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KN2-4 Table 2 - Necrotizing Fasciitis Managed with HBO Managed without HBO Author Number Died Mortality Author Number Died Mortality Aasen (1989) 9 1 11.1 Farrell (1988) 11 5 45.5 Bakker (1984) 27 5 18.5 Ledingham (1975) 3 0 0.0 Chevallier (1987) 13 4 30.8 Mader (1988) 12 6 50.0 Gozal (1986) 16 2 12.5 Majeski (1984) 20 10 50.0 Him (1988) 11 1 9.1 Oh (1982) 28 10 35.7 Krasova (1992) 11 3 27.3 Pessa (1988) 33 13 39.4 Ledingham (1975) 9 8 88.9 Reigels-Nielsen(1984) 5 1 20.0 Mader (1988) 10 2 20.0 Riseman (1990) 12 8 66.7 Riseman (1990) 17 4 23.5 Rouse (1982) 27 20 74.7 Duke University(1991)54 11 20.3 Spirnak (1984) 20 9 45.0 Wang (1992) 18 6 33.3 Woodburn (1992) 19 7 36.8 TOTAL 141 28 20.1% TOTAL 208 95 47.4% Gas Gangrene Managed with HBO Managed without HBO Author Number Died Mortality Author Number Died Mortality Bakker (1988) 409 48 11.7 DeLalande (1981) 22 9 40.9 Caplan (1976) 34 11 32.4 Freischlag (1985) 21 11 52.0 Gibson (1986) 29 9 31.0 Gibson (1986) 17 12 70.6 Gurtner (1983) 73 23 31.5 Hichcock (1976) 33 14 42.4 Hart (1983) 139 27 19.4 Kaiser (1981) 20 8 42.4 Heimbach (1980) 58 3 5.2 Katlic (1981) 7 5 71.4 Him (1988) 32 9 28.1 Paillier (1986) 20 8 41.0 Holland (1975) 49 13 26.5 Vo (1986) 77 31 40.0 Nier (1984) 78 30 38.5 Shupak (1984) 4 1 25.0 Unsworth (1984) 73 15 20.5 Duke University(1991)35 7 20.0 TOTAL 141 28 20.1% TOTAL 217 98 45.2% Refractory osteomyelitis - The use of HBO for the treatment of osteomyelitis is reserved for those patients who have refractory osteomyelitis characterized as a failure to respond to respond to antibiotics, debridement and correction of any soft-tissue defects. For selected “refractory” patients the use of the Ilizarov technique may permit “en block” resection of infected bone from the appendicular skeleton. However in those instances involving refractory osteomyelitis of the spine, sternum, skull, or other settings, which do not permit such aggressive resection, HBO therapy becomes an treatment option. Controlled animal studies have demonstrated the hypoxic nature of chronically infected bone and verified the benefits of HBO. 30,31,32,33,34,35 Specifically, HBO enhanced collagen production, capillary angiogenesis, improved osteoclast and neutrophil function. Problem wounds - Problem or chronic wounds are characterized as those defects that fail to respond to 4-6 weeks of established medical and surgical management. The associated pathology is usually an interplay between hypoxia and infection. Tissue oxygen tension in or near such wounds is usually 20 mm
KN2-5 Hg or less. The attendant hypoxia blunts fibroblast proliferation, collagen production and capillary angiogenesis. As previously noted, the oxidative killing capacity of the leukocyte is markedly diminished as well as bacterial phagocytosis. 36 Experimentally the elevation of oxygen tension may be as effective as antibiotic administration. 37 More recent investigations have pursued the concept of oxygen as a cell regulator. The discovery of nitric oxide as a cell signal has opened the possibility that other gases, such as oxygen, may also regulate cell function at the nuclear level. Experimental findings have associated oxygen with upregulation of platelet derived growth factor receptor gene expression, nitric oxide synthase gene upregulation, production of epidermal growth factor receptors, production of vascular endothelial growth factor and sustained fibroblast proliferation for periods of 24-72 hrs following a single dose of HBO. 6-8,38,39,40,41 Patient selection – Although tissue hypoxia may be inferred on clinical grounds, it has been difficult to reliably confirm its presence until recently. The development of transcutaneous oxygen measurements (TCOM’s) now permits an evidenced based use of hyperbaric oxygen therapy. 42 Padberg demonstrated that there is no single threshold value that is associated with healing but rather a probability continuum. When the periwound pO2 is 20 mm Hg the probability of spontaneous healing is less than 50%. 43 Typical TCOM studies are a two-stage process. The first phase involves calibration and measurements on room air to determine the distribution and magnitude of hypoxia. The second phase utilizes an “oxygen challenge” wherein the patient is placed on 100% oxygen for 10 minutes. When these 2 elements are combined, they answer two important questions: is hypoxia a limiting factor in healing and is it correctable by oxygen supplementation. Transcutaneous oxygen values are increasingly recognized as the most reliable noninvasive measure of perfusion, oxygen tensions and predictor of clinical outcome. In addition TCOM’s help to select the most distal amputation level that is associated with spontaneous healing and has been demonstrated to be superior to clinical judgment. 44 Choosing the most distal amputation level that will heal is difficult. Mars et al compared clinical site selection versus clinical opinion augmented with TCOM data and found that the amputation revision rate was reduced from 51% to 8.2% when TCOM’s were used to supplement clinical opinion. Following the primary crush injury, the secondary complications of infections and problem wounds there may be a third wave of complications, which occur if flaps or grafts become compromised during the reconstructive phase. Here too, HBO therapy is beneficial when provided in a timely manner. A number of studies have demonstrated enhanced survival of flaps and graft with HBO therapy. 45,46,47,48,49 In the early work of Champion et al, using a rabbit pedicle flaps, 100% survival was achieved using HBO. 50 In contrast, the non HBO group experienced 40% necrosis. Perrins demonstrated improved outcome of skin grafts in a prospective randomized trial of HBO. In terms of the “reconstructive ladder” the free flap is the most complex option. 51 Stevens et al designed a model to simulate a free flap procedure with a period of secondary ischemia. In this model, an axial skin flap is subject to six hours of ischemia, which would simulate the initial interruption of perfusion that occurs with the creation of a free flap followed by 2 hours of reperfusion. This was than followed by a secondary ischemia time of 6, 10, or 14 hours which simulated flap compromise which may occur from hematoma, thrombosis, dressings, or venous outflow obstruction. The animals were separated into three treatment groups consisting of air, 100% oxygen or hyperbaric oxygen. The secondary ischemic time at which 50% of the flap survived was 6 hours for both the air and oxygen groups. For the HBO animals, the secondary ischemic time for 50% survival was increased to 10 hours. 52 CATEGORY II - HEMORRHAGE / SHOCK The physiology for using high-pressure oxygen as a blood substitute is well established. At three atmospheres absolute (ATA) pressure, the plasma content of dissolved oxygen is sufficient to support life without blood. Given the dwindling reserve of blood and the logistics of blood deployment, HBO offers a short-term solution, which permits rapid evacuation of injured troops to a more centralized location or short-term stabilization while blood is being transferred. However there is now evidence that
Page 1 and 2: RTO-MP-062 NORTH ATLANTIC TREATY OR
Page 3 and 4: NORTH ATLANTIC TREATY ORGANIZATION
Page 5 and 6: Operational Medical Issues in Hypo-
Page 7 and 8: Contents Executive Summary iii Synt
Page 9 and 10: Respiratory Changes and Consequence
Page 11 and 12: Introduction Technical Evaluation R
Page 13 and 14: In addition to cabin pressurisation
Page 15 and 16: critical. The so-called technical d
Page 17 and 18: levator veli palatini, like when sw
Page 19 and 20: Present and Future Compromises in A
Page 21 and 22: KN1-3 (RGE) as the safety criterion
Page 23 and 24: Pulmonary Barotrauma KN1-5 Free ven
Page 25 and 26: KN1-7 Future fighter aircraft may w
Page 27 and 28: KN1-9 Figure 1 Cabin Pressurisation
Page 29 and 30: KN1-11 Figure 3 The relationships b
Page 31 and 32: +\SHUEDULF 2[\JHQ $ 6FLHQWLILF 8SGD
Page 33: KN2-3 recovers spontaneously withou
Page 37 and 38: KN2-7 8 Tompach PC, Lew D, Stoll JL
Page 39 and 40: USAF Experience with Hyperbaric The
Page 41 and 42: Exposure Results and Discussion The
Page 43 and 44: Symptomotology Symptom presentation
Page 45 and 46: Air Force Altitude DCS Treatment Al
Page 47 and 48: References 1. Atlas of Injuries in
Page 49 and 50: Headache and Decompression Sickness
Page 51 and 52: Numerous studies have been done to
Page 53 and 54: 8. Madeline LA and Elster AD. Sutur
Page 55 and 56: Figure 2. Sutural Movement with Spi
Page 57 and 58: Patent Foramen Ovale as a Risk Fact
Page 59 and 60: 90 minutes prior to the start of th
Page 61 and 62: The Relevance of Patent Foramen Ova
Page 63 and 64: In a human population, Glen et al (
Page 65 and 66: Studies evaluating PFO detection me
Page 67 and 68: References 1. O’Rahilly, R., Mull
Page 69 and 70: 55. Giroud, M., Tatou, E., Steinmet
Page 71 and 72: Introduction Altitude DCS Susceptib
Page 73 and 74: Cumulative DCS Incidence, % 100 90
Page 75 and 76: Pharmacological Correction of the H
Page 77 and 78: metabolic regulation remedies [A.S.
Page 79 and 80: asis of these indicators there were
Page 81 and 82: liquidation of energetic debt in mu
Page 83 and 84: Analysis of correlation structures
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Interesting data on bemithylum pres
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to high altitude hypoxia and allows
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35. Shanazarov, A.S., Ryskulova, G.
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Prognozing of the Resistance to Hyp
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autonomic cardiac control whereas i
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METHOD Subjects 21 male military pi
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mean R-R interval (X), STV, LTV (ms
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• Significant negative correlatio
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DISCUSSION Hypoxic Tolerance Our re
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8. Casa M., Casa H., Pages T., Rama
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66. Sheffield P., Heimbach R. Respi
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Abstract Alternobaric Vertigo: Inci
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12. Nagai H. et al. Effect of incre
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Neuropsychometric Test in Royal Net
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Table 4 Results of neuropsychometri
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Summary: Spanish Navy Up to Date Da
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Hypobaric Training for Royal Air Fo
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c. Fast jet high level. Climb to 18
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Introduction Hypobaric Training Iss
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To be able to tolerate breathing pr
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during the change in ambient pressu
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Designing Efficient and Effective,
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The Type II profile involves positi
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Pressurized, Cabin below 10,000 ft
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than 10 minutes at a hypoxia level
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Military Personnel Selection and Di
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expressed by them, are closely inte
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of shortage of blood circulation fu
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The results of the conducted resear
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15-9
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15-11
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In norm there is A > B, and the reg
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Burger, M., 1921, Uber der klinisch
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In: Sbornik nauchno-prakticheskih r
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Templeton, A.W., 1965, Renal Aortog
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Some Psycho-Physiological and Cogni
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Testing in hypobaric chamber condit
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supply immediately recovered. Subje
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The Role of PWC in Declaring a Dive
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Out of 1200 ergometric examinations
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Application of Hypo and Hyperbaric
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evaluation of mountain-climber's hy
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Figure 2 % oxyhemoglobin saturation
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The Effects of Normobaric Hypoxia i
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Memory Scanning Task: Cadets with p
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The statistical analysis of the beh
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ACKNOWLEDGMENTS The authors wish to
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Severe Decompression Illness Follow
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In this set of studies, observation
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pulmonary oedema, a diuretic may be
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Decompression Sickness Research: Ne
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Figure 3. Pigs treated with methano
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Abstract Using “Technical Diving
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ecreational diving training agencie
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After the intermediate or “deco
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include paresthesia, headache, dizz
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practice. Some dives were conducted
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Abstract Into the Theater of Operat
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Procedures: The FCT evaluation init
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The matrix of tests conducted, some
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6. Kennedy, T. Concept of Operation
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The Relevance of Hyperbaric Oxygen
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In reperfusion injury, HBO diminish
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HBO has long been known to favorabl
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3-Nitrotyrosine Predicts Healing in
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corresponded respectively to the si
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that in these diabetic subjects, ne
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Summary Role of a Clinical Hyperbar
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Benefits to the Defence Secondary C
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The study has been deferred due to
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ABSTRACT Incidence of Decompression
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Table 1: Number of Diving Incidents
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Introduction Evaluation of Treatmen
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Table 6A (CF TT6A, initial recompre
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INTRODUCTION Modelling and Validati
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moved to the treatment chamber. Fiv
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Figure 3 The predicted gas in bubbl
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Table 5 shows the same information
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CONCLUSIONS Although it would have
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Respiratory Changes and Consequence
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Table 2 Inspired-expired oxygen dif
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Figure 2 Respiratory patterns, expe
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Apnoea is characteristic of herniat
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Effect of Exercise on Bubble Activi
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The KISS is an index derived from i
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DISCUSSION: In all group comparison
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Thermography - A Method for the Eva
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level atmospheric pressure O2 parti
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lower extremities cephalic extremit
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1-st group - flying crews We divide
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ABSTRACT Altitude Decompression Sic
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Table 1. Results of validation Prof
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Summary Altitude Decompression Illn
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17 oxygen demand regulator with a p
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During these altitude exposures a n
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Subject Number Subject Number Subje
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that this discrepancy in the incide
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Extrapolation of the data presented
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MITCHELL SJ & LEE VM. (2000) A surv
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Expression of Neuronal and Inducibl
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Experimental procedures Groups of 1
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immunoreactive Purkinje cells were
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Western blotting Cerebral cortical
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certain proteins as substrates for
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Griffiths, T., Evans, M.C. and Meld
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Simon, R.P., Griffiths, T., Evans,
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RESUME Intérêt du caisson d’alt
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3. TYMPANOMETRIE La tympanométrie
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quelconque douleur. Dans ce cas, il
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Altitude DCS Research in Support of
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Altitude, feet X 1000 30 25 20 15 1
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2. POST-LANDING EXERCISE AND RISK O
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addition to observed or reported DC
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% DCS 100 80 60 40 20 0 25,000 30,0
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Modeling Approach for Oxygen Exchan
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The first equation states that the
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may cause the remaining discrepanci
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0 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 F
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Sa (%) Pa (mmHg) 100 80 60 40 V’E
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Sa (%) Pa (mmHg) V’E (L/min) 100
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Changes of Ventilator Generated Vol
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Emergency descent : Oxylog 2000 : C
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&DELQ $OWLWXGH IHHW Table 6 &DELQ D
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The Effect of Increased Full Covera
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assembly incorporating FCAGTs infla
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Following garment fitting, subjects
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Mean CBV (cm/s) 70 60 50 40 30 20 1
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Alveolar Carbon Dioxide Tension Alv
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Phase 2 All experimental exposures
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Diffusion coefficient for carbon mo
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Mean arterial pressure (mmHg) 140 1
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In previous studies (Ernsting, 1966
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Determination of the Most Effective
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Decompression Sickness, Extravehicu
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As a corollary, what about the alle
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Introduction Optimizing Denitrogena
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Cumulative % DCS 100 90 80 70 60 50
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Benefit of Acclimatization to Moder
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. Following completion of the quest
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Discussion This study demonstrated
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12. White, D.P., K. Gleeson, C.K. P
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Introduction: Physiological and Cli
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The steepness of hypoxia-induced de
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RESUME Évaluation d’équipements
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2.1. Règlement TSO-C99 Le règleme
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autre personne s’assure que, sans
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Il est équipé de l’équipement
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REPORT DOCUMENTATION PAGE 1. Recipi
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NORTH ATLANTIC TREATY ORGANIZATION
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