Elevation of serum creatine kinase in divers with arterial gas embolization

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.