Decompression illness with hypovolemic shock and neurological failure symptoms after two risky dives: a case report

Hypovolemia is known to be a predisposing factor of decompression illness (DCI) while diving. The typical clinically impressive neurological symptoms of DCI may distract from other symptoms such as an incipient hypovolemic shock. We report the case of a 61‐year‐old male Caucasian, who presented with an increasing central and peripheral neural failure syndrome and massive hypovolemia after two risky dives. Computed tomography (CT) scans of the chest and Magnetic resonance imaging scans of the head revealed multiple cerebral and pulmonary thromboembolisms. Transesophageal echocardiography showed a patent foramen ovale (PFO). Furthermore, the patient displayed hypotension as well as prerenal acute kidney injury with elevated levels of creatinine and reduced renal clearance, indicating a hypovolemic shock. Early hyperbaric oxygen (HBO) therapy reduced the neurological deficits. After volume expansion of 11 liters of electrolyte solution (1000 mL/h) the cardiopulmonary and renal function normalized. Hypovolemia increases the risk of DCI during diving and that of hypovolemic shock. Early HBO therapy and fluid replacement is crucial for a favorable outcome. To our knowledge, the presented case of a severe pulmonary and neurologic decompression illness (DCI) in an experienced diver is the first documented incident related to such volume depletion resulting in a hypovolemic shock syndrome requiring catecholamines and an aggressive intravenous volume expansion therapy. Treatment of an acute DCI should include effective on‐site management with initial normobaric 100% oxygen breathing and administration of oral/venous fluids, as well as rapid hyperbaric oxygenation in a pressure chamber in order to terminate further bubble development, reduce size of existing bubbles, and dramatically increase inert gas clearance from tissue and blood. Since fast inert gas clearance from tissues also needs adequate intra‐ and extravascular fluids as transport solvent to the lung, an appropriate volume substitution should be rated highly in every DCI treatment.