Diving accident

1. Diving accidentDiving accident
นตนต. . คมสัน วุฒิประเสริฐ รนคมสัน วุฒิประเสริฐ รน..
กองเวชศาสตร์ใต้นำำาและการบิน กองเวชศาสตร์ใต้นำำาและการบิน
กรมแพทย์ทหารเรือกรมแพทย์ทหารเรือ

2. Classification of Diving InjuriesClassification of Diving Injuries
Increase in atmospheric pressure (during Increase in atmospheric pressure (during
descent)descent)
Middle ear/ sinus barortauma of descent.Middle ear/ sinus barortauma of descent.
barotrauma to inner ear.barotrauma to inner ear.
At depthAt depth
Salt water aspirationSalt water aspiration
Nitrogen NarcosisNitrogen Narcosis
UnconsciousnessUnconsciousness

3. Classification of DivingClassification of Diving InjuriesInjuries
Decrease in atmospheric pressure (during Decrease in atmospheric pressure (during
ascent)ascent)
barotrauma of ascentbarotrauma of ascent
Decompression illnessDecompression illness
Arterial EmbolismArterial Embolism
On surfaceOn surface
Salt water aspirationSalt water aspiration
DrowningDrowning
Physical injury (environment/water craft)Physical injury (environment/water craft)

4. BarotraumaBarotrauma
Middle & inner ear barotraumaMiddle & inner ear barotrauma
Sinus barotraumaSinus barotrauma
Pulmonary barotraumaPulmonary barotrauma
Equipment BarotraumaEquipment Barotrauma
““mask squeeze”/ facial barotraumamask squeeze”/ facial barotrauma
“ “suit squeeze”/ skin barotraumasuit squeeze”/ skin barotrauma
Dental BarotraumaDental Barotrauma

5. Boyle’s lawBoyle’s law
- If the temperature remain constant , - If the temperature remain constant ,
the volume of the given mass of gas is the volume of the given mass of gas is
inversely proportional to the absolute pressureinversely proportional to the absolute pressure
PP11VV11 = P = P22VV22

6. Boyle’s LawBoyle’s Law
If mass and temperature remain constant, the volume of a If mass and temperature remain constant, the volume of a
given mass of gas is inversely proportional to the absolute given mass of gas is inversely proportional to the absolute
pressurepressure
PP
11VV
11 = P = P
22VV
22
Surface
10 m10 m
20 m20 m
30 m30 m
2 ATA2 ATA
3 ATA3 ATA
4 ATA4 ATA
1 ATA
1/21/2
1/31/3
1/41/4
6 L
3 L3 L
2 L2 L
1.5 L1.5 L 3 L3 L
6 L6 L
4 L4 L
{12 L}

7. Middle ear barotrauma

10. Middle Ear Barotrauma of Middle Ear Barotrauma of DescentDescent
Causes of Blockage of Eustachian TubeCauses of Blockage of Eustachian Tube
URI and allergies (anything that can cause URI and allergies (anything that can cause
mucosal congestion)mucosal congestion)
alcohol ingestionalcohol ingestion
cigarette smokingcigarette smoking
mucosal polypsmucosal polyps
head down positionhead down position

11. Middle Ear Barotrauma of Middle Ear Barotrauma of DescentDescent
ManagementManagement
Stop Diving Stop Diving (( temporary ) temporary )
avoid Valsalva manoeuvre/ strainingavoid Valsalva manoeuvre/ straining
decongestantsdecongestants
serial audiometry (compare to last medical)serial audiometry (compare to last medical)
advice on ear clearing techniquesadvice on ear clearing techniques
preventionprevention

12. Middle Ear Barotrauma of Middle Ear Barotrauma of AscentAscent
less common - usually equalises passivelyless common - usually equalises passively
damage from distension by enclosed gases damage from distension by enclosed gases
within the middle ear that continues to expand within the middle ear that continues to expand
with ascentwith ascent
more serious as it restricts more serious as it restricts ASCENTASCENT
discomfort to pain discomfort to pain
alternobaric vertigoalternobaric vertigo
avoid decongestants, diving with a coldavoid decongestants, diving with a cold

14. Grade 0 - Symptoms without signsGrade 1 - Injection of the TM
(especially along the handle of the
malleus)

15. Grade 2 - Injection plus slight
haemorrhage within TM
Grade 3 - Gross haemorrhage
within the TM

16. Grade 4 - Free blood in the middle ear
Grade 5 - Perforation/Rupture of
the TM

17. Inner Ear BarotraumaInner Ear Barotrauma
(Perilymph Fistula)(Perilymph Fistula)

18. Inner Ear BarotraumaInner Ear Barotrauma
Symptoms and SignsSymptoms and Signs
1.1.TinnitusTinnitus
2.2.High frequency hearing lossHigh frequency hearing loss
3.3.Vestibular disturbanceVestibular disturbance
nausea, vomiting, vertigo, ataxianausea, vomiting, vertigo, ataxia
Sensation of blockage in affected earSensation of blockage in affected ear
+/- features of middle ear barotrauma+/- features of middle ear barotrauma

19. Inner Ear BarotraumaInner Ear Barotrauma
ManagementManagement
Avoid increase in CSF pressureAvoid increase in CSF pressure
Immediate bed rest with head elevated 30Immediate bed rest with head elevated 30
°°
Consider operative interventionConsider operative intervention
avoid diving and flyingavoid diving and flying

20. Sinus BarotraumaSinus Barotrauma

21. Sinus BarotraumaSinus Barotrauma
pain over sinus during descentpain over sinus during descent
may continue as dull persistent ache for may continue as dull persistent ache for
several hoursseveral hours
usually frontal, less frequently retro-orbital,usually frontal, less frequently retro-orbital,
maxillary pain uncommon but may refer to maxillary pain uncommon but may refer to
upper teethupper teeth
numbness over maxillary division of the numbness over maxillary division of the
trigeminal nerve is possibletrigeminal nerve is possible
Symptoms and Signs:

22. Sinus BarotraumaSinus Barotrauma
PreventionPrevention
refrain from diving with URTI/sinus infectionsrefrain from diving with URTI/sinus infections
discourage use of decongestants while divingdiscourage use of decongestants while diving
appropriate treatment of allergic rhinitis with appropriate treatment of allergic rhinitis with
topical steroidstopical steroids
cease smokingcease smoking

23. Sinus BarotraumaSinus Barotrauma
ManagementManagement
decongestantsdecongestants
analgesicsanalgesics
antibioticsantibiotics
stop diving and flying until resolvedstop diving and flying until resolved

24. mask squeeze/ facial barotraumamask squeeze/ facial barotrauma

25. Facial Barotrauma of DescentFacial Barotrauma of Descent
puffy, oedematous facial tissue, especially under puffy, oedematous facial tissue, especially under
the eyesthe eyes
purpuric haemorrhagespurpuric haemorrhages
conjunctival haemorrhagesconjunctival haemorrhages
generalised bruising of skin underlying the maskgeneralised bruising of skin underlying the mask

27. Pulmonary barotraumaPulmonary barotrauma

28. Pulmonary Barotrauma of AscentPulmonary Barotrauma of Ascent
burst lung or pulmonary overinflation syndromeburst lung or pulmonary overinflation syndrome
result of overdistension and rupture of the lungs result of overdistension and rupture of the lungs
by expanding gases during ascentby expanding gases during ascent

29. Pulmonary Barotrauma of AscentPulmonary Barotrauma of Ascent
Precipitating factorsPrecipitating factors
inadequate exhalationinadequate exhalation caused by panic, faulty caused by panic, faulty
apparatus, inexperienceapparatus, inexperience
Predisposing factorsPredisposing factors
asthmaasthma, intrapulmonary fibrosis, cysts, infection, , intrapulmonary fibrosis, cysts, infection,
pleural adhesions, sarcoidosis, pleural adhesions, sarcoidosis, previous previous
pneumothoraxpneumothorax

31. Decompression sickness.Decompression sickness.
The liberation of gas
bubbles from solution,
into tissues or blood,
in an individual
exposed to a reduction
of environmental
pressure.

32. Henry’s lawHenry’s law
- At a constant temperature - At a constant temperature
the amount of a gas that will dissolve in a liquid the amount of a gas that will dissolve in a liquid
is proportion to the partial pressure of the gas is proportion to the partial pressure of the gas
over the liquidover the liquid

33. 1 atm 2 atm 3 atm

34. PathologyPathology
-BubbleBubble form first inform first in tissuetissue and thenand then
inin venous bloodvenous blood
--TheThe lunglung are usually an effective filterare usually an effective filter
for bubblefor bubble ( ( pulmonary arteriolespulmonary arterioles ) )

35. PathologyPathology
--The ability of lung to filter the bubbleThe ability of lung to filter the bubble
which thenwhich then resolve by gas resolve by gas diffusion todiffusion to
the alveolithe alveoli
--Bubble can also be bypassed through Bubble can also be bypassed through
anatomical defectanatomical defect  patent foramenpatent foramen
ovale ( PFO)ovale ( PFO)

36. Effects of Tissue BubblesEffects of Tissue Bubbles..
Obstruction of vascular flow Obstruction of vascular flow
External compression to vascular , nerveExternal compression to vascular , nerve
lymphatics and sensory cell lymphatics and sensory cell
Mechanical damage to tissues and Mechanical damage to tissues and
structuresstructures
Activation of inflammatory responseActivation of inflammatory response..

37. Extravasations of fluid
Increased hemoglobin concentration
Progressive worsening of blood flow

38. Decompression sicknessDecompression sickness
Type 1Type 1
- - limb or joint pain ( bends )limb or joint pain ( bends )
Type 2Type 2
- - sign or symptom ,cause bysign or symptom ,cause by
involvement of CNS , cardiopulmonary systeminvolvement of CNS , cardiopulmonary system
Type 3Type 3
- - DCS + AGE DCS + AGE

39. Traditional Signs & Symptoms.Traditional Signs & Symptoms.
PainPain
Pins and needlesPins and needles
Paresthesia/ paralysisParesthesia/ paralysis

40. More commonly experienced More commonly experienced
Signs & Symptoms.Signs & Symptoms.
painpain
paraesthesiaparaesthesia
headacheheadache
tinglingtingling
dizzinessdizziness
numbnessnumbness
lethargylethargy
NauseaNausea
Difficulty concentratingDifficulty concentrating
FatigueFatigue
Difficulty walking Difficulty walking
acheache
tiredtired
visual distvisual dist
weaknessweakness
vertigovertigo
chest painchest pain
dizzydizzy
itchingitching
light headedlight headed

41. DCS type 1 DCS type 1
Bend
Limb and joint pain only
Skin rash

42. DCS type 2DCS type 2
- - Cardiopulmonary systemCardiopulmonary system
- “- “chokechoke””
-Nervous systemNervous system
- numbness - numbness
- “- “spinal cord hitspinal cord hit””
- spinal cord DCS - spinal cord DCS

43. Spinal cord DCSSpinal cord DCS
Venous infarction of cordVenous infarction of cord
- Venous gas embolism block the pulmonary arterioles- Venous gas embolism block the pulmonary arterioles
- Rise in intra-thoracic pressure- Rise in intra-thoracic pressure
( ( pulmonary hypertensionpulmonary hypertension ) )
- Interferes drainage of venous system - Interferes drainage of venous system
( ( spinovertebral-azygos systemspinovertebral-azygos system ) )
Autochthonous bubbleAutochthonous bubble
EmbolismEmbolism
- Spinal cord is - Spinal cord is relativelyrelatively poor perfusionpoor perfusion when compare to the when compare to the
brainbrain

44. First Aid.First Aid.
Remove from waterRemove from water
Lie FlatLie Flat
100% O2100% O2
oral /IV fluidoral /IV fluid
Emergency Service Emergency Service
AmbulanceAmbulance
Air (Helo/ Air Ambulance)Air (Helo/ Air Ambulance)

45. First Aid.First Aid.

46. First Aid.First Aid.

47. First Aid.First Aid.

48. First Aid.First Aid.

49. First Aid.First Aid.

50. First Aid.First Aid.

51. First Aid.First Aid.

52. First Aid.First Aid.

53. Patient Assessment.Patient Assessment.
Dive details.Dive details.
- ascent, at depth and descent.- ascent, at depth and descent.
- contributing factors- contributing factors
- exclusion of alternate potential causes- exclusion of alternate potential causes
- onset of symptoms- onset of symptoms
Physical assessment.Physical assessment.
- neurological assessment- neurological assessment

54. TreatmentTreatment..
Hyperbaric Oxygen Therapy.Hyperbaric Oxygen Therapy.
Mechanical compression of bubbles.Mechanical compression of bubbles.
Washout of inert gas (N2).Washout of inert gas (N2).
IV fluids.IV fluids.
Rehydration.Rehydration.
IV Lignocaine.IV Lignocaine.
Stabilization of cell membranes.Stabilization of cell membranes.
NSAIDS.NSAIDS.
Combats inflammatory response. Combats inflammatory response.

57. Decompression IllnessDecompression Illness
PrognosisPrognosis
avoid dive - 4 weeksavoid dive - 4 weeks
avoid fly 2-4 weeksavoid fly 2-4 weeks
Review 4 weeksReview 4 weeks
? Further ? Further
investigationsinvestigations

58. Flying after divingFlying after diving

59. New guideline New guideline
> > Flying after a single no-decompression Flying after a single no-decompression
divedive:: A minimum preflight surface interval of A minimum preflight surface interval of 11
22 hours is suggested. hours is suggested.

60. New guidelineNew guideline
> > Flying after multiple no-decompression Flying after multiple no-decompression
dives in a single day or multiple days of no-ddives in a single day or multiple days of no-d
ecompression divingecompression diving:: A minimum preflight su A minimum preflight su
rface interval of rface interval of 1818 hours is suggested. hours is suggested.

61. New guidelineNew guideline
> > Flying after dives requiring Flying after dives requiring
decompression stopsdecompression stops:: There is little experimen There is little experimen
tal or published evidence on which to base a rectal or published evidence on which to base a rec
ommendation for decompression dives. A prefliommendation for decompression dives. A prefli
ght surface interval substantially ght surface interval substantially longer thanlonger than 11
88 hours appears prudent. hours appears prudent.

62. 
cabin altitudes of cabin altitudes of 2,0002,000 to to 8,0008,000 feet for feet for
divers who do not have symptoms of decompresdivers who do not have symptoms of decompres
sion sickness (DCS). sion sickness (DCS).

63. The recommended preflight surface intervals The recommended preflight surface intervals do do
not guaranteenot guarantee avoidance of DCS. avoidance of DCS.
Longer surface intervals will reduce DCS Longer surface intervals will reduce DCS
risk furtherrisk further. .

64. Emergency air evacuationEmergency air evacuation
-Aircraft pressurized 1 ATA ( if possible)-Aircraft pressurized 1 ATA ( if possible)
-Un-pressurized aircraft-Un-pressurized aircraft
- - no more than 1000 feetno more than 1000 feet

-Have the patient breath 100% oxygen -Have the patient breath 100% oxygen
during transportduring transport

65. Emergency air evacuationEmergency air evacuation
Aircraft pressurized 1 ATA ( if possible)Aircraft pressurized 1 ATA ( if possible)
Un-pressurized aircraft Un-pressurized aircraft
- - no more than 1000 feetno more than 1000 feet
Have the patient breath 100% oxygen Have the patient breath 100% oxygen
during transportduring transport

66. THANK YOU