1. Objectives Review physics of compressed air diving
Complications during descent
Medical problems at depth
Complications during ascent
Prevention of complications
Prehospital care of dive injuries
Hyperbaric therapy for dive injuries

2. Case Report
Veteran police diver is pulled from the water with no vital signs during a training exercise
The 50-year-old diver signalled her partner that she had encountered some sort of difficulty
The partner pulled the officer back into the boat and began administering CPR enroute back to land
On arrival, paramedics encounter a female police officer with no vital signs
The partner, a 48 year old male officer is short of breath and complaining of back pain

3. Your next steps? What do you want to know? What do you want to do?
What triage decisions do you make?
What resources do you need?

5. A brief history of diving
Breath-hold diving for food and resources for thousands of years
Evidence of Neanderthal divers 40,000 years ago
Fires built by Fuegian Indian divers in Straits of Magellan to warm themselves (hence “Tierra del Fuego”)
Ancient Greece and Persia recorded military use of diving bells (e.g. to cut anchor cables, bore holes in ships)

6. Compressed air diving
Mid-1800’s – first practical surface-supplied diving suit
French engineers pioneer compressed air to keep underwater chambers dry for work on bridge footings
1943 – Cousteau and Gagnon invent SCUBA
Presently has recreational, scientific commercial, and military applications
Enhancements: rebreather systems, mixed gas diving

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Physics
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8. Effects of ambient pressure
Sea level
1 ATM
Effects of ambient pressure
Boyles Law:
As ambient pressure increases,
volume decreases
SCUBA delivers increasing amounts of gas to maintain normal volume against ambient pressure
10 m
2 ATM
20 m
3 ATM
30 m
4 ATM

9. Dive Medicine and Hyperbaric Therapy
Dr. Michael Feldman
Sunnybrook-Osler Centre for Prehospital Care

10. Henry’s Law

11. Ascent
Dissolved gas comes out of solution and is exhaled
Descent
Increased pressure increases dissolved gas

12. Descent Ambient pressure increases tremendously
Body tissues act as a non-compressible fluid and the force is not perceptible
Gas-filled spaces (sinuses, middle ear, lung, gastrointestinal tract) are compressible
Lung is filled with SCUBA-supplied gas at increased pressures, which resists the compressive force of water
Increased partial pressures in lungs responsible for increased dissolved gases in the bloodstream

13. Barotrauma of Descent Mask barotrauma Sinus barotrauma
External ear barotrauma (if air is trapped by hood)
Barotitis media
Inner ear barotrauma (round or oval window can be ruptured by either increased pressure in middle ear or forceful Valsalva maneuver)
Suit squeeze
Dental barotrauma
Lung squeeze (breath-hold divers, >30 m depth)

14. Mask Barotrauma
As diver descends, air must be added to airspace between mask and face
If the diver forgets, periorbital edema, ecchymosis, and subconjunctival hemorrhage may result
This is usually benign despite the dramatic appearance

15. Sinus barotrauma
If any of the sinuses are blocked, a relative vaccuum develops
Patient presents with severe pain in the affected sinus (usually frontal sinus)
On ascent, the expanding gas may result in expulsion of blood and mucous into the nose and mask

16. Barotitis Media
During descent, pressure in the middle ear must be equalized at regular intervals
Diver may experience ear pain as water pressure distorts the tympanic membrane
Rupture of tympanic membrane will relieve the pain, but may be accompanied by severe vertigo as cold water enters the middle ear

17. Lung Squeeze Rare complication in breath hold diving
“No limits” diving – men’s world record 172 m; women’s record 160 m
Well-documented dive in which a Belgian diver flooded his sinuses and eustachian tubes during descent; reached 210 m
Lungs get compressed to very small volumes, causing pulmonary edema

18. Complications at Depth
Nitrogen narcosis – increased dissolved nitrogen acts as an intoxicant, possibly by altering electical properties of excitable membranes
Begins at m: euphoria, deterioration in judgment
70-90 m: auditory and visual hallucinations
120 m: loss of consciousness
Treated by ascent
Prevented by heliox commercial diving gas mixtures

19. Oxygen Toxicity Pulmonary toxicity CNS toxicity
Can cause alveolar damage and pulmonary edema
Not a problem in diving (but a consideration in hyperbaric chambers – breathing 100% O2 at 3 ATM)
CNS toxicity
Occurs when breathing 100% O2 at high ambient pressures
Causes oxygen-induced seizures in hyperbaric chambers
Treatment: removal of supplemental O2

20. Ascent Decreased ambient pressure allows gas-filled spaces to expand
Decreased partial pressure of gases in lungs allows dissolved gases to come out solution
Bubbles form in tissues
Pressure in lungs forces air across alveolar membrane
Alveolar rupture

21. Pulmonary Barotrauma
Expansion of trapped alveolar gas (e.g. against a closed glottis)
Divers usually have a history of rapid or uncontrolled ascent (out of air, uncontrolled positive buoyancy)
A pressure difference of 80 mmHg (1 m ascent) is sufficient to force air across pulmonary alveolar membrane into interstitial space or vascular system
May result in pneumothorax, pneumomediastinum, pneumoperitoneum, or arterial gas embolism

22. Pulmonary Overpressurization
26 year old naval seaman
One hour dive between 3 and 10 m depths
Chest pain, neck swelling, hoarse voice immediately on surfacing
Treated with 100% O2; resolved within 2 days without sequelae

23. Arterial Gas Embolism
The most dramatic injury associated with compressed air diving
Air bubbles forced into pulmonary microcirculation and through to left atrium, where they are dispersed to arterial circulation
Result in mechanical occlusion of small arteries and disruption of BBB resulting in cerebral edema
Clinical presentation is usually sudden and dramatic
Anyone who has neurologic symptoms or loss of consciousness within 5 minutes of surfacing should be presumed to have AGE

24. Cerebral Arterial Gas Embolism
42 year old recreational diver with 2 years experience
Seen to have suddenly surfaced
When reached by the boat, he had no vital signs. His air tank was empty and his buoyancy compensator fully inflated
CPR started immediately, with return of circulation 12 minutes later
Seizures and decorticate posturing in ED
Hyperbaric treatment (USN table 6A) for 7 hours
Now confined to wheelchair; able to carry out most ADLs

25. Cerebral Arterial Gas Embolism

26. Decompression Sickness I
Pain in joints with the consequent loss of function
The pain often described as a dull ache, most common in shoulders or knees
The pain is initially mild and divers may attribute early DCS symptoms to overexertion
Skin bends: rashes, mottling, itching and lymphatic swelling

27. Decompression Sickness II
CNS, pulmonary, or circulatory involvement
Spinal cord is the most common site for Type II DCS
Low back pain may start within minutes and may progress to paresis, paralysis, paresthesias, and loss of sphincter control
Other symptoms may include headaches, visual disturbances, dizziness, and changes in mental status or cognition
Labyrinthine DCS (the staggers) causes nausea, vomiting, vertigo, nystagmus, tinnitus and hearing loss. Labyrinthine disturbances not associated with other symptoms of DCS likely due to barotrauma
Pulmonary DCS (the chokes) causes (1) substernal discomfort, (2) non-productive cough, and (3) respiratory distress
Hypovolaemic shock – fluid shifts from intravascular to extravascular space

28. Prevention of Decompression Sickness
Limit time spent at depth
Slow and staged ascents (decompression stops) so that body’s burden of nitrogen is eliminated without forming bubbles
USN and commercial dive tables
Dive computers to track dive profile and calculate decompression requirements
Avoidance of flight for 24 hours after last dive
Protective effect of vigourous exercise

29. USN Navy Dive Table

30. Prehospital Care of Diving Injuries
100% O2 to facilitate washout of N2
Crystalloid infusion – maintains capillary perfusion for elimination of bubbles
Diazepam may relieve labyrinthine vertigo (if not responsive to dimenhydrinate)
ASA (bubbles may cause platelet aggregation)
ALS procedures as appropriate (e.g. needle decompression)
Transport to hyperbaric facility

31. Hyperbaric Oxygen Therapy
Toronto hyperbaric chamber at UHN General site
Multiplace chamber can dive to 2 to 5 ATM
Other Ontario chambers in Hamilton, Ottawa, Tobermory
Access via DAN or Criticall

32. HBOT - Indications Air or gas embolism
Carbon monoxide poisoning ± cyanide
Clostridal myositis (gas gangrene) and necrotizing soft tissue infection
Crush injury, compartment syndrome (acute traumatic ischemia)
Decompression sickness
Problem wound healing
Exceptional blood loss (anemia)
Intracranial abscess
Osteomyelitis (refractory)
Delayed radiation injury (soft tissue and bony necrosis)
Compromised skin grafts and flaps
Thermal burns and frostbite

33. Recompression Treatment
Air breathing

34. Objectives Review physics of compressed air diving
Complications during descent
Medical problems at depth
Complications during ascent
Prevention of complications
Prehospital care of dive injuries
Hyperbaric therapy for dive injuries

35. Questions?