For the purposes of this guideline, a diving accident is defined as an event that is either potentially life-threatening or hazardous to health as a result of a reduction in ambient pressure while diving or in other hyperbaric atmospheres with and without diving equipment. This national consensus-based guideline (development grade S2k) presents the current state of knowledge and recommendations on the diagnosis and treatment of diving accident victims. The treatment of a breath-hold diver as well as children and adolescents does not differ in principle. In this regard only unusual tiredness and itching without visible skin changes are mild symptoms. The key action statements: on-site 100% oxygen first aid treatment, immobilization/no unnecessary movement, fluid administration and telephone consultation with a diving medicine specialist are recommended. Hyperbaric oxygen therapy (HBOT) remains unchanged as the established treatment in severe cases, as there are no therapeutic alternatives. The basic treatment scheme recommended for diving accidents is hyperbaric oxygenation at 280 kPa.
Ein Tauchunfall im Sinne dieser Leitlinie ist ein potenziell lebensbedrohliches oder gesundheitsschädigendes Ereignis, hervorgerufen durch Abfall des Umgebungsdruckes beim Tauchen oder aus sonstiger hyperbarer Atmosphäre mit und ohne Tauchgerät. Diese nationale S2k-Leitlinie legt den aktuellen Stand der Erkenntnisse und der konsentierten Empfehlungen in der Diagnostik und Behandlung von Patienten nach Tauchunfällen dar. Die Behandlung von Apnoetauchern sowie Kindern und Jugendlichen unterscheidet sich prinzipiell nicht.Milde Symptome sind nur die auffällige Müdigkeit und ein Hautjucken ohne sichtbare Hautveränderungen.Wesentliche Bedeutung bei der Versorgung von Tauchunfällen hat die frühzeitige Atmung von 100%igem Sauerstoff. Weiterhin werden die Ruhiglagerung/keine unnötige Bewegung, eine moderate Flüssigkeitsgabe und eine Taucherärztliche Telefonberatung empfohlen.Die hyperbare Sauerstofftherapie (HBOT) ist bei schweren Dekompressionsunfällen unverändert ohne therapeutische Alternative. Als Behandlungsschema wird grundsätzlich eine HBOT bei 280 kPa empfohlen.

Carbon monoxide (CO) can occur in numerous situations and ambient conditions, such as fire smoke, indoor fireplaces, silos containing large quantities of wood pellets, engine exhaust fumes, and when using hookahs. Symptoms of CO poisoning are nonspecific and can range from dizziness, headache, and angina pectoris to unconsciousness and death. This guideline presents the current state of knowledge and national recommendations on the diagnosis and treatment of patients with CO poisoning. The diagnosis of CO poisoning is based on clinical symptoms and proven or probable exposure to CO. Negative carboxyhemoglobin (COHb) levels should not rule out CO poisoning if the history and symptoms are consistent with this phenomenon. Reduced oxygen-carrying capacity, impairment of the cellular respiratory chain, and immunomodulatory processes may result in myocardial and central nervous tissue damage even after a reduction in COHb. If CO poisoning is suspected, 100% oxygen breathing should be immediately initiated in the prehospital setting. Clinical symptoms do not correlate with COHb elimination from the blood; therefore, COHb monitoring alone is unsuitable for treatment management. Especially in the absence of improvement despite treatment, a reevaluation for other possible differential diagnoses ought to be performed. Evidence regarding the benefit of hyperbaric oxygen therapy (HBOT) is scant and the subject of controversy due to the heterogeneity of studies. If required, HBOT should be initiated within 6 h. All patients with CO poisoning should be informed about the risk of delayed neurological sequelae (DNS).
Kohlenmonoxid (CO) kann in zahlreichen Situationen und Umgebungen auftreten, beispielsweise Brandrauch, Feuerstellen in geschlossenen Räumen, Silos mit großen Mengen an Holzpellets; Motoren-Abgase und der Gebrauch von Wasserpfeifen.Die Symptome einer Kohlenmonoxidvergiftung sind unspezifisch und können Schwindel, Kopfschmerz, Angina pectoris bis zu Bewusstlosigkeit und Tod umfassen.Diese Leitlinie legt den aktuellen Stand der Erkenntnisse und der nationalen Empfehlungen in der Diagnostik und Behandlung von Patienten mit Kohlenmonoxidvergiftungen dar.Die Diagnose einer Kohlenmonoxidvergiftung erfordert klinische Symptome und eine nachgewiesene oder wahrscheinliche Exposition mit Kohlenmonoxid. Ein negativer CO-Hämoglobin (Hb)-Nachweis soll nicht zum Ausschluss einer Kohlenmonoxidvergiftung führen, wenn Anamnese und Symptome übereinstimmend sind. Durch eine reduzierte Sauerstofftransportkapazität, die Beeinträchtigung der zellulären Atmungskette und immunmodulatorische Prozesse kann es auch nach Reduktion des CO-Hb zu myokardialen und zentralnervösen Gewebeschäden kommen.Bei Verdacht auf eine Kohlenmonoxidvergiftung soll präklinisch sofort mit einer 100% Sauerstoffatmung begonnen werden.Die klinische Symptomatik der Patienten korreliert nicht mit der CO-Hb Clearance aus dem Blut. CO-Hb-Kontrollen allein sind für eine Therapiesteuerung ungeeignet. Insbesondere bei fehlender Besserung unter Therapie sollte eine Reevaluation für andere möglicherweise vorliegende Differentialdiagnosen erfolgen.Die Evidenz zum Nutzen der hyperbaren Sauerstofftherapie (HBOT) ist aufgrund der heterogenen Studienlage niedrig und wird kontrovers diskutiert.Der Beginn einer HBOT soll gegebenenfalls innerhalb von 6 Stunden erfolgen.Jeder Patient mit Kohlenmonoxidvergiftung soll über das Risiko eines verzögert einsetzenden neurologischen Defizites (delayed neurological sequelae, DNS), aufgeklärt werden.

BACKGROUND: Idiopathic sudden sensorineural hearing loss (ISSHL) is an otolaryngologic emergency. The Undersea and Hyperbaric Medicine Society (UHMS) revised practice guidelines in 2014 adding ISSHL to approved indications. This study investigated whether the UHMS guidelines influenced referral and practice in Australia and New Zealand.
METHODS: Retrospective review of 319 patient referrals in two time periods (five years prior to addition of ISSHL to indications (T-PRE) and three years post (T-POST)).
RESULTS: Seven of eight participating hyperbaric facilities provided data down to the level of the indication for HBOT for analysis. In T-PRE 136 patients were treated with HBOT for ISSHL, representing between 0% and 18% of the total cases to each facility. In the T-POST period 183 patients were treated for ISSHL, representing from 0.35% to 24.8% of the total patients in each facility. Comparison between the two periods shows the proportion of patients treated with ISSHL among all indications increased from 3.2% to 12.1% (P < 0.0009). One facility accounted for 74% (101/136) of ISSHL patients receiving HBOT in T-PRE and 63% (116/183) in T-POST. ISSHL case load at that facility increased from 18% to 24.8% (P = 0.009) after the UHMS guideline publication. Three of the seven units had a significant increase in referrals after the guideline change.
CONCLUSIONS: There remains equipoise regarding HBOT in the management of ISSHL. Only three out of seven units had a significant increase in ISSHL patients after the UHMS guidelines publication. Without well controlled RCTs to develop guidelines based on good evidence this is unlikely to change and practice variation will continue.

Dr Sherlock asks for clarification on the approach adopted by the European Committee on Hyperbaric Medicine (ECHM) to assessing evidence for establishing indications for hyperbaric oxygen treatment (HBOT). Firstly, regardless of the strict process of editing and proof-reading of tables included in the above-mentioned publication, we received comments from some readers that identified imperfect layout of Table 1 and incorrect layout of Table 2 which significantly changed the conclusions to be drawn from them. This concerned both the details of the methodology used and description of the ECHM recommendations and associated levels of evidence. Therefore, those tables are republished in their correct forms in this issue, hoping that this will explain at least some of the doubts and misunderstandings. Both the Editor and ourselves apologise for these errors of publication. Secondly, in the ECHM Consensus Conference methodology, we scored the evidence for clinical studies requiring double-blind randomised controlled trials (RCT) as Level A and B when, at the same time, some scoring scales require simply \'RCT\', as correctly pointed out by Dr Sherlock. Long experience in organising evidence based medicine (EBM) meetings and discussions has taught us that RCTs that are not double blinded are often criticised as having serious potential bias and so are denied as level A evidence. Although we acknowledge that double blinding a clinical study in HBOT is a source of difficulty, we chose a priori to consider only double-blinded RCTs in our grading scale to avoid endless discussions about this potential bias. We are well aware that doing so means that Level A evidence is a difficult target for the hyperbaric community. We agree that many evidence scoring systems have a low level of inter-observer agreement. This is why we treat the Consensus Conference as a valuable tool that provides a better opportunity for discussing the evidence than analysis by a small group of \'experts\'. This is because the whole process is transparent and available to all participants\' comments and input. The final process of voting by the audience after the general discussion thus truly reflects the position of the professional hyperbaric community in Europe on the issued recommendations. By these two mechanisms, the blind application of disputable evidence scoring systems may be avoided or, at least, decreased. Thirdly, the problem of \'sham\' treatments in hyperbaric research has been raised. While this has been discussed many times in the past, hyperbaric research is not the sole field where such sham treatment raises some difficulty. Surgery is probably the best example where RCTs with control arms utilising sham surgical procedures (possibly including the administration of anaesthesia) are rare and can raise major ethical problems. Nevertheless, from an EBM viewpoint, the difficulty of designing a double-blind study is never taken into account during evaluation of clinical studies. Finally, Dr Sherlock pointed out her doubts on the recommendations issued by the ECHM on idiopathic sudden sensorineural hearing loss (ISSHL). While there is no possibility to cite here the full experts\' report on that issue presented during the conference, we understand that a detailed report from the Conference is being prepared for publication. In brief, the strength of evidence has been scored as Level B, in general agreement with the last Cochrane review and the UHMS Committee report. Based on this level of evidence, the Type 1 recommendation was issued with the agreement of the large majority of the Consensus Conference participants.

The ECHM Consensus Conference on indications for hyperbaric oxygen treatment (HBOT) was a welcome update of the evidence for HBOT use. However, clarification is requested in relation to how the GRADE system (Grades of Recommendation, Assessment, Development and Evaluation) was modified and how levels of evidence were applied in the case of idiopathic sudden sensorineural hearing loss (ISSHL). GRADE has a low kappa value for inter-observer agreement, so is modification valid? The original GRADE criteria, using consensus, grades evidence (defined as high, low and very low) and uses this to adjust the strength of recommendations. Randomised controlled trials (RCTs) score highly. The ECHM have modified the GRADE system without explanation, assigning grades as levels 1 to 4 and have asserted that RCTs which are double-blinded constitute level 1 or 2 evidence. This has important implications for HBOT research. The term double-blinded is not used in the abstract, which leads the reader to wonder; where do RCTs which are not double-blinded fit in? The ECHM, by including the term double blinded as a requirement for level 1 or 2, has lifted the evidence bar. Does this constitute a form of research \"bracket creep\"? Double-blinding is viewed by many to require a \'sham\' treatment in hyperbaric research. Many conditions require multiple doses requiring daily hospital attendance with associated costs of lost time from work and daily transport costs. Even with a crossover after the sham, a requirement of many ethics committees, the lost time for a patient is a considerable burden. Delaying HBOT until crossover in those randomised to the control group in a disease that has a narrow therapeutic temporal window, such as idiopathic sudden sensorineural hearing loss (ISSHL), may affect the chance of recovery. Double blinding is logistically difficult with HBOT. A sham treatment may be achieved by using air instead of oxygen; however, this exposes the non-intervention group to a risk that the intervention group does not have, that of decompression sickness (DCS). This may be considered to be unethical. Researchers have used hypoxic air mixtures to compensate for the higher oxygen partial pressure at depth as the control, but this is complex and increases the nitrogen load (and thus the risk of DCS). RCTs which control by other methods should still be considered high level evidence (as the original GRADE system recognised). Many indications for HBOT have multiple therapies against which to compare, which could act as a control. The requirement for double-blinding to achieve level 1 or 2 evidence may hamper research; an unintended negative consequence. There is lack of consistency of definitions in relation to levels of evidence used by the ECHM. The authors state that for clinical research the levels of evidence are; levels A to F, which they defined. The ECHM jury used a grading scale of level 1 to 4. For ISSHL, this results in a recommendation to treat based on level B evidence. Is this the same as level 2 in their modified system? This is confusing. The authors have not explained why they modified the GRADE system which is itself non-validated. The lack of references to the publications which provide the foundation for the strength of the recommendations leaves the reader unable to determine the true strength of the evidence. The GRADE system has been criticised as it dissociates recommendations from the evidence that the recommendation is founded upon. Further, the application of the GRADE system has been questioned when strong recommendations are made with it as this may cause ethics committees to question whether equipoise exists, further hampering research. How do we present a well-designed trial for ISSHL to an ethics committee when a strong recommendation has already been made despite the Cochrane review on ISSHL concluding there is a need for large, well designed RCTs in this area?

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Wound bed preparation is an organized approach to create an optimal environment for wound healing by the use of the most cost-effective therapeutic options. It has become an essential part of wound management and seeks to use the latest findings from molecular and cellular research to maximize the benefits of today\'s advanced wound care products. The international advisory panel on wound bed preparation met in 2002 to develop a systemic approach to wound management. These principles of this approach are referred to by the mnemonic TIME, which stands for the management of nonviable or deficient tissue (T), infection or inflammation (I), prolonged moisture imbalance (M), and nonadvancing or undermined epidermal edge (E). One critical element of pathophysiology, understanding of the hypoxic nature of the wound and correction of hypoxia as a critical element of wound bed preparation, is not covered. This article proposes to add correction of hypoxia to the TIME principle (TIMEO2 principle) based on the evidence. The evidence that will support the reason and the need for modification of the wound bed preparation protocol is discussed.