Dive Emergencies – The First 24 Divers Alert Network (DAN .

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American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Diving EmergenciesThe First 24 HoursSamuel D. Miller IV, D.O.Emergency Medicine - Marian Medical CenterUndersea and Hyperbaric MedicineNAUI #13227LPADI #161841SSI Pro 5000Dive Emergencies – the First 24Divers Alert Network (DAN)2008 Annual ReportBackground. Largely based on 2006 eventsDescent / Ascent Injuries Project Dive Exploration (PDE)The first 10-15 MinutesThe First 24 Hours Dive injuriesThe ER experience Dive fatalitiesHyperbaric Medicine Breath-hold incidents.Table 1: Occurrence of Sports Injuries for 1996Source: Accident Facts, 1998 Edition (detailing 1996 data), National Safety Council.Incidence of NonfatalDiving Number ofParticipantsReported InjuriesIncident 00093,206.154Fishing45,600,00076,828.168Roller 58Tennis11,500,00023,550.204Water skiing7,400,0009,854.133Scuba1,000,000935.094Table 1: Occurrence of Sports Injuries for 1996Source: Accident Facts, 1998 Edition (detailing 1996 data), National Safety Council.P-1

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012DIVING FATALITIESDiver PhysiologyPressureSCUBA Diving.003-.005%Rock climbing.034%Effects of pressureGas absorptionAround 100 SCUBA diving deaths per yearAbsolute Pressure Gauge Pressure 1AtmWhat is pressure?Atmosphere1 Atmosphere 14.7 psi 760 mmHg 33 fsw 10 msw 34 ffw 1.03 kg/cm2 1.01 bar 101 kPa14.7 psi1 atmSea LevelATA Atmospheres Absolute(psia)33 fsw1 atmAtm Atmospheres Gauge(psig)33 fsw1 atm2 ata33 fsw1 atm14.7 psig66 fsw2 atm29.4 psig3 ataDissolving GasPressure / VolumeHenry’s Law: amount of gas (nitrogen,oxygen, etc.) dissolved in the bodyincreases as surrounding total pressureincreasesMechanical Effects of Pressure– Robert BoyleOver time reaches stateof equilibriumMay become “supersaturated”P-2

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012DIVING MEDICINEThe first 10-15 Minutes– Barotraumamask, sinuses, ear, suit, dentalPulmonary InjuryArterial Gas Embolism (AGE)The First 24 Hours– Decompression Sickness (DCS)DCS Type 1DCS Type IIcombined AGE and DCSPulmonary ChokesVestibular DCS– Strains/OveruseEAR BAROTRAUMAEAR BAROTRAUMAClinical Presentation– Fullness and pain– Mild tinnitus– /- vertigonausea, vomiting, vertigo, disorientation– Hearing loss– With TM rupturePain often relievedCold caloric stimulation vertigo, nausea,vomitingEAR BAROTRAUMATreatment– Decongestants– Analgesics– No pressure changes for 7-14 days– Inner Ear - avoid increased CSF pressureTEED SYSTEMMiddle Ear Barotraumavalsalva, straining, lifting, coughing– avoid loud noisesP-3

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012MASK BAROTRAUMAClinical– Periorbital/facial edema– Purpuric hemorrhages– Conjunctival hemorrhagesTreatment– Symptomatic– Cold compresses– AnalgesicsSINUS BAROTRAUMAInadequate PressureEqualizationCauses– Thickened tissue(cold)– Extra tissue– MassesSINUS BAROTRAUMASINUS BAROTRAUMAClinical PresentationTreatment– Pain– Frontal sinus most common– Epistaxis– Pain– Paresthesias– Decongestants– Analgesics– ?Antibiotics? for secondary infection– Surgical drainage if indicated (rare)– No atmospheric changes for 7-14 daysP-4

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012OTHER BAROTRAUMABAROTRAUMA OF ASCENTExternal Ear CanalSkinDentalEar and Sinus– similar to barotrauma ofdescentAlternobaric Vertigo– Unilateral increase in middleear pressure– unequal vestibularstimulation– vertigo, nystagmus, vomiting– symptoms short durationPULMNARYBAROTRAUMAGastrointestinal BarotraumaSwallowed airAbdominal pain,belching, flatusNovice divers thatswallow air,carbonatedbeverages, eatingheavily before divingLocal lung injuryMediastinalSubcutaneousPneumothoraxArterial gasembolismPulmonary BarotraumaEtiology– Running out of air supply– Dropping weight belt– Uncontrolled buoyancy– Panic and breath-holdingascent– Preexisting blebs or bulla– Gas trappingP-5

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Direct Pulmonary DamageShortness of breathChest painHypoxiaPossible hemoptysisDecreased breath soundsPneumomediastinumSubcutaneous EmphysemaMost common manifestationChest pain, shortness of breath,hoarseness and dysphoniaSubcutaneous air “Rice Crispy Skin”Detailed neurologic exam for AGERx. Observation, 100% oxygen, restP-6

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012PneumothoraxRare: 10% of pulmonary barotraumaPleuritic chest pain, dyspneaUnilateral decreased breath soundsRX:– 100% oxygen, observe, repeat CXR– Tube thoracostomy (chest tube)– May need needle thoracostomy in fieldTypes of Gas EmbolismGas EmbolismVenous Gas Embolism (VGE)Arterial Gas Embolism (AGE)Venous Gas Embolism (VGE)Venous Gas Embolism (VGE)CausesHow much is too much?– Diving, neurosurgical procedures,central venous catheterization, trauma,high-pressure mechanical ventilation,Thoracocentesis, Hemodialysis,invasive vascular procedures,Laparoscopic procedures (CO2)–Traditionally 3-5ml/kg–In some cases 10-20ml–2-3ml in the cerebral system is fatal–0.5ml in the LAD causes V-FibP-7

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Venous Gas Embolism (VGE)Venous Gas Embolism (VGE)Venous to arterial gasshuntingTreatment– Supportive– 30% PFO incidence in thegeneral population– Oxygen– Leads to arterializations ofvenous gas bubbles.– HBO usually not warranted in mild cases.Arterial Gas Embolism (AGE)Signs and symptoms– Depends on amount and location of gas– LOC, stupor, confusion, headache, corticalblindness, monoplegia, hemipalegia, focalparalysis, paresthesias, sensory disturbances,convulsions, aphasia, visual field defects,vertigo, dizziness are frequent findings– Sudden Death (5%)Arterial Gas Embolism (AGE)Diagnosis– Onset within short duration ofascent (10-15 minutes)– Clinical suspicion– CXR– CT head– MRI?, Labs?– May be a delayed diagnosisbecause of not considering it.P-8

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Arterial Gas Embolism (AGE)Gas LockWith high volumes of gas, a gas-lockmay occur in the left ventricle leadingto cardiovascular collapse.P-9

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Arterial Gas Embolism (AGE)Treatment– Supportive Care– High flow oxygen– Hyperbaric Oxygen Therapy– FluidsArterial Gas Embolism (AGE)Hyperbaric Oxygen TreatmentDIVING MEDICINERationale– Reduces bubble size– Increases diffusion gradient ofembolized gas– Oxygenates hypoxemictissues– Reduces cerebral edemaThe First 24 Hours– Decompression Sickness (DCS)DCS Type 1DCS Type IIcombined AGE and DCSPulmonary ChokesVestibular DCS“Decompression Illness - DCI”Treatment Protocol– USN TT 6 (TT6A)– Hart TT (monoplace chamber)Decompression SicknessSigns and Symptoms of DCSDepend on ultimate location of bubbles– Bubbles preferentially form around jointsand in spinal cord venous plexusOccurs usually within 3 hours ofsurfacingGrecian Bend– May delayed up to 6-12 hours– rare to present 24 hours after diving(unless altitude exposure)Brooklyn Bridge – CaissonDr. Andrew SmithP-10

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012DCS - Time to onset ofsymptomsDecompression SicknessDCS Type I– Pain, fatigue, Skin and lymphatic bendsPERCENT CASESDCS Type IITIME TO ONSET– Neurologic or spinal cord50 30 minutes of surfacingPulmonary DCS “chokes”85 1 hour of surfacingVestibular DCS95 3 hours of surfacing1delayed 6 hoursDCS Type IIIMusculoskeletal DCS(the bends)DCS - Sport DiversSYMPTOMSFREQUENCYjoint pain50%neurologic symptoms50%Joint painShoulders and elbowsFatigueDysbaric osteonecrosisSkin Manifestations of DCS:“Skin Bends”Cutaneous DCS – CutismarmorataPruritus, erythema, heat sensationShort livedDifferentiate from sun reactions,marine envenomationsCutis marmorata– Blotchy, marbled lesionsP-11

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Neurologic DCSSpinal cord and peripheral nervesymptoms predominateParesthesiasWeaknessUrinary retentionCerebral dysfunctionDifferentiation of Inner EarBarotrauma from Inner Ear DCSPulmonary DCS (the chokes)Inner earbarotraumaVenous gas emboliCough, chest pain, dyspneaTachycardia, tachypnea, shockPulmonary edemaInitial descentHx of difficulty equalizing middle earpressureHx of forceful valsalvaPhysical finding of middle ear barotraumaInner ear DCS Significant time and depth underwater Treatment of inner ear DCS is HBO Inner ear barotrauma may beworsened by HBOAGE vs DCS ?FactorsAGEDiving profileascentDCStime/depth profile(rapid, breath-holding) (minimum exposure)SymptomonsetType ofsymptoms0-10 minutes minutes-hourspulmonarycerebralneurologicjoint painspinal cordP-12

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Prehospital CareDECOMPRESSION ILLNESS - DCIAirway, Breathing, CirculationPositionOxygenFluidsSecure gear / BuddyTransportAGE & DCS– different initiating event with similarclinical presentation– “Type III DCS”– AGE precipitates DCS– DCS precipitates AGETransport and theEmergency RoomTransport and theEmergency RoomIV fluidsOxygenMonitorWatch for changing neurologicdeficitsObtain as complete a story / info aspossible.EKGXray, CTLabs as needed (CPK for DCS)Rule out other causes ie: CardiacEarly consult with DAN / HyperbaricfacilityHyperbarics - HistorySpawned from DivingHistory– Breath Hold– Heavy Vessel1500’s Diving Bell1870’s Caissons– Helmet1823 Deane’s Smoke Helmet– SCUBA1943, Frenchmen, EmileGagnan and Jacques CousteauP-13

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Hyperbarics - HistoryHyperbarics - History1928 “Steel Ball Hospital”Dr. Cunningham1662 Henshaw - the “Domocilium”1670 Boyle Describes DCS in snake1930’s Behnke:– narcotic effect of nitrogen– O2 for the tx of DCS1775 - Priestly discovers Oxygen1940’s US Navy publishestreatment table1879 - Fontaine built a mobile hyperbaricsurgical chamberHyperbaric MedicineHow it WorksAdverse Effects of HBOOxygen Diffusion EffectsMiddle Ear / Sinus BarotraumaPulmonary BarotraumaArterial Gas EmbolismCNS Oxygen ToxicityPulmonary Oxygen ToxicityVisual Refractive ChangesHyperbarics - ContraindicationsHyperbarics - ContraindicationsAbsoluteRelative– Untreated pneumothorax– Inability to equalize ears or sinuses– Certain meds– Emphysema with CO2 retention– Seizure Disorder– PregnancyURI, OM, sinusitis, eustachian tube dysfunctionDoxorubicin, bleomycin, disulfiram,cis-platinum, sulfamylonNOT contraindicated in an emergency– Dead patients– ClaustrophobiaP-14

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012UCSD Hyperbaric ChamberChambersUCSD HyperbaricMedicine Dept.619-543-6400Diving Clinic619-471-9210Long Beach MemorialCatalina HyperbaricChamber - USC(562) 933-696024 Hour Emergency Line310-510-1053USN Treatment Table 6AUSN Treatment TablesUSN Table 4USN Table 5USN Table 6USN Table 6AUSN Table 7P-15

American Osteopathic College of Occupational and Preventive MedicineOMED 2012, San Diego, Wednesday, October 10, 2012Hart AGE/DCSMonoplace Treatment Table100% O2 @ 3.0 ATA for 30 minutes2.5 ATA for 60 minutesDescent / Ascent Time 5 min/ATM2.5 ATA3.0 ATA60 minutes30 minutesApproximately 110 minutesWhat to do when help is not near?Hart AGE/DCS RepeatMonoplace Treatment TableTo transfer or not?100% O2 @ 2.5 ATA for 90 minutesAfter 4 hr SIT if still symptomaticHow long until transport?How far to transport?Risk vs Benefits.2.5 ATADo the symptoms warrant the transfer?90 minutesApproximately 105 minutesP-16

– Pain, fatigue, Skin and lymphatic bends DCS Type II – Neurologic or spinal cord Pulmonary DCS “chokes” Vestibular DCS DCS Type III DCS - Time to onset of symptoms PERCENT CASES 50 85 95 1 TIME TO ONSET 30 minutes of surfacing 1 hour of surfacing 3 hours of surfacing delayed 6 hours DCS - Sport Divers SYMPTOMS FREQUENCY joint .

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