Fulminant DCS is a poorly defined entity, but the term is sometimes used to describe those cases in which, in addition to combinations of the foregoing symptoms, there is clear evidence of widespread systemic effects of bubbles such as haemoconcentration, shock and coagulopathy. This form of the disease is frequently fatal unless there is expert and comprehensive intervention. In this regard, it is notable that access to supportive therapy such as sedation, appropriate airway management, fluid resuscitation, and pharmacologic support of haemodynamics may be a more pressing priority than recompression per se. If patients with fulminant DCS are recompressed without appropriate supportive therapy in place, the outcome is likely to be poor.
CASE REPORT 11.1: A rebreather diver suffered an equipment malfunction after 9 minutes at 110-metre depth and made an uncontrolled ascent to the surface. He was sighted arriving at the surface and retrieved onto the boat, where he was found to be unconscious and apnoeic. He quickly resumed breathing and regained consciousness when cardiopulmonary resuscitation was initiated. A helicopter evacuation was extremely expeditious, and he arrived at a major tertiary hospital with a hyperbaric unit less than 1 hour after surfacing, having been treated with oxygen by a non-rebreather mask. He was complaining of dyspnoea and severe back pain. He had marked widespread cutis marmorata and quadriplegia. The pulse was 152, and peripheral pulses were unpalpable. The initial blood tests revealed marked haemoconcentration (haemoglobin, 254g/l), coagulopathy (activated partial thromboplastin time, 105; international normalized ratio, 2.0) and metabolic evidence of shock (pH, 7.24; lactate, 5; base excess, −12). He was diagnosed with fulminant DCS and catheterized, had large-bore intravenous access established, arterial and central venous lines placed and was aggressively fluid resuscitated and supported with vasopressors as the chamber was prepared for recompression. After sedation and intubation he was recompressed on a maximally extended US Navy Table 6. When sedation was withdrawn after 24 hours, he had recovered almost all motor function. After two further recompressions he, somewhat remarkably, made an essentially complete recovery.