Smith R M, Neuman T S
Division of Pulmonary and Critical Care Medicine, University of California, San Diego School of Medicine.
N Engl J Med. 1994 Jan 6;330(1):19-24. doi: 10.1056/NEJM199401063300104.
Arterial gas embolism due to pulmonary barotrauma and the resultant cerebral gas embolism are catastrophic complications of diving. Previous studies have only rarely noted evidence of gas embolism to noncranial sites.
Among 142 persons with diving-related injuries evaluated between January 1982 and July 1991, we identified 29 who had arterial gas embolism and who underwent biochemical studies indicative of muscle injury. Of the 29 patients, 4 were excluded because cardiopulmonary resuscitation had been performed and 3 were excluded because the duration of their dives met or exceeded standard limits set for dives not requiring staged decompression. The outcome at the time of hospital discharge in the remaining 22 patients was correlated with clinical factors and the results of biochemical studies. We also studied 22 subjects after uncomplicated dives and 11 patients who had sustained blunt trauma.
All the patients with diving-associated gas embolism had elevated serum creatine kinase activity (normal, < or = 175 U per liter); the values were markedly elevated (> 900 U per liter) in 14. The MB isoenzyme of creatine kinase was detected in the serum of 13 of 20 patients in whom it was measured and was > or = 4 percent of total creatine kinase activity in 6 patients. In three patients electrocardiography showed myocardial injury. Changes in serum creatine kinase activity of similar magnitude were not present in the subjects who had uncomplicated dives or in the patients with blunt trauma. Thirteen patients recovered fully, four had minor residual neurologic deficits, three were severely impaired, and two died. Logistic-regression analysis revealed a significant correlation between peak serum creatine kinase values and clinical outcome.
Biochemical evidence of muscle injury is frequently found after diving-associated arterial gas embolism. The correlation between serum creatine kinase activity and outcome suggests that serum creatine kinase is a marker of the size and severity of arterial gas embolism.
肺气压伤导致的动脉气体栓塞以及由此引发的脑气体栓塞是潜水的灾难性并发症。以往研究很少提及气体栓塞至非颅脑部位的证据。
在1982年1月至1991年7月间评估的142例与潜水相关损伤的患者中，我们确定了29例患有动脉气体栓塞且接受了提示肌肉损伤的生化研究的患者。在这29例患者中，4例因已进行心肺复苏而被排除，3例因潜水时间达到或超过了无需分级减压潜水的标准时限而被排除。其余22例患者出院时的结局与临床因素及生化研究结果相关。我们还研究了22例潜水未出现并发症的受试者以及11例遭受钝性创伤的患者。
所有与潜水相关气体栓塞的患者血清肌酸激酶活性均升高（正常范围为≤175 U/L）；14例患者的值显著升高（>900 U/L）。在20例检测了肌酸激酶同工酶MB的患者中，13例血清中检测到该同工酶，6例患者中其活性占总肌酸激酶活性的≥4%。3例患者心电图显示心肌损伤。潜水未出现并发症的受试者或钝性创伤患者血清肌酸激酶活性未出现类似程度的变化。13例患者完全康复，4例有轻微的残余神经功能缺损，3例严重受损，2例死亡。逻辑回归分析显示血清肌酸激酶峰值与临床结局之间存在显著相关性。
潜水相关动脉气体栓塞后常可发现肌肉损伤的生化证据。血清肌酸激酶活性与结局之间的相关性表明，血清肌酸激酶是动脉气体栓塞大小和严重程度的标志物。
