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Diving Related Injuries

Diving Related Injuries. Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com / www.TEAEMS.com. Diving Emergency Categories. Environmental: Hypothermia, sunburn, physical trauma Aquatic Activities: Submersion injuries, motion sickness, envenomations Scuba Diving Injuries:

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Diving Related Injuries

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  1. Diving Related Injuries Amy Gutman MD ~ EMS Medical Director prehospitalmd@gmail.com / www.TEAEMS.com

  2. 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

  3. Standard Management Flowchart for Diving-Related Injuries

  4. 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

  5. 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 = 1 • Partial Pressure B = 2 • Partial Pressure C = 3 • A + B + C = 6 (Total Pressure) A=1 B=2 C=3 6

  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 1 1 1 1 1 1 Pressure = 6

  7. 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 & organs • Common: brain, skin, inner ear, muscles, joints

  8. Diving Emergencies: Classification • Surface Injuries • Strangulation • Descent Injuries • Barotrauma • Floor Injuries • Nitrogen narcosis • Ascent Injuries • Decompression illness • Pulmonary overpressure & subsequent arterial gas embolism, pneumomediastinum, or pneumothorax

  9. Blackouts Deep 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 CO2levels • 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

  10. Blackout “Zones”

  11. Diving Emergencies: Assessment • Ascent rate • Diver experience • Depth gauge function • PMH including prior diving illness • Prescribed / illicit meds (i.e. ETOH)

  12. Diving Emergencies: Assessment • Time of onset • Breathing apparatus used • Hypothermia-protective garment type worn • Aircraft travel following dive • Dive “Table” Parameter • # dives, depth, & duration

  13. US Navy / PADI Dive Tables Depth Time 35 310 40 200 50 100 60 60 70 50 80 40 90 30 100 25 110 20 115 15 120 13 130 10

  14. 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, parasthesiaslymphedema • Neuro: seizure, HA, AMS, paralysis, fatigue • GI: abdominal pain, N/V • Skin: pruritis • Vasomotor: hypotension, tachycardia • Management: • Slow, controlled hyperbaric chamber recompression

  15. Decompression Illness Treatment • ABCs & resuscitation as needed • Supportive care • Hyperbaric 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)

  16. Barotrauma • Mask Squeeze • TM rupture • Middle ear squeeze • Barosinusitis / Barodentalgia • Vertigo • Suit squeeze • GI barotrauma • Mediastinalemphysema • Pneumothorax / Hemothorax

  17. Arterial Gas Embolism • Severe 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

  18. Arterial Gas Embolism Can Occur in Brain, Lungs, Heart, Joints, Skin

  19. Arterial Gas Embolism Treatment • ABCs, IV, Monitor • Airway management • Resuscitation as needed • Supine position or reverse Tradeleburg • Frequent vital signs • Corticosteroids? • Rapid transport to a recompression chamber

  20. Pulmonary Overpressure • Failure 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

  21. 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”

  22. Nitrogen Narcosis • Occurs during dive • Signs and Symptoms • AMS • Impaired judgment may lead to further injury • Treatment • Return to shallow depth • Hyperbarics • Use O2/helium mix during dive (heliox)

  23. Diving Emergencies • Patients generally triaged to local hospital for initial stabilization, then transferred to hyperbaric-capable facility • Diver’s Alert Network • Consultation & referrals 24/7 • (919) 684-8111 Dan the Diving Dog

  24. References • NFPA1670 • DAN Network • www.uptodate.com • Wikipedia, Google • Buzzacott P. Epidemiology of injury in scuba diving.Med Sport Sci. 2012 • Salahuddin M. SCUBA medicine: a first-responder's guide to diving injuries. CurrSports Med Rep. 2011

  25. Summaryprehospitalmd@gmail.com/ 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

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