan. sebaiknya pasien atau peserta hiperbarik menilai dan menganalisa alat hiperbarik yang baik, aman, dan benar sesuai dengan standar yang berlaku di dunia internasional tentang pelayanan hiperbarik. pikirkan seribu kali jika anda akan melakukan terapi hiperbarik secara bersama sama dalam pengertian dalam satu kali terapi ada lebih dari satu orang dalam satu ruangan secara bersamaan, pastikan apakah ruangan hiperbarik itu merupakan multiplace chamber yang memiliki ruangan lebih dari satu didalammnya, jika bukan pikirkan jika terjadi sesuatu di dalam terhadap salah satu pasien atau peserta terapi, apa yang bisa dilakukan. Hati hati pasien yang lain akan gagal terapi paling ringan resikonya. tp jk pasien yang mengalami itu memiliki masala serius bisa saja akan naik ke permukaan dan kita bisa terkena penyakit dekompresi. Sekali lagi pastikan jika anda melakukan terapi hiperbarik lebih dari satu orang maka ruangannya pun harus lebih dari satu ruangan didalamnya.
2.Kelas B manusia (monoplace chamber): ruangan hiperbarik seperti ini diperuntukan bagi manusia dengan kapasitas satu orang atau tunggal didalamnya. dan biasanya pasien sendiri didalam tidak ditemani oleh tenaga medis. tenaga edis hanya mengawasi dan memantau dari luar. semua instruksi, peralatan pendukung dan kendali ada diliuar.
3. Kelas C Binatang bukan untuk manusia.
Jadi ruangan hiperbarik itu ada 3 janis, pertama jenis multiple place berarti diperuntukan untuk lebih dari satu orang. hati hati jika ada ruangan hiperbarik atau alat hiperbarik yang hanya memiliki satu ruangan tetapi melayani pasien atau orang lebih dari 1 orang. pertimbangkan dengan baik dan bijaksana untuk keselamatan anda.
berikutnya ruangan hiperbarik monoplace untuk satu orang. jadi jika dialam ruangan hiperbarik hanya memiliki satu ruangan walaupun besar sebaiknya diperuntukan untuk satu orang. demi keselamatan pasien atau peserta hiperbarik.
berikutnya adlah ruangan hiperbarik untuk binatang.
Hal yang dijelaskan diatas baru satu asfek penting bagi kita jika ingin menjalankan terapi hiperbarik. hal lainnya yang sebaiknya para pasien atau peserta hiperbarik ketahui adalah :
I. Ketenagaan :
1. apakah unit hiperbarik ini di awasi dan dibimbing oleh dokter ahli hiperbarik
2. apakah perawat pelaksana yang mengendalikan dan menjadi pendamping merupakan perawat yang telah mendapat pendidikan di bidang hiperbarik atau hanya sekedar perawat yang tidak mendapatkan pelatihan hiperbarik. ( hati hati mereka hanya bisa menjalankan alat tanpa tahu maksud dan tujuannya, apa dan bagaimana yg terjadi jika mereka melakukan sesuatu mereka tidak mengerti, bahkan buat keselamatan diri mereka sendiri dan temannya pun mreka tidak tahu apa yg akan terjadi, beberapa kecelakaan terhadap para perawat seperti ini sudah beberapa kali terjadi di beberap fasilitas hiperbarik milik swasta).
3. apakah ada teknisi yang ahli dibidang hiperbarik yang selalu mengawasi jalannya peralatan hiperbarik. Beberapa ada yang tidak diawasi, beberapa lagi ada tp bukan teknisi hanya sekedar tenaga yg tidak berpendidikan atau mengerti tehnik ttg hiperbarik, yg duduk disana (banyak pada asilitas hiperbarik yang dikelola swasta).
II. Pengawasan atau pengendalian sebelum menjalankan terapi hiperbarik
1. apakah dilakukan pemeriksaan oleh dokter terhadap semua hal yang merupakan kontra indikasi untuk dapat melakuan terapi hiperbarik.
2. apakah dilakukan pemeriksaan foto rontgent dada sebagai seleksi terhadap seseorang apakah laya dan aman ntuk melakukan terapi hiperbarik
3. adakah panduan dari dokter atau paramedis tentang langah yang harus dilakukan dalam program terapinya. juga tentang penyakit penyakit dan obat obatan yang merupakan kontra indikasi untu terapi hiperbarik
hati hati jika tidak dilakukan hal hal seperti diatas, bukan kesehatan atau kesembuhan yang anda dapat tetapi fatality atau kecelakaan yg akan menimpa anda. Sebaiknya konsultasikan dengan rinci tentang penyakit yang anda derita tentang obat obatan yang anda konsumsi jangan sampai anda melakukan terapi hiperbarik tanpa pengawasan dokter maka masalah yang akan anda alami mungkin akan berakibat buruk buat anda. knosultasikanlah segalanya kepada dokter ahli hiperbarik apa yang boleh dan tidak boleh anda lakukan dan konsumsi selama anda menjalani terapi hiperbarik. dan berapa lama program yg dianjurkan oleh dokter ahli hiperbarik tersebut.( hati hati karena masih langkanya dokter hiperbarik banyak rumah sakit dan pengusaha hanya menyediakan dokter dokter umum yang tidak memiliki kompetensi di bidang hiperbarik yang akan melayani anda !!!!).
III. peralatan pendukung
jika bisa coba anda perhatikan peralatan pendukung apakah sudah memenuhi standar keamanan menurut anda. misalkan
1.katup katup yang dipakai sudah sesuai untuk peruntukannya, jangan sampai anda melakukan terapi hiperbarik dimana katup katup yang mengalirkan udara tekanan tinggi menggunakan katup yang biasa kita jumpai di matrial bangunan atau yang biasa dipakai untuk keperuan rumah tangga di kamar mandi. apakah oksigen yang dipakai betul oksigen 100%, oksigennya cair atau gas ( yg baik adalah oksigen cair, buat pengusaha oksigen cair boros dan mahal)
2.Kompresornya apakah sudah sesuai dengan kompresor untuk hiperbarik, anda gak sulit untuk mengetahuinya. jika kompresor itu anda belum pernah lihat bentuknya dan agak aneh biasanya kompresor itu sesuia standar, tp jika anda melihat kompresornya sering anda lihat di pnggir jalan, tukang cat pinggir jalan pakai, mereknya pun banyak di matrial atau toko bangunan, supermarket bangunan biasanya alat itu gak standar.
3. Masker yang anda pakai apakah standar, caranya gampang jika anda sering lihat bentuk masker seperti itu dan salurannya juga banyak dijual untuk peralatan rumah tangga hati hati biasanya tidak standar. tp jika maskernya seperti pilot pesawat kemungkinan masker tersebut sesuai standar. (biasa dipakai di RSAL maskr spt ini)
4. alat pendukung medis
apakah alat pendukung medis tersedia di dalam dan diluar ruangan hiperbarik. jika tidak ada, anda harus berhati hati terhadap faslitas hiperbarik seperti ini. keamanan anda yang lebih utama. cari tahu dan konsultasikan dengan ahlinya.
IV. Keluhan yg dialami
1. selesai terapi hiperbarik pusing, mual, nyeri telinga, hati hati terhadap kualitas alat hiperbariknya.
sedikit berbagi demi keselamatan kita bersama. kita perlu hati hati bukan berarti mencugiai. waspada terhadap keselamatan diri sendiri berdasarkan analisa anda dari informasi para ahli bukan dari pedagang merupakan hal penting yg perlu dilakukan.
selamat melakukan terapi hiperbarik dan hati hati !!!!!!
fr. dr. Erick Supondha
Hyperbaric & Diving Medicine Consultant
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