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ObjectivesObjectives
BarotraumaBarotraumaDecompression IllnessDecompression IllnessGas ProblemsGas Problems
Putting it togetherPutting it together
1. pre-existing medical condition eg myocardial 1. pre-existing medical condition eg myocardial
infarctioninfarction
2. trauma/drowning/hypothermia2. trauma/drowning/hypothermia
3. Barotrauma3. Barotrauma
4. Decompression Illness4. Decompression Illness
5. Gas Problems5. Gas Problems
BarotraumaBarotrauma
Boyles LawBoyles Law
Volume inversely Volume inversely proportional to proportional to pressure pressure
Gas attempts to contract or expand IAW Boyle’s Law
In closed spaces, gas cannot enter or escape
Therefore, a pressure differential will develop
Squeese or reverse squeese
1. 1. Non pulmonary barotraumaNon pulmonary barotrauma suit/mask squeezesuit/mask squeeze
sinusessinuses
earsears
teethteeth
bowelbowel
2. 2. Pulmonary barotraumaPulmonary barotrauma arterial gas embolismarterial gas embolism
mediastinal emphysemamediastinal emphysema
pneumothoraxpneumothorax
subcutaneous emphysemasubcutaneous emphysema
EarsEars
Barotrauma Barotrauma Teeds 0-5Teeds 0-5
Alternobaric vertigoAlternobaric vertigoDraeger EarDraeger EarPerilymphatic fistulaPerilymphatic fistulaFacial BaroparesisFacial Baroparesis
Barotrauma TreatmentBarotrauma Treatment
Middle EarMiddle Ear
Restrict diving until resolved;Restrict diving until resolved;Mild (0-1) 24 to 72 hoursMild (0-1) 24 to 72 hoursModerate (2-3) 1 to 8 daysModerate (2-3) 1 to 8 daysSevere (4-5) may take up to six weeksSevere (4-5) may take up to six weeks
decongestant , +/- antibioticdecongestant , +/- antibiotic
Perilymphatic fistulaPerilymphatic fistula ENT referral – may need surgery ENT referral – may need surgery
Facial BaroparesisFacial Baroparesis need to reverse due to ischemia need to reverse due to ischemia -myringotomy-myringotomy
Dental- fractured tooth/abcessDental- fractured tooth/abcess
Bowel- possible surgical consultBowel- possible surgical consult
On ascent or descentOn ascent or descent
Pulmonary BarotraumaPulmonary Barotrauma
1. Arterial Gas Embolism1. Arterial Gas Embolism
2. Pneumothorax2. Pneumothorax
3. Mediastinal Emphysema3. Mediastinal Emphysema
4. Subcutaneous Emphysema4. Subcutaneous Emphysema
Breath-hold on ascentBreath-hold on ascentPanic, buddy breathing, laryngospasmPanic, buddy breathing, laryngospasm
Local air trapping in lungsLocal air trapping in lungs Obstructive lung disease, scarring/fibrosisObstructive lung disease, scarring/fibrosis
Frequent Change in PressureFrequent Change in Pressure
SymptomsSymptomsRapid onset (less than 5 min)Rapid onset (less than 5 min)Likely on ascentLikely on ascentConscious/LOCConscious/LOCAny neurological symptom/sign (internal carotid most likely)Any neurological symptom/sign (internal carotid most likely)HemoptysisHemoptysisShortness of breathShortness of breathHigh pitched cryHigh pitched cryPleuritic type Chest painPleuritic type Chest painSubcutaneous emphysemaSubcutaneous emphysema
Can co-existCan co-exist
with pneumothorax or mediastinal/subcutaneous with pneumothorax or mediastinal/subcutaneous emphysema emphysema
TreatmentTreatment
ABC sABC s
Lie down, on side if unconsciousLie down, on side if unconscious
Head down only for short time if at allHead down only for short time if at all
Catheterization if unconsciousCatheterization if unconscious
100% oxygen100% oxygen
Transport to nearest RCCTransport to nearest RCC
Maintain 1 ATA ambient pressure if possibleMaintain 1 ATA ambient pressure if possible
Treatment Table 6
0
4 Hours 46 Minutes
20 5 20 5 20 5
30
5 20 5 20 5 20 5 20 5 20 5 20
30
ASCENT RATE: 0.3 m/min (1 ft/min)
DESCENT RATE: 18 m/min (60 ft/min)
09 m(30 ft)
18 m(60 ft)
O2 periods3 at 18 msw (60 fsw)6 at 09 msw (30 fsw)
Time to Tx of A.G.E. and ResponseTime to Tx of A.G.E. and Response
Time to Tx (hrs)
Cases Cured
Cases Not Cured
Percentage Cured
< 1 16 8 67% 1 – 2 13 2 87% 2 – 3 12 4 75% 3 – 4 7 4 64% 4 – 5 3 4 43% > 5 7 9 44%
Total 58 31 65%
Decompression IllnessDecompression Illness
Compressed airCompressed air 79% nitrogen79% nitrogen
20% oxygen20% oxygen
Venous bubbles unlike AGEVenous bubbles unlike AGE
Left/right shunt could become arterial eg patent Left/right shunt could become arterial eg patent foramen ovale foramen ovale
1929 Clark infused 2,000 ml air at 50ml/hour into a 1929 Clark infused 2,000 ml air at 50ml/hour into a dog with no signs of DCIdog with no signs of DCI
Asymptomatic Military divers can be shown to have Asymptomatic Military divers can be shown to have
bubbles (on doppler) after experimental divesbubbles (on doppler) after experimental dives
Deeper/longer divesDeeper/longer dives
Inadequate decompressionInadequate decompression
AgeAge
Fatigue before divingFatigue before diving
Cold during decompressionCold during decompression
Heavy exercise before during or after divingHeavy exercise before during or after diving
Dehydration (alcohol consumption)Dehydration (alcohol consumption)
Infection, medicationInfection, medication
Flying after divingFlying after diving
Rapid decompression at altitudeRapid decompression at altitude
Bubbles cause Blood / bubble interface activates Bubbles cause Blood / bubble interface activates
blood componentsblood components
Body treats the bubble as a foreign object and coats Body treats the bubble as a foreign object and coats
it in proteinit in protein
RBC agglutination, platelet consumption, vascular RBC agglutination, platelet consumption, vascular
permeability, leukocyte activation, etc.permeability, leukocyte activation, etc.
Endothelial injury. Bubbles activate complement Endothelial injury. Bubbles activate complement
system in some individuals. system in some individuals.
Decompression sickness/stress ContinuumDecompression sickness/stress Continuum
No diveNo stress
Death
Severe DCSType II
Mild DCSType I
Decompressionstress withsymptoms
Decompressionstress without
symptoms
Mild SymptomsMild SymptomsFatigueFatigue
Fleeting joint discomfort (niggles)Fleeting joint discomfort (niggles)
Skin itch and erythemaSkin itch and erythema
Joint painJoint pain
LymphaticLymphatic
Skin (cutis marmorata)Skin (cutis marmorata)
Severe SymptomsSevere SymptomsCNS/ SpinalCNS/ Spinal
Labyrinthine (staggers)Labyrinthine (staggers)
Pulmonary (chokes)Pulmonary (chokes)
Time to symptomsTime to symptoms
During decompression During decompression RareRare0-30 min0-30 min 50% 50%30-60 min30-60 min 75%75%1-6 hours1-6 hours 90%90%6-12 hours6-12 hours 95%95%12-24 hours12-24 hours 99%99%
TreatmentTreatment
100 % oxygen 100 % oxygen delivers oxygen to tissuesdelivers oxygen to tissues
nitrogen gradient (elimination)nitrogen gradient (elimination)
IV Ringers/normal salineIV Ringers/normal saline
RCC RCC even if symptoms have resolvedeven if symptoms have resolved
Gas ProblemsGas ProblemsSYMPTOMS AT DEPTHSYMPTOMS AT DEPTH
NitrogenNitrogen
OxygenOxygen
Carbon DioxideCarbon Dioxide
ImpuritiesImpurities
O2 COO2 CO
Partial pressure at 1ATA =.21 0.01 %Partial pressure at 1ATA =.21 0.01 %
At 30m 4ATA =.84 0.04At 30m 4ATA =.84 0.04
At 60m 7ATA =1.47 0.07At 60m 7ATA =1.47 0.07
Oxygen ToxicityOxygen Toxicity
PulmonaryPulmonaryCNS occurs at partial pressure 1.6 ATA O2 70m on airCNS occurs at partial pressure 1.6 ATA O2 70m on air 6m on 100% O26m on 100% O2
CONCON – Convulsion– Convulsion
VV – Visual aberrations– Visual aberrations
EE – Ears, ringing, bells, etc– Ears, ringing, bells, etc..NN – Nausea– Nausea
TT – Twitching of facial muscles– Twitching of facial muscles
II – Irritability, behavior changes– Irritability, behavior changes
DD – Dizziness– Dizziness
Nitrogen narcosisNitrogen narcosis
Martini’s lawMartini’s law -- 1 martini per every 10 m after 20m depth1 martini per every 10 m after 20m depth
Carbon dioxideCarbon dioxide
1-10 % symptoms1-10 % symptoms
Headache, nausea, fatigue, sweating, tachycardiaHeadache, nausea, fatigue, sweating, tachycardia
SOB, confusionSOB, confusion
Putting it TogetherPutting it TogetherHistory - History - most importantmost important
dive buddydive buddy
Where Where did the symptoms start and did the symptoms start and WhenWhen descentdescent bottombottom surface 1) immediatelysurface 1) immediately 2) delayed2) delayedType of diveType of dive
Prexisiting conditionsPrexisiting conditions
Physical exam- Physical exam- ABC s ABC s
neuro examneuro exam
Signs- resolving, static, progressingSigns- resolving, static, progressing
AGE or DCS treatment is the same “4 min neuro”AGE or DCS treatment is the same “4 min neuro”
examplesexamplesCase 1 VertigoCase 1 Vertigo
21 year old diver with cold symptoms, pain in ear on descent.21 year old diver with cold symptoms, pain in ear on descent.
Forced valsalva- sudden ( in water) onset of vertigo, tinnitus, Forced valsalva- sudden ( in water) onset of vertigo, tinnitus, hearing losshearing loss
Barotrauma to ear alternobaric vertigoBarotrauma to ear alternobaric vertigo perilymphatic fistulaperilymphatic fistula
Did he get better on the surfaceDid he get better on the surface
CompareCompare
Diver on air 30m for 25 minutes -no decompression stops. Diver on air 30m for 25 minutes -no decompression stops. Develops vertigo tinnitus hearing loss 30 mins after surfaceDevelops vertigo tinnitus hearing loss 30 mins after surface
Diver on air 10m for 120 minutes Diver on air 10m for 120 minutes
Case 2Case 2
Diver on air 15m after 10 mins at depth Diver on air 15m after 10 mins at depth feels dizzy, headache, nauseafeels dizzy, headache, nausea
Surfaces feels fine after 5 mins O2Surfaces feels fine after 5 mins O2
CO2,CO, anxiety, non diving medical CO2,CO, anxiety, non diving medical conditioncondition
Case 3Case 3
24 yr old diver feels unwell at 30m after 20 24 yr old diver feels unwell at 30m after 20 mins. On surface anxious tingling in the mins. On surface anxious tingling in the face and arms feels fatigued, rapid face and arms feels fatigued, rapid breathingbreathing
Physical normalPhysical normal
Unsure – trial of pressure?Unsure – trial of pressure?
Trial of Pressure/Treatment Table 5
0
09 m(30 ft)
18 m(60 ft)
DESCENT RATE: 18 m/min (60 ft/min)
2 Hours 16 Minutes
ASCENT RATE: 0.3 m/min (1 ft/min)
20 5 20
30
5 20
30
O2 periods2 at 18 msw (60 fsw)1 at 09 msw (30 fsw)
5
Case 4Case 4
Diver on vacation several consecutive Diver on vacation several consecutive days diving. Flying home develops pain in days diving. Flying home develops pain in shoulder.shoulder.
Can calculate “repat” group or wait 24 Can calculate “repat” group or wait 24 hours. Do not dive on a travel dayhours. Do not dive on a travel day