Lacunar disease – the simptomokompleks which is formed at formation of gas bubbles in vessels and fabrics against the background of bystry decrease in atmospheric pressure. Can be sharp or chronic. It is shown by joint, muscles pains, Menyer's syndrome, dyspepsia, signs of defeat of TsNS, sharp pulmonary and cardiovascular insufficiency. At diagnosis are used anamnestichesky yielded and results of objective survey, the X-ray analysis, ultrasonography, MPT, KT is applied to assessment of a condition of various bodies. Treatment – a rekompressiya with the subsequent slow decompression, symptomatic medicinal therapy.
The lacunar disease (decompressive disease, DKB) – a complex of the changes developing upon transition from high atmospheric pressure to normal is more rare – from normal to lowered. Pathology received the name from the word "caisson" designating the camera created in the forties the 19th century and intended for work under water or in the conditions of water-saturated soil. DKB is considered occupational disease of the submariners and experts working in the conditions of lacunar cameras, is in some cases diagnosed for pilots. In recent years because of wide circulation of diving comes to light at other groups of the population. According to statistical data, the frequency of a disease makes 2-4 cases on 10 000 immersions.
Bystry decrease in atmospheric pressure at change of depth of immersion in water is an immediate cause of DKB, is more rare – when lifting the plane on considerable height. The quicker atmospheric pressure – the more risk of developing of this pathology changes. As the factors increasing probability of development of a disease are considered:
- Aging of an organism. In process of aging the condition of all bodies worsens. It becomes the reason of decrease in compensatory opportunities of lungs and hearts during change of pressure.
- Overcooling. Is followed by delay of a blood-groove in peripheral vessels. Blood from the remote parts of the body comes to pulmonary vessels more slowly, gas is to a lesser extent emitted from blood in the physiological way.
- Dehydration. Viscosity of blood at this state increases that provokes blood circulation delay. At change of external pressure upon peripheries arises which is aggravated with formation of the bubbles blocking a gleam of vessels.
- Physical activity. Exponentiates violation of uniformity of a blood-groove owing to what conditions for intensive dissolution of gases in blood with the subsequent emergence of "silent" bubbles are created. Characteristic is adjournment of microbubbles in joints and increase in probability of developing of pathology at the following immersions.
- Lipidemiya, excessive weight. Fats have the increased water repellency therefore at their high content bubbles are more actively formed. Cells of fatty tissue intensively dissolve the inert gases which are a part of respiratory mixes.
- Giperkapniya. Develops at poor quality of respiratory mix or attempts "to save" it, holding the breath. Increase in quantity of CO2 provokes shift of the acid and main state in the sour party. Because of it in blood more inert gases are dissolved.
- Alcoholic intoxication. At alcohol intake there is dehydration. Besides, molecules of alcohol cause connection of small bubbles in larger and become the centers around which the big bubbles corking blood vessels are formed.
At elevated pressure gases of respiratory mix owing to diffusion in significant amounts are dissolved in blood of capillaries of pulmonary fabric. When pressure decreases, the opposite phenomenon is observed – gases "come out" liquid, forming bubbles. The quicker pressure changes, the more intensively there is a process of the return diffusion. At bystry rise blood of the patient "begins to boil", the emitted gases form a set of large bubbles which can block vessels of different caliber and damage various bodies.
Large bubbles connect with small, to the formed bubbles platelets "stick", the blood clots which are attached to walls of small vessels and blocking their gleam are formed. A part of blood clots comes off with fragments of a vascular wall, migrates on the blood course and blocks other vessels. At a congestion of a large number of such educations the gas embolism develops. At considerable damage of walls integrity is broken, there are hemorrhages.
Emergence of bubbles and formation of their complexes with platelets starts the cascade of biochemical reactions owing to which various mediators are thrown out blood, there is an intra vascular folding. Bubbles are also formed out of the vascular course, in articulate cavities and myagkotkanny structures. They increase in volume and squeeze the nervous terminations, provoking pains. Pressure upon myagkotkanny educations becomes the reason of their damage with formation of the centers of a necrosis to muscles, sinews and internals.
Because of a possibility of defeat of various bodies, essential distinctions in weight and the forecast of the most rational from the practical point of view systematization of types of a disease on the basis of the prevailing manifestations is considered. Clinical classification of M. I. Jacobson represents the developed option of allocation of degrees of a lacunar disease taking into account symptomatology. Distinguish four forms of pathology:
- Easy. Artralgiya, mialgiya, neuralgia caused by a sdavleniye of the nervous terminations by gas bubbles prevail. At a number of patients the itch, greasiness of skin caused by obstruction of small superficial veins, channels grease and sweat glands comes to light .
- Average weight. Frustration from a vestibular mechanism prevail, an eye and the GIT arising owing to an embolism of capillaries and a labyrinth, a congestion of gas bubbles in vessels of a bryzheyka and intestines, a passing spasm of retinalny arteries.
- Heavy. It is shown by quickly accruing symptoms of damage of a spinal cord, as a rule, at the level of srednegrudny segments that is caused by tendency of a myelin to absorption of nitrogen and a weak vaskulyarization of srednegrudny department because of what actively formed bubbles do not migrate with blood, and squeeze nervous tissue. Signs of involvement of a brain come to light much less often. Disorders of warm and respiratory activity are possible.
- Lethal. Arises at the total termination of blood circulation in lungs or a medulla, development of an acute heart failure. It is provoked by formation of a large number of the large bubbles which are at the same time blocking a set of vessels.
In traumatology also apply the simplified classification including two types of sharp DKB to assessment of threat of life of the patient and definition of optimum tactics of treatment. The first type is characterized by defeat of peripheral structures (skin, musculoarticulate system). The second is followed by changes from nervous, respiratory, cardiovascular, digestive systems, in the absence of treatment death is possible. Besides, distinguish chronic option of a lacunar disease which can develop in the presence of sharp pathology in the anamnesis or without the previous sharp phenomena; long time working in the conditions of caissons is diagnosed for people.
In case of severe defeat of manifestation can arise the first minutes after emersion, however more often the clinical picture of a decompressive disease is formed gradually. At a half of patients the symptomatology comes to light within an hour. In 6 hours symptoms of pathology it is found in 90% of patients. The delayed emergence of symptoms is seldom observed (for 1-2 days). At an easy form joint pains, bone structures, muscular tissue, area of a back are noted. The pain syndrome is usually more brightly expressed in shoulder and elbow joints. Patients describe the feelings as "drilling", "deep", amplifying at the movements. Rash, a skin itch, the increased greasiness, a mramornost of coloring of integuments is often noted. Increase in lymph nodes is possible.
At a lacunar disease of average weight Menyer's syndrome caused by damage of an organ of equilibrium and including dizzinesses, a headache, pallor, perspiration, nausea, vomiting is observed. Violations of activity of a GIT are shown by pains, vomiting and diarrhea. The angiospasm of a retina is followed by emergence of fotomorfopsiya, "front sights" and "fog" before eyes. The severe form is characterized by the lower spastic paraplegia, pelvic frustration, violation of sensitivity in the lower half of a body on conduction type. A hemiparesis or a hemiplegia, headaches, the violations of the speech, psychotic frustration having passing character is sometimes observed.
Cardiovascular and respiratory symptoms are found at a severe form and reach the greatest expressiveness at lethal option of a disease. Weakness, pallor, short wind, intensive breast pain, cough, falling HELL is defined. When progressing symptomatology hypostasis of lungs develops, breath becomes frequent, superficial, pulse is slowed down, integuments get a cyanotic or pale gray shade. Heart attacks of lungs and a myocardium are possible. The lethal form is followed by an acute heart failure, asphyxia owing to blockade of pulmonary blood circulation or violation of regulation of breath by a medulla.
The most widespread display of a chronic decompressive disease is the deforming arthrosis caused by the repeating impact of small bubbles on bone and articulate structures. Opinions of scientists concerning a miodegeneration of heart, early atherosclerosis and frequent diseases of a middle ear at the people occupied with works as a lacunar way disperse. One experts consider the listed pathologies the investigation of the repeating subclinical DKB, others – result of influence of other factors arising at stay deeply.
The type and weight of complications are defined by a disease form, timeliness and adequacy of therapeutic actions. The chronic syndrome of Menyer and aeropaticheskiya are considered as the most widespread consequences of a sharp decompressive disease. Other possible complications are pneumonia, myocarditis, an endocarditis, cardiodystrophy, a cardiosclerosis, paresis, paralyzes, sensitivity violations, an aseptic osteonecrosis.
The sharp form of a lacunar disease is diagnosed on the basis of complaints of the patient, anamnestichesky yielded and results of external survey. On roentgenograms vials of gas in joints, muscular tissue, fastion, tendinous vaginas can be found. For definition of a condition of TsNS appoint tomographic researches back and a brain. Confirmation of the diagnosis is improvement of a condition of the patient when carrying out a rekompressiya. The program of inspection at development of complications is defined by the nature of estimated pathology, can include the ECG, an echocardiography, a X-ray analysis, ultrasonography, MPT and KT of various bodies.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Therapy of a disease depending on a form, expressivenesses of symptoms of complications is carried out by resuscitators, traumatologists, pathologists and other experts. At unsharply expressed skin, muscular and articulate manifestations observation in dynamics is admissible. In other cases the urgent rekompressiya in the conditions of a pressure chamber is shown. In the beginning pressure is increased to the indicators corresponding to depth of immersion of the patient. At serious condition of the victim apply pressure above initial. The minimum duration of a rekompressiya makes 30 minutes, at preservation of symptoms the procedure is continued before normalization of a condition of the patient. Then carry out a slow decompression, reducing pressure upon 0,1 atmosphere every 10 minutes. After pressure decrease to 2 atmospheres use inhalation of oxygen for nitrogen removal process acceleration. At emergence of signs of DKB after normalization of pressure carry out a repeated rekompressiya.
According to indications appoint symptomatic therapy. Perform infusions of solution of glucose, plasma, salt solutions. Apply pharmaceuticals to normalization and stimulation of activity of cardiovascular system. In need of the plan of treatment include vasodilating means. At an intensive pain syndrome use not narcotic analgetics. Narcotic pharmreparata are not shown because of the possible oppressing action on the respiratory center. At mialgiya and artralgiya recommend the local warming and anesthetizing medicines. After an exit from a pressure chamber carry out physiotherapy: , diathermy, medical bathtubs.
Forecast and prevention
The outcome of DKB is defined by weight of defeat and time of the beginning of a rekompressiya. At 80% of patients the absolute recovery is noted. Lethal outcomes are observed rather seldom, usually at the emergency rise or lack of the specialized help. Prevention of a lacunar disease includes use of the high-quality equipment for diving and professional works at a depth, strict observance of rules of rise taking into account these specially developed tables, regular medical examinations, an exception of the factors increasing risk of DKB. Preventive measures also assume establishment of a sufficient time interval between the first and the subsequent immersions or flights on air transport, restriction of time of stay in conditions of elevated pressure for divers and workers of caissons.