A scuba diver ascends and develops mottled skin and arthritis in the shoulder and knee that is not worsened by movement. What is the diagnosis and initial treatment?

A scuba diver ascends and develops mottled skin and arthritis in the shoulder and knee that is not worsened by movement. What is the diagnosis and initial treatment?

• A. Decompression sickness Type 1 — 100% oxygen; IV fluids; Recompression therapy (hyperbaric oxygen); Lidocaine
• B. Decompression sickness Type 2 — 100% oxygen; IV fluids; Recompression therapy (hyperbaric oxygen); Lidocaine
• C. Pulmonary embolism — 100% oxygen; IV fluids; Heparin; Analgesics
• D. Arterial gas embolism — 100% oxygen; IV fluids; Recompression therapy; Lidocaine

Answer: (A)

Gas bubbles formed during rapid ascent from depth cause decompression sickness when nitrogen comes out of solution in tissues and blood. The pattern of symptoms helps stage the illness. In this scenario, mottled skin (cutis marmorata) and joint pains that are not worsened by movement point to involvement of skin and musculoskeletal tissues without central nervous system or serious pulmonary signs. That constellation is classic for decompression sickness Type I, which is the milder form. Initial management focuses on rapidly reducing bubble size and improving tissue oxygenation. Start 100% oxygen immediately to maximize oxygen delivery and promote nitrogen washout from tissues. Establish IV access and give fluids to support perfusion and help circulate dissolved nitrogen. Arrange hyperbaric recompression therapy as soon as possible; this is the definitive treatment because it directly compresses the bubbles and accelerates nitrogen resolution. Analgesia for joint pain is often provided; lidocaine may be used in some protocols as an adjunct but the essential steps are oxygen, fluids, and hyperbaric therapy. Pulmonary embolism or arterial gas embolism would present with different features, such as acute cardiopulmonary symptoms or rapid neurologic deterioration, and are not the fitting explanation for the skin findings and non-worsening joint pain described here.

Gas bubbles formed during rapid ascent from depth cause decompression sickness when nitrogen comes out of solution in tissues and blood. The pattern of symptoms helps stage the illness. In this scenario, mottled skin (cutis marmorata) and joint pains that are not worsened by movement point to involvement of skin and musculoskeletal tissues without central nervous system or serious pulmonary signs. That constellation is classic for decompression sickness Type I, which is the milder form.

Initial management focuses on rapidly reducing bubble size and improving tissue oxygenation. Start 100% oxygen immediately to maximize oxygen delivery and promote nitrogen washout from tissues. Establish IV access and give fluids to support perfusion and help circulate dissolved nitrogen. Arrange hyperbaric recompression therapy as soon as possible; this is the definitive treatment because it directly compresses the bubbles and accelerates nitrogen resolution. Analgesia for joint pain is often provided; lidocaine may be used in some protocols as an adjunct but the essential steps are oxygen, fluids, and hyperbaric therapy.

Pulmonary embolism or arterial gas embolism would present with different features, such as acute cardiopulmonary symptoms or rapid neurologic deterioration, and are not the fitting explanation for the skin findings and non-worsening joint pain described here.