Recommendations on Adjunctive Therapy by the Undersea and Hyperbaric Medical Society UHMS 135

The UHMS has recently published guidelines for the use of adjunctive therapy for DI. These describe specific aspects related to drug therapy in greater detail 135. The following is an extract of the UHMS Document

"Adjunctive Therapy for Dysbaric Illness (DI): Summary of Undersea and

Hyperbaric Medical Society Guidelines December 2002":

Oxygen

100% O2 administration can be safely administered for 12 hours with air breaks; thereafter, at the discretion of the receiving physician. Fluids

For intravenous administration, lactated Ringer's solution or other glucose-free isotonic crystalloids are suggested, unless otherwise indicated. Patients who have been immersed for prolonged periods may require additional fluid because of immersion-induced diuresis. NSAIDs.

NSAIDs are not currently recommended for use in the field. The only evidence thus far applies to the use of tenoxicam, a nonselective inhibitor of cyclo-oxygenase (COX) for pain-only DI 136. Anti-coagulants.

Routine therapeutic anticoagulation or use of thrombolytics or IIB/IIIA anti-platelet agents in patients with neurological DI is not recommended, due to concern about worsening hemorrhage in spinal cord or inner ear DI. Low molecular weight heparin (LMWH) is suggested for all DI patients with an inability to walk. Enoxaparin 30 mg, or its equivalent, subcutaneously every 12 hours, should be started as soon as possible after injury. These guidelines are extrapolated from observations in patients with traumatic spinal cord injury. Neither the efficacy nor the safety of these guidelines in neurological DI has been specifically confirmed in patients with DI. However, deaths have occurred in divers due to documented pulmonary thromboembolism. Furthermore, there is a recognized need for prophylaxis in traumatic spinal cord injury. Thus specific prophylaxis against DVT in spinal cord DCS has been assigned a 1A guideline. Corticosteroids

Corticosteroids are not recommended for the treatment of DI. Lidocaine / Lignocaine

There is insufficient evidence to support the routine use of Lidocaine / Lignocaine for DI, and it is not considered standard of care. However, if it is to be used, evidence suggests that an appropriate end-point is attainment of a serum concentration suitable for an anti-arrhythmic effect (26 mg/L or ug/mL). Intravenous dosing of 1 mg/kg then subsequent boluses of 0.5 mg/kg every 10 minutes to a total of 3 mg/kg, while infusing continuously at 2-4 mg/minute, will typically produce therapeutic serum concentrations. Use of more than 400 mg within the first hour may be associated with major side effects unless the patient is continuously monitored in a medical unit with the appropriate facilities and personnel. In the field, intramuscular administration of 4-5 mg/kg will typically produce a therapeutic plasma concentration 15 minutes after dosing, lasting for around 90 minutes.

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