Capítulo 3: Diagnóstico de enfermedad descompresiva

“While DCS is commonly thought of as a bubble disease, bubbles are probably only the gateway to a complex array of consequences and effects.”

DCS may develop when a diver’s degree of supersaturation is so high (or, stated another way, if the elimination gradient is so steep) that a controlled transfer of inert gases from the body’s tissues to the bloodstream — and then from the bloodstream to the lungs and the lungs to the environment — is not possible. If that removal process is inadequate, inert gases will come out of solution and form bubbles that can distort tissues, obstruct blood flow, cause mechanical damage (to the joints, for example) and/or trigger a cascade of biochemical responses.

Aunque mucho se sabe de la EDC, sus mecanismos de agresión aún están siendo investigados. Y mientras se piensa en la EDC como una enfermedad de burbujas, éstas son, probablemente, sólo la puerta de entrada a una variedad compleja de consecuencias y efectos.

In this chapter, you’ll learn about:

Una piel moteada o marmolada como ésta es una característica de “cutis marmorata”, (piel marmórea) una condición que puede advertirnos del probable desarrollo de síntomas más serios de EDC Tipo 2.

Signos y síntomas de la enfermedad descompresiva

The collective insult to the body’s systems can produce symptomatic DCS. The condition’s primary effects may be evident in the tissues that are directly insulted. Its secondary effects can compromise the function of a broad range of tissues, further jeopardizing the diver’s health.

The ability to recognize the signs, or objective evidence, and the symptoms, or subjective perceptions, of DCS — and to differentiate them from signs and symptoms less likely to be associated with DCS — is important. A variety of classification systems have been established for DCS. One common approach is to describe cases as Type 1 or Type 2.

EDC Tipo 1

Type 1 DCS is usually characterized by musculoskeletal pain and mild cutaneous, or skin, symptoms. Common Type 1 skin manifestations include itching and mild rashes (as distinct from a clear mottled or marbled and sometimes raised discoloration of the skin — a condition that is known as cutis marmorata that may presage the development of the more serious symptoms of Type 2 DCS). Less common but still associated with Type 1 DCS is obstruction of the lymphatic system, which can result in swelling and localized pain in the tissues surrounding the lymph nodes — such as in the armpits, groin or behind the ears.

Lugares comunes de dolor músculo-esquelético asociado con la EDC Tipo 1.

Los síntomas de EDC Tipo 1 pueden aumentar en intensidad. Por ejemplo, el dolor puede originarse como una molestia leve cerca de una articulación o un músculo, y luego aumentar en magnitud. Sin embargo, el dolor asociado con la EDC generalmente no aumenta con el movimiento de la articulación afectada, aunque mantener el miembro en una posición más que en otra puede reducir la incomodidad. Dicho dolor, puede, en última instancia, ser bastante grave.

EDC Tipo 2

La prueba de Romberg evalúa el control postural. La prueba de Romberg mejorada, que incluye cruzar los brazos y colocar un pié delante del otro, es más sensible a cambios en el equilibrio estático. La prueba de Romberg mejorada se utiliza comúnmente como parte de la evaluación neurológica de buzos lesionados.

Type 2 symptoms are considered more serious. They typically fall into three categories: neurological, inner ear and cardiopulmonary. Neurological symptoms may include numbness; paresthesia, or an altered sensation, such as tingling; muscle weakness; an impaired gait, or difficulty walking; problems with physical coordination or bladder control; paralysis; or a change in mental status, such as confusion or lack of alertness. Inner-ear symptoms may include ringing in the ears, known as “tinnitus”; hearing loss; vertigo or dizziness; nausea; vomiting; and impaired balance. Cardiopulmonary symptoms, known commonly as “the chokes,” include a dry cough; chest pain behind the sternum, or breastbone; and breathing difficulty, also known as “dyspnea.” The respiratory complaints, which are typically due to high bubble loads in the lungs, can compromise the lungs’ ability to function — threatening the affected diver’s health, and even life, if treatment is not sought promptly.

Type 2 symptoms can develop either quickly or slowly. A slow build can actually obscure the seriousness of the situation, by allowing denial to persist. For example, fatigue and weakness are common enough concerns, especially if their onset is protracted, that they can be very easy to ignore. Less common symptoms, such as difficulty walking, urinating, hearing or seeing — especially if their onset is quick — can sometimes prompt faster recognition of the existence of a problem. It is fair to say that divers can initially be reluctant to report symptoms, though they usually will do so if their symptoms do not go away. This is a shortcoming divers should be aware of, lest they fall prey to it.

Presentación de la EDC

The presentation of DCS is frequently idiosyncratic — that is, its “typical” pattern can be atypicality. In some cases, an affected diver’s chief complaint may draw attention away from more subtle but potentially more important symptoms. The following list ranks the initial manifestations of DCS, from those most commonly to least commonly reported (Vann et al. 2011):

  • Dolor, particularmente cerca de las articulaciones.
  • Entumecimiento o parestesia.
  • Constitutional concerns — such as headache, lightheadedness, unexplained fatigue, malaise, nausea and/or vomiting, or anorexia
  • Vértigo.
  • Debilidad motriz.
  • Cutaneous, or skin, problems — such as an itch, rash, or mottling (“cutis marmorata”)
  • Malestar muscular.
  • Estado mental alterado.
  • Pulmonary problems — such as breathing difficulties (“the chokes”)
  • Coordinación alterada.
  • Nivel de consciencia reducido.
  • Auditory symptoms — such as hearing sounds that are not there or having a hard time hearing
  • Lymphatic concerns — such as regional swelling
  • Bladder or bowel dysfunction — such as retention of urine
  • Función cardiovascular comprometida.

De acuerdo con esta revisión reciente, el dolor y el entumecimiento, también conocido como parestesia, fueron reportados inicialmente en casi dos tercios de los casos de EDC síntomas específicos en aproximadamente el 40 por ciento de los casos, mareo/vértigo, y debilidad motora en alrededor del 20 por ciento, y síntomas cutáneos en aproximadamente 10 por ciento de los casos. (Vann et al. 2011)

Diagnóstico diferencial de la enfermedad descompresiva

La EDC es una lesión de buceo de alto perfil a causa de su gravedad potencial. Pero es necesario que los buzos recuerden que no todos los problemas relacionados con el buceo se transforman en EDC. Cuando dos o más condiciones tienen síntomas que se superponen, como sucede en el caso de muchas lesiones relacionadas con el buceo, el diagnóstico diferencial es el proceso por el cual el personal médico determina cuál de las potenciales condiciones es, probablemente, más responsable de los síntomas.

The term decompression illness (DCI) was coined to encompass both DCS and the related condition known as arterial gas embolism (AGE), the latter arising from barotrauma of the lungs that introduces gas into the systemic bloodstream. Some of the other conditions and circumstances that involve similar symptoms include inner-ear barotrauma; middle-ear or maxillary sinus overinflation; contaminated breathing gas; oxygen toxicity; musculoskeletal strains or trauma sustained before, during or after a dive; marine life envenomation; immersion pulmonary edema; water aspiration; and coincidental neurological disorders, such as stroke (Vann et al. 2011). Thermal stress — sometimes due to excessive heat, but usually due to cold exposure — can also be responsible for similar symptoms. In some cases, a careful medical history can easily rule out one diagnosis or another. For example, symptoms of immersion pulmonary edema often develop at depth. In such a case, a good history would rule out DCS, which only develops after significant decompression stress during ascent.

Es esencial para los buzos con cualquiera de estos síntomas buscar la evaluación y el apoyo médico. Mientras que el personal que brinda los primeros auxilios puede hacer el análisis inicial de una persona lesionada realizando una evaluación neurológica in situ, las capacidades de los que no son médicos no se acercan a las habilidades y conocimientos clínicos que poseen los especialistas experimentados.

Siguiente: Chapter 4 – Treating Decompression Sickness >

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