Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

From the Abyss to the ER: Decoding the Depths of a Code Stroke Reveals Underwater Enigma of Decompression Illness Secondary to Arterial Gas Embolism Dakota Becker-Greene, OMS-III, Nicole Gentile, OMS-III, Brandon Davis, MD Background Clinical Images

Case Summary

Figure 1. CT Code Stroke Head without contrast demonstrating no intracranial abnormalities

Arterial Gas Embolism (AGE) is one of two types of decompression illness that commonly occurs during hyperbaric exposure, such as scuba diving. AGE occurs when gas expands rapidly leading to the rupture of alveolar capillaries allowing that gas to then enter arterial circulation ( image 1 ). If the gas causes vascular obstruction, it can result in stroke-like symptoms. There are fewer reports of scuba fatalities to the Divers Alert Network (DAN) in the past few years, but age of incidence is increasing due to older divers having an increased likelihood of having co-morbidities which increases the risk of decompression illness.

A 73-year-old male with HTN, CAD s/p CABG (5 years prior), type-2 DM, and history of recurrent DVTs on apixaban, weighing 95.3 kg, was brought in by ambulance complaining of weakness, dizziness, nausea, and incontinence after a near syncopal episode. Patient also reported a cramping neck sensation shortly after EMS arrival. Initial VS on scene were 150/92 w/ MAP 111, pulse 68, RR 16, SpO 2 96%, temperature 96.9 ° F, BS 230, GCS 15. Before arrival, he had been placed on 15 LPM O 2 via NRB and 12-lead EKG showed sinus bradycardia. On arrival to ED, the patient's left arm was completely flaccid with decreased grip strength. No facial droop, slurred speech, or unequal leg strength noted, but he did report diplopia and dizziness. Patient employed as a scuba diving instructor and reports had been diving approximately 2-3 hours prior to arrival, but notes he took proper decompression steps and did not ascend too quickly. Tele-neurology consulted and determined a NIHSS of 3 due to left leg drift and some arm effort against gravity, so tPA therapy was not indicated. CT head without contrast ( figure 1 ) demonstrated no acute intracranial bleeding and CTA of head and neck was negative for stenosis, occlusion, or aneurysms of all major arterial vasculature. Blood work demonstrated erythrocytosis and hyperglycemia, but no significant coagulopathy. CXR ( figure 2 ) negative for cardiopulmonary abnormalities. EKG ( figure 3 ) non-ischemic with RBBB, RAD, and occasional PACs. At that time, the inpatient team consulted for further work-up and based on their evaluation of symptom recurrence including newly noted left-sided facial droop, it was deemed best for the patient to receive emergent hyperbaric oxygen (HBO) therapy for decompression sickness with possible air gas embolism. Patient transferred to the closest 24/7 HBO facility in stable condition via ambulance.

Image 1, from Vann et al.

Figure 2. Chest X-Ray taken in ED on presentation

ED Presentation

CC: 73-year-old male PMHx HTN, CAD s/p CABG, T2DM, DVT presents to ED via EMS as code stroke 2/2 left arm paralysis, diplopia, and dizziness. HPI : On arrival to ED, patient presents with left arm weakness, dizziness, and blurry vision. Patient reports onset of weakness, dizziness, nausea, vomiting, diarrhea, and a near syncopal episode approximately 1.5 hours prior to arrival while getting out of his truck after returning from a scuba diving trip. Patient also reports experiencing a cramping neck sensation shortly after EMS arrived on scene. Code Stroke was initiated based on the patient's left arm paralysis with decreased grip strength and diplopia. No facial droop, slurred speech, or unequal leg strength noted at that time. Patient denies any weakness, nausea, vomiting, joint pain, neck pain, or decreased visual acuity. Wife at bedside confirms medication list including atorvastatin 80mg qd, nitroglycerin prn, metformin 500mg qd, and apixaban 5mg bid. Additionally, she reports finding him incontinent lying on the driveway unable to get up, which prompted her call to EMS. Pertinent P/E : BP 101/89, HR 107, temperature 98 ° F, RR 23, SpO 2 95% on RA. At bedside, patient WDWN in NAD, AOx4. CN XI left-sided shoulder shrug weakness with other CN grossly intact. No numbness or decreased sensation. Initially 0/5 LUE strength improved to 5/5 LUE strength on re evaluation ~45 min later. 5/5 strength in all other extremities with intact gait, good eye contact, affect and behavior. Head AT/NC, eyes PERRLA, EOMI with no RAPD, normal conjunctiva, and moist MM. Cardiac and lung exam revealed RRR, symmetric 2+ radial and distal pulses with no respiratory distress or wheezing.

Conclusion

Even with a substantial history of diving, DCS should still be included in the differential and patients should be started on 100% oxygen until HBO therapy is available.

Clinical Images

Clinical symptoms of decompression sickness typically presents within 24 hours of surfacing after scuba diving. Patients with CNS symptoms present more quickly, with 56% of patients having symptoms within 10 minutes of surfacing.

Special thank you to Spartanburg Regional and Dr. Brandon Davis, as well as both the emergency department and inpatient team who cared for and managed the patient. Thank you to our patient for allowing us to learn from him and share his unique presentation.

Figure 3. EKG demonstrated a rate of 72 bpm in sinus rhythm with occasional premature atrial complexes, abnormal right axis deviation (QRS 256), and right bundle branch block seen upright in V1-V3.

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2024 Research Recognition Day