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Hyperbaric Treatment in N2 Injection Injuries


BlueSkies

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I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions. Hx: 47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4". Injuries: The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow. What I think happened based on the evidence found: When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger. Assessment: The Pt revealed intact PMS in the right hand. Cap refill was normal at <2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable. Tx: Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood. The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further. He was airlifted off the platform to the closest appropriate facility to see the awating ER MD. Outcome: Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage. F/U 48 hrs later: He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist. My Questions for you: A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice. His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process. I was kind of busy when we were discussing this and I of course did not catch the entire reasoning. So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient. What would you have done differently and why? Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!!

I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions.

Hx:

47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4".

Injuries:

The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow.

What I think happened based on the evidence found:

When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger.

Assessment:

The Pt revealed intact PMS in the right hand. Cap refill was normal at <2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable.

Tx:

Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood.

The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further.

He was airlifted off the platform to the closest appropriate facility to see the awating ER MD.

Outcome:

Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage.

F/U 48 hrs later:

He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist.

My Questions for you:

A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice.

His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process.

I was kind of busy when we were discussing this and I of course did not catch the entire reasoning. So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient.

What would you have done differently and why?

Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!!

I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions.

Hx:

47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4".

Injuries:

The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow.

What I think happened based on the evidence found:

When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger.

Assessment:

The Pt revealed intact PMS in the right hand. Cap refill was normal at &lt;2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable.

Tx:

Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood. The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further.

He was airlifted off the platform to the closest appropriate facility to see the awating ER MD.

Outcome:

Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage.

F/U 48 hrs later:

He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist.

My Questions for you:

A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice.

His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process.

I was kind of busy when we were discussing this and I of course did not catch the entire reasoning.

So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient.

What would you have done differently and why?

Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!!

Edited by Gulfmedic9538
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High pressure injection injuries are a surgical emergency and their outcome depends on good surgical consult. I don't think hyperbarics would have made a difference. The nitrogen is not in the blood stream so this is not from the bends. I would guess that there may be a compartment syndrome occurring somewhere in the wrist. Here is a good article from emedicine:

http://emedicine.medscape.com/article/826620-overview

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Sorry, I left out one small detail and I tried to edit it but it just kept putting my new post under my old one. I would love to erase the top two scenarios and only have the 3rd.

You're my hero Doc! Compartment syndrome had crossed my mind as well but I did not realize that this would have been a surgical emergency. As a matter of fact, surgery was not even suggested until this afternoon and today was greater than 72 hours post injury. I was with this patient all total 2 and a half hours and then he had a helicopter ride with another medic that was 1 hour and 10 mins. So all total before definitive care was 3 hours and 40 mins.

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I don't think the initial injury was a compartment syndrome, but I think he developed a compartment syndrome which is why he developed all of the changes after 48 hours.

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I can delete your post, but can't edit it. It's ok, it's obvious what happened. It's a problem the site has been dealing with for a bit...

I don't see treatment wise what you might have done differently. And as Doc mentioned, your diver doc seems to be assuming that nitrogen introduced into the body, regardless of the mechanism, is all the same. I would think that a nitrogen injection injury would be completely different than serum/intravascular issues.

I can't speak to the hyperbaric treatment, though strangely enough I'm about to trial Dylan with it for his autism. I can't see really where it would help nitrogen wise, but perhaps might in general wound healing, as it seems to in other traumas.

It would be interesting to hear the specific treatment justification from the dive doc to see what his reasoning/theoretical reason is/might have been.

Thanks for posting. Interesting injury!

Dwayne

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I also don't think your treatment should have been changed think you did a good job.

I was wondering if maybe the Dive doc was thinking that since the nitrogen is in the tissue that the hyperbaric pressure treatment will help it push back in to serum and be expelled back out the lungs faster. Realizing that it was not introduced through or in to the blood stream initially, but it is still in the tissue and was introduced under extreme pressure possibly creating the compartment syndrome because the nitrogen is now taking up space? The pressure of the hyperbaric chamber could desolve the nitrogen in to the blood stream and expel it from the body like in the bends.

Im thinking of this kind of like when they inflate the abdomen for a lap-chole, there is always some gas left in the cavity following surgery but since that is a hollow space it is not as important that all the gas is eliminated. It has room to be there till it can be absorbed and eliminated through the lungs. Except this is in the hand and wrist where there is not room for the additional gas to take up space. creating the compartment syndrome along with the additional swelling from the initial trauma.

Made sense in my head, What do you think ?

Race

Edited by RaceMedic
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Honestly like I told Doc, Compartment Syndrome from the soft tissue damage was my first thought. When the idea of nitrogen bubbles was introduced into my thought process it really threw me for a loop. I did not speak to the Dive Doc myself, this was feedback I was receiving from another employee out here that has no medical experience. Although he is intelligent I am sure that some parts of the assessment and details of the injury were left out when he spoke to the Doc.

Being in this new realm of medicine out here is fairly nerve wracking sometimes. These are your friends and family and you grow to love these guys. Any feedback I receive is taken to heart and I try to improve myself as a provider daily. Industrial medicine is a different animal when you mix in all the chemicals and pressurized equipment we have on board.

My time frame with the patients and scope of practice grew exponentially as soon as I sat foot into international waters. Factor in OSHA, CFR Rules, Company policy from not only my company but from the client company as well and it quickly becomes a beast.

Thank you all for the responses and I am sure I will be picking your brains again in the very near future.

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Unfortunately another aspect of these injuries in this environment is the, "I can probably move my thumb, but it's worth a hell of a lot more money if I can't" syndrome.

It may be a shitty thing to say, but I'm guessing that you've already seen a few of those patients. Even the heard working guys don't want to gut themselves out of a decent settlement sometimes, and that can make the initial assessment tough, and the follow up, "I've had some time to think" assessment even tougher.

I loved the guys on my rig, and most of them were stand up, but I rarely saw an injury that didn't have at least a flavor of that...

Will you be able to follow this to resolution if he doesn't return to the rig?

Dwayne

Edit. I didn't mean to imply that the entire injury, or the majority of it was faked..only trying to show how sometimes assessments can be retarded in an environment with an employer with really, really deep pockets.

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I agree with you Dwayne. Some of the people can be shady when it comes to a quick payday. My client company is massive and a major oil conglomerate so people can get the dollar sign syndrome.

I will be able to follow up on this to its conclusion and I will post more info as I get it myself. Today marks 96 hours post incident.

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