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Diving Related Injuries. Amy Gutman MD ~ EMS Medical Director [email protected] / www.TEAEMS.com. Diving Emergency Categories. Environmental: Hypothermia, sunburn, physical trauma Aquatic Activities: Submersion injuries, motion sickness, envenomations Scuba Diving Injuries: - PowerPoint PPT Presentation
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Diving Emergency Categories
Environmental: Hypothermia, sunburn, physical
trauma
Aquatic Activities: Submersion injuries, motion
sickness, envenomations
Scuba Diving Injuries: Pressure changes Breathing gases at elevated
partial pressures Barotrauma Arterial Gas Embolism Decompression Sickness
Today’s lecture focuses on scuba-related injuries & barotrauma
Standard Management Flowchart for Diving-
Related Injuries
Diving Emergencies: Boyle’s Law
The volume of a gas is inversely proportional to it’s pressure if the temperature is constant
Translation: The more pressure exerted on a gas, the less volume of gas there is in a closed container
Dalton’s Law
Total pressure of a mixture of gases is equal to the sum of partial pressures of the individual gases
Translation:Partial Pressure A = 1Partial Pressure B = 2Partial Pressure C = 3A + B + C = 6 (Total
Pressure)
A=1 B=2 C=3
6
Diving Emergencies: Henry’s Law
The amount of gas dissolved in a given volume of liquid is proportional to the pressure of the gas above it
Pressure = 6
1
1
1
1
1
1
Diving Emergencies: Pathophysiology
Henry’s Law: Increased dissolution of gases during descent
Boyle’s Law:Gases have smaller volume in water than on surface
In controlled ascents, gases escape through respiration
In uncontrolled ascents, gases rapidly come out of solution (blood) forming nitrogen bubbles in tissues & organsCommon: brain, skin, inner ear, muscles, joints
Diving Emergencies: Classification
Surface InjuriesStrangulation
Descent InjuriesBarotrauma
Floor InjuriesNitrogen narcosis
Ascent InjuriesDecompression illnessPulmonary overpressure & subsequent arterial gas
embolism, pneumomediastinum, or pneumothorax
BlackoutsDeep Water Blackout Shallow Water
Blackout Hypoxia upon ascent from
depth
O2 partial pressure in lungs under pressure at bottom of a deep free-dive adequate to support consciousness at that depth
O2 levels drop below blackout threshold as the water pressure decreases upon ascent forcing gases out of bloodstream (Henry’s law)
Divers often hyperventilate prior to swimming or diving
Urge to exhale triggered by rising blood CO2 levels
Hyperventilation depletes CO2 leaving diver susceptible to sudden loss of consciousness from hypoxia
There is no bodily sensation that warns a diver of an impending blackout & divers victims lose consciousness & drown without alerting anyone they are in distress
Typically found on ocean floor
Diving Emergencies: AssessmentAscent rate
Diver experience
Depth gauge function
PMH including prior diving illness
Prescribed / illicit meds (i.e. ETOH)
Diving Emergencies: AssessmentTime of onset
Breathing apparatus used
Hypothermia-protective garment type worn
Aircraft travel following dive
Dive “Table” Parameter # dives, depth, & duration
US Navy / PADI Dive TablesDepth Time35 31040 20050 10060 6070 5080 4090 30100 25110 20115 15 120 13 130 10
Decompression Illness
Dives >33 ft, or shallow depth if (+) PMH
Nitrogen gas coming out of solution Symptoms between 5 mins-8
hrs post surfacing
Clinical Manifestations: MS: joint pain, parasthesias
lymphedema Neuro: seizure, HA, AMS,
paralysis, fatigue GI: abdominal pain, N/V Skin: pruritis Vasomotor: hypotension,
tachycardia
Management: Slow, controlled hyperbaric
chamber recompression
Decompression Illness TreatmentABCs & resuscitation as needed
Supportive careHyperbaric chamber
recompression If air evacuated, maintain cabin
pressure at sea level or fly at low altitude
Send diving equipment for analysis
Full cardiac & neurological work-up necessary to evaluate for underlying cause(s)
BarotraumaMask SqueezeTM rupture Middle ear squeezeBarosinusitis /
Barodentalgia VertigoSuit squeezeGI barotraumaMediastinal
emphysemaPneumothorax /
Hemothorax
Arterial Gas EmbolismSevere form of barotrauma
Onset of symptoms immediately upon ascent CVA, MI, cardiac arrest, LOC,
seizure, HA Suspect in patient with
neurological deficits immediately after ascent
Pressure induced gas transfer across alveolar-capillary membrane causes bubbles to enter arterial circulation
Treatment is hyperbaric chamber & resuscitation
Arterial Gas Embolism Can Occur in Brain, Lungs,
Heart, Joints, Skin
Arterial Gas Embolism TreatmentABCs, IV, Monitor
Airway managementResuscitation as needed
Supine position or reverse Tradeleburg
Frequent vital signs
Corticosteroids?
Rapid transport to a recompression chamber
Pulmonary OverpressureFailure to exhale during ascent
Can occur with dives in <6 ft of water
Lung rupture leaks air into pleural space compressing lung & aorta
SSX: Bloody sputum Chest pain Reduced chest movement Respiratory distress
Treat as a pneumothorax
Pneumomediastinum
Failure to exhale during ascent
Lung rupture forces air into neck, mediastinum, around heart & other organs
Symptoms Bloody sputum / dyspnea Chest pain Arrythmia Hypotension with narrow
pulse pressure Neck swelling, difficulty
swallowing, hoarse voice
Chest wall feels like “rice krispies”
Nitrogen Narcosis
Occurs during diveSigns and Symptoms
AMSImpaired judgment may
lead to further injury
TreatmentReturn to shallow depthHyperbaricsUse O2/helium mix during
dive (heliox)
Diving Emergencies
Patients generally triaged to local hospital for initial stabilization, then transferred to hyperbaric-capable facility
Diver’s Alert NetworkConsultation & referrals
24/7(919) 684-8111 Dan the Diving Dog
ReferencesNFPA 1670DAN Networkwww.uptodate.comWikipedia, GoogleBuzzacott P. Epidemiology
of injury in scuba diving. Med Sport Sci. 2012
Salahuddin M. SCUBA medicine: a first-responder's guide to diving injuries. Curr Sports Med Rep. 2011
[email protected] / www.TEAEMS.com
Diving physics review
Assessment & management of diving injuries
Treatment involves ABCs, stabilization & symptomatic management, & often resuscitation followed by a dive in a hyperbaric chamber
