Rosen & Barkin's 5-Minute Emergency Medicine Consult (359 page)

If patient is stable for discharge, follow-up with neurologist and/or neurosurgeon is essential

• LP should not be performed in obstructive hydrocephalus (risk of herniation)
  
• Suspect hydrocephalus in children whose head circumference is growing rapidly
  
• Consider hydrocephalus in patients with CSF shunts and any neurologic complaint
  

• Conn HO. Normal pressure hydrocephalus (NPH): More about NPH by a physician who is the patient.
  Clin Med
  . 2011;11:162–165.
  
• Graff-Radford NR. Normal pressure hydrocephalus.
  Neurol Clin
  . 2007;25:809–832.
  
• Krause JK, Halve B. Normal pressure hydrocephalus: Survey on contemporary diagnostic algorithms and therapeutic decision-making in clinical practice.
  Acta Neurochir.
  2004;146:379–388.
  
• Newman JP, Segal R. Images in clinical medicine: Communicating hydrocephalus.
  N Engl J Med.
  2004;351:e13.
  
• Rekate HL. A contemporary definition and classification of hydrocephalus.
  Semin Pediatr Neurol
  . 2009;6:9–15.
  

See Also (Topic, Algorithm, Electronic Media Element)

Ventricular Peritoneal Shunts

CODES

• 331.3 Communicating hydrocephalus
  
• 331.4 Obstructive hydrocephalus
  
• 331.5 Idiopathic normal pressure hydrocephalus (INPH)
  

BASICS

• Administration of 100% oxygen at >1 atm (typically 2–3 atm)
  
• Mechanisms of action:
  
  • Increases oxygen availability at the cellular level:
    
    • Breathing 100% oxygen at 3 atm supplies enough dissolved oxygen to support life without hemoglobin.
      
  • Compresses formed gas bubbles (in cases of air embolism or decompression sickness)
    
• 2 types of hyperbaric oxygen chambers:
  
  • Monoplace:
    
    • Accommodates 1 supine patient
      
    • Technician outside the chamber for monitoring
      
    • Compressed with 100% oxygen
      
  • Multiplace:
    
    • Holds multiple patients
      
    • Holds attendants who “dive” with the patients
      
    • Airlocks available for medication/equipment transfer outside of the chamber
      
    • Compressed with air—patients breath oxygen by face mask, endotracheal tube, or face hood.
      

DIAGNOSIS

Indications for hyperbaric oxygen therapy:

• Arterial gas embolism
  
• Decompression sickness
  
• Carbon monoxide toxicity
  
• Soft tissue infections:
  
  • Clostridial myonecrosis
    
  • Necrotizing fasciitis
    
  • Refractory osteomyelitis
    
  • Chronic nonhealing wounds
    
• Wound care:
  
  • Radiation-induced tissue injury
    
  • Crush injuries
    
  • Thermal burns
    
  • Compromised skin grafts and flaps
    

• Determine need for hyperbaric oxygen therapy as described above.
  
• Perform a comprehensive physical exam to screen for contraindications to therapy and to establish a pretreatment baseline exam.
  
• Contraindications to therapy:
  
  • Untreated pneumothorax is the absolute contraindication:
    
    • May convert to a tension pneumothorax
      
  • Cardiovascular instability:
    
    • Unstable patient cannot be treated in a monoplace chamber.
      
    • Such a patient may be treated in multiplace chamber if benefit outweighs risk.
      

Arterial blood gas:

• To evaluate for hypoxia in appropriate cases
  

Chest radiography:

• To evaluate for occult pneumothorax
  

TREATMENT

• Manage ABCs
  
• Establish IV access.
  
• 100% oxygen
  
• Cardiac monitor (when appropriate)
  

• Determine need for hyperbaric oxygen therapy.
  
• Fill any devices with balloons (Foley catheters, endotracheal tubes) with fluid to avoid rupture during therapy.
  
• Pretreat patients with any sinus complaints with decongestants.
  
• Place myringotomy tubes in obtunded or mechanically ventilated patients or in patients with middle ear pathology (e.g., otitis media).
  

FOLLOW-UP

• Arterial gas embolism
  
• Decompression sickness
  
• Significant carbon monoxide toxicity
  

Stable patient with resolved symptoms

• May need to transfer to a facility that has a hyperbaric oxygen chamber
  
• Evaluate risks and benefits when considering the transfer of a potentially unstable patient.
  
• Divers Alert Network:
  
  • 24 hr emergency hotline for consultation of dive-related injuries
    
  • Referral source for hyperbaric oxygen chambers
    
  • Telephone number:
    
    • 919-684-9111
      
  • Website:
    
    • www.diversalertnetwork.org
      

Hyperbaric follow-up for repeat recompression therapy.

• Fill any devices with balloons (Foley catheters, endotracheal tubes) with fluid to avoid rupture during therapy.
  
• Check for occult pneumothorax.
  

• Buckley NA, Juurlink DN, Isbister G, et al. Hyperbaric oxygen for carbon monoxide poisoning.
  Cochrane Database Syst Rev
  . 2011;(4):CD002041.
  
• Guzman, JA. Carbon monoxide poisoning.
  Crit Care Clin
  . 2012;28(4):537–548.
  
• Weaver LK. Carbon monoxide poisoning.
  N Engl J Med
  . 2009;360:1217–1225.
  

See Also (Topic, Algorithm, Electronic Media Element)