Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

decompression sickness or arterial gas embolism

1st line – advanced life support

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ACUTE
|
decompression sickness or arterial gas embolism
1st line – 

advanced life support

Initial first-aid treatment should be given according to accepted principles of basic and advanced life support.

Prompt administration of 100% oxygen has been shown to improve clinical outcome.[43]

Isotonic oral fluids can be given in a conscious patient with mild decompression illness. Otherwise, 1-2 litres of intravenous fluids during the first post-injury hour is recommended, followed by an infusion with the goal of normotension and urine output of 0.5 to 1.0 mL/kg/hour.[1]​​

Wet divers are often cold and should be dried, as hypothermia will slow inert gas washout. Conversely, increased body temperature may encourage bubble formation.[45]

To minimise the detrimental effect of bubble expansion with decreased atmospheric pressure at altitude, transport to a suitable facility should ideally be via ground or by aircraft pressurised to sea level.[47]​ In patients with air embolism, horizontal positioning of the patient helps reduce the risk of further embolism or emboli migration while in transit to a hyperbaric chamber.

Plus – urgent recompression

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ACUTE
|
decompression sickness or arterial gas embolism
Plus – 

urgent recompression

Treatment recommended for ALL patients in selected patient group

Patients with decompression sickness should be recompressed in a hyperbaric chamber as soon as is practically possible. Prompt recompression is key. A 95% probability of relief has been demonstrated if treatment is initiated within 30 minutes. This drops to 77% if the delay exceeds 6 hours.[46]​ In the hyperacute setting, recompression may act to mechanically reduce bubble volume (Boyle’s law) and/or force gas back into solution (Henry’s law). In addition to reduction in bubble volume, hyperbaric oxygen’s modulation of systemic inflammatory response likely also plays a significant role, especially in more delayed presentations.[48]​ Empirically derived recompression schedules (or 'treatment tables') have been developed, which vary in their maximum depth (pressure), duration, and the breathing gas mixture used.

In patients with air embolism, treatment follows the principles of decompression illness. Administration of 100% oxygen by close-fitting mask will help dissolve and dissipate emboli, treat hypoxia, reduce cerebral oedema, and limit the acute inflammatory reaction. Due to the risk of occult pneumothorax, femoral central venous lines are preferred to those in jugular or subclavian veins. Any pneumothorax must be drained with a chest tube before recompression, to avoid progression to a tension pneumothorax during hyperbaric exposure. Air in the endotracheal cuffs of intubated patients should be replaced with an equivalent amount of liquid (e.g., saline or distilled water) or monitored through pressure changes by staff to prevent loss of seal or overinflation.[Figure caption and citation for the preceding image starts]: A typical multi-place hyperbaric chamberFrom the collection of Dr Oliver Firth; used with permission [Citation ends].com.bmj.content.model.Caption@2f7044a5

Consider – anticonvulsant

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ACUTE
|
decompression sickness or arterial gas embolism
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

Cerebral arterial gas embolism can present with generalised seizures, which are treated similarly to seizures from any other cause.

First-line anticonvulsants are intravenous lorazepam, or rectal diazepam if there is no intravenous access. If seizures recur or fail to respond within 30 minutes, either a phenytoin or a phenobarbital infusion may be used.

Doses presented here are for acute repetitive seizures/status epilepticus; maintenance dosing (if required) is beyond the scope of this topic.

Primary options

lorazepam: 4 mg intravenously as a single dose, may repeat in 10-15 minutes according to response, maximum 8 mg/total dose

OR

diazepam rectal: 0.2 mg/kg rectally as a single dose, may repeat once in 4-12 hours according to response

Secondary options

phenytoin: 15-20 mg/kg intravenously as a single dose, may give an additional dose of 10 mg/kg after 20 minutes according to response

OR

phenobarbital: 15-20 mg/kg intravenously as a single dose, may give an additional dose of up to 15 mg/kg after 15 minutes according to response

barotrauma

1st line – avoidance of pressure changes

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ACUTE
|
barotrauma
1st line – 

avoidance of pressure changes

Avoidance of pressure changes until tissue damage has resolved is common to the treatment of all barotraumas.

Plus – nasal or oral decongestant

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ACUTE
|
barotrauma
|
middle ear
Plus – 

nasal or oral decongestant

Treatment recommended for ALL patients in selected patient group

Middle-ear barotraumas can be treated with nasal or oral decongestants to reduce the inflammation, although this is seldom warranted.

Pseudoephedrine-containing medications are associated with a risk of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medicines should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[51]

Primary options

ephedrine: (0.25%) 1-2 sprays in each nostril three to four times daily

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – analgesia

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ACUTE
|
barotrauma
|
middle ear
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Analgesics can be administered for pain relief. Simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac may be adequate. A short course of opioids (e.g., paracetamol/codeine) may be considered in refractory cases.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

paracetamol/codeine: 1-2 tablets orally every 4-6 hours when required, maximum 60 mg/dose (codeine) or 4000 mg/day (paracetamol)

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Plus – conservative measures

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ACUTE
|
barotrauma
|
inner ear
Plus – 

conservative measures

Treatment recommended for ALL patients in selected patient group

Conservative measures are bed rest, head elevation, and minimisation of perilymph pressure increases. The patient should avoid coughing, sneezing, equalising, and any physical exertion (e.g., the use of stool softeners is recommended).

Consider – analgesia

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ACUTE
|
barotrauma
|
inner ear
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Analgesics can be administered for pain relief. Simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac may be adequate. A short course of opioids (e.g., paracetamol/codeine) may be considered in refractory cases.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

paracetamol/codeine: 1-2 tablets orally every 4-6 hours when required, maximum 60 mg/dose (codeine) or 4000 mg/day (paracetamol)

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Consider – surgical repair

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ACUTE
|
barotrauma
|
inner ear
Consider – 

surgical repair

Additional treatment recommended for SOME patients in selected patient group

If symptoms persist or deteriorate, operative intervention is considered. Oval or round window repair prevents further perilymph leakage and may improve vertigo, tinnitus, and hearing.

Plus – oxygen therapy or conservative measures

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ACUTE
|
barotrauma
|
pulmonary
Plus – 

oxygen therapy or conservative measures

Treatment recommended for ALL patients in selected patient group

Pulmonary tissue damage: 100% oxygen is administered to correct arterial hypoxaemia, avoiding positive pressure ventilation where possible as this may exacerbate lung damage. Haemodynamic support may be required.

Pneumothorax: mild cases may resolve with normobaric 100% oxygen.

Mediastinal emphysema: if asymptomatic, rest and observation may suffice. Mild symptomatic cases may resolve with normobaric 100% oxygen.

Consider – recompression ± surgery

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ACUTE
|
barotrauma
|
pulmonary
Consider – 

recompression ± surgery

Additional treatment recommended for SOME patients in selected patient group

Recompression in a hyperbaric chamber is only very rarely indicated in severe cases of mediastinal emphysema or when air embolism is present.

Myringotomy may be required if patients are unable to equalise their middle-ear spaces voluntarily during recompression treatment.

Consider – chest drain or thoracostomy

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ACUTE
|
barotrauma
|
pulmonary
Consider – 

chest drain or thoracostomy

Additional treatment recommended for SOME patients in selected patient group

In patients with pneumothorax, placement of a chest drain or emergency needle thoracostomy may be required, depending on clinical severity.

Plus – nasal or oral decongestant

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ACUTE
|
barotrauma
|
sinus
Plus – 

nasal or oral decongestant

Treatment recommended for ALL patients in selected patient group

Nasal or oral decongestants are generally used to reduce the inflammation.

Pseudoephedrine-containing medicines are associated with a risk of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medicines should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[51]

Primary options

ephedrine: (0.25%) 1-2 sprays in each nostril three to four times daily

OR

pseudoephedrine: 60 mg orally (immediate-release) every 4-6 hours when required, maximum 240 mg/day

Consider – analgesia

Back
ACUTE
|
barotrauma
|
sinus
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Analgesics can be administered for pain relief. Simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac may be adequate. A short course of opioids (e.g., parcetamol/codeine) may be considered in refractory cases.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

paracetamol/codeine: 1-2 tablets orally every 4-6 hours when required, maximum 60 mg/dose (codeine) or 4000 mg/day (paracetamol)

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Consider – intranasal corticosteroid

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ACUTE
|
barotrauma
|
sinus
Consider – 

intranasal corticosteroid

Additional treatment recommended for SOME patients in selected patient group

If the cause of obstruction is mucosal swelling due to allergy or nasal polyps, an intranasal corticosteroid can be added.

Primary options

fluticasone propionate nasal: (50 micrograms/spray) 100 micrograms (2 sprays) in each nostril once daily

OR

beclometasone nasal: (50 micrograms/spray) 50-100 micrograms (1-2 sprays) in each nostril twice daily

Consider – endoscopic surgery

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ACUTE
|
barotrauma
|
sinus
Consider – 

endoscopic surgery

Additional treatment recommended for SOME patients in selected patient group

In refractory or recurrent cases, endoscopic exploration or surgery may be needed to improve patency of the ostia or to remove obstructions such as polyps or redundant mucosal folds.

Plus – analgesia plus surgical repair

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ACUTE
|
barotrauma
|
dental
Plus – 

analgesia plus surgical repair

Treatment recommended for ALL patients in selected patient group

Dental barotraumas are treated with analgesics and repair of dental injuries. Dental barotrauma is usually very painful and analgesics are generally required. Simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac may be adequate. A short course of opioids (e.g., paracetamol/codeine) may be considered in refractory cases.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

paracetamol/codeine: 1-2 tablets orally every 4-6 hours when required, maximum 60 mg/dose (codeine) or 4000 mg/day (paracetamol)

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Consider – surgical repair

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ACUTE
|
barotrauma
|
gastrointestinal
Consider – 

surgical repair

Additional treatment recommended for SOME patients in selected patient group

Gastrointestinal barotrauma is rarely severe, but if gastric rupture occurs, stomach contents may enter the peritoneal cavity and emergent surgical repair is imperative.

Plus – observation

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ACUTE
|
barotrauma
|
mask/suit squeeze
Plus – 

observation

Treatment recommended for ALL patients in selected patient group

Mask/suit squeeze does not require any treatment, as it resolves spontaneously.

Consider – analgesia

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ACUTE
|
barotrauma
|
mask/suit squeeze
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Analgesics can be administered for pain relief. Simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac may be adequate. A short course of opioids (e.g., paracetamol/codeine) may be considered in refractory cases.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

paracetamol/codeine: 1-2 tablets orally every 4-6 hours when required, maximum 60 mg/dose (codeine) or 4000 mg/day (paracetamol)

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

nitrogen narcosis

1st line – ascent

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ACUTE
|
nitrogen narcosis
1st line – 

ascent

This condition is entirely reversible by reduction of ambient pressure (i.e., ascent to shallow depths).[3]​ Persistent symptoms after return to ambient pressure should not be attributed to nitrogen narcosis and alternative diagnosis should be sought.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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