Appendix 8
Specialist Trauma Transfer Guidelines - 8.3 Barotrauma

Primary Hospital Management
Assessment

• Full neurological assessment including detailed assessment for sensory and motor deficits.

• If symptoms have arisen following underwater diving or work in a compressed air environment, ascertain details of pressure exposure, for example: depth of dive, gas mix breathed, time at pressure, number of pressurisations and decompression profile.

• CXR-screen for pneumothorax.

• FBE-may helpful to assess for haemoconcentration in acute cases.
  

Management

• Oxygen-aim for inspired concentration of 100 per cent using:
  • occlusive mask or
  • CPAP or SCUBA mouthpiece or
  • ETT supplied by non-rebreathing bag with reservoir and high flow or demand valve or anaesthetic machine at high flow.

• Fluid load-IV normal saline or Hartman's solution.

• Position patient supine. Never sit acute patient upright as cerebral embolism can result.

• Urinary catheter if indicated.

• Ongoing monitoring, especially for silent neurological progression.
  

Indications for Transfer to Hyperbaric Service

• Consultation should occur with the Hyperbaric Service in all cases.

• All decompression related cases require hyperbaric treatment even if symptoms resolve on normobaric oxygen, except those cases involving lethargy only or transient, migratory musculoskeletal symptoms only without signs and without major inert gas load.

• Hyperbaric oxygen treatment is also recommended in iatrogenic or traumatic gas embolism cases.

Time-Critical Cases

• Any arterial gas embolism case (even if spontaneous improvement has occurred-relapse is common).

• Significant reduction in conscious state.

• Vestibular decompression illness.

• Neurological disease with areas of complete loss of sensation, any motor deficit or bladder or bowel dysfunction.

• Respiratory decompression illness ('Chokes').

• Patients with progressive disease or a high potential as a result of high inert gas load (deep, long and/or multiple dives).
  

Transport

• Transport arrangements should be initiated immediately for urgent cases.

• Other cases can be arranged following consultation.

• Altitude exposure must be avoided. Transport at less than 300m effective altitude is required and preferably at 150m maximum. This does not preclude air transport which can usually be achieved by low level helicopter flight, pressurised fixed wing retrieval aircraft or low level over water flight, depending upon flying conditions and geography.
  

Referral Process

Mon-Sat: 0800-1700
Phone: 03 9276 2269
Hyperbaric Service, The Alfred Hospital
Head, Hyperbaric Service, Dr Ian Millar

After hours: 03 9276 2000
Page Hyperbaric Registrar on call, The Alfred (03) 9276 2000