9. Diving Related Injury-น.ท.นพ.เสฏฐสิริ

Diving Related Injury

CDR.Sethasiri Sangsuwan

ประวตั กิ ารศึกษา

• แพทยศาสตร์บัณฑติ วทิ ยาลยั แพทยศาสตร์พระมงกฎุ เกล้า รุ่น 23
• แพทย์ผู้เช่ียวชาญสาขาเวชศาสตร์ป้ องกนั แขนงอาชีวเวชศาสตร์
• วทิ ยาศาสตร์มหาบณั ฑติ จุฬาลงกรณ์มหาวทิ ยาลยั
• หลกั สูตรแพทย์เวชศาสตร์ใต้นํา้ และความกดบรรยากาศสูง รร.พบ.กศษ.พร. รุ่น 1
• หลกั สูตรแพทย์เวชศาสตร์การบนิ สวบ.ทอ. รุ่น 25
• หลกั สูตรเสนาธิการทหารเรือ รุ่น 71
• Health Aspects of Disaster UQ Brisbane

ประวตั กิ ารรับราชการ

• แพทย์ประจํา รพ.สมเดจ็ พระนางเจ้าสิริกติ ์ิ
• แพทย์ประจาํ รพ.อาภากรเกยี รตวิ งศ์ ฐท.สส.
• ผ.บ.ร้อย พ กอง สน. กปช.จต.
• รรก.หน.อาชีวอนามยั กกป. รพ.อาภากรเกยี รตวิ งศ์

ฐท.สส.
• ประจาํ แผนกเวชศาสตร์การบิน กวตบ.พร.
• ช่วยราชการ กผ.พร.
• หน.เวชศาสตร์การบิน กวตบ.พร.

Scuba divers

• Scuba divers
– environmental exposures : hypothermia, sunburn,
and physical trauma
– aquatic activities: submersion accidents, motion
sickness, and marine envenomations
– dysbarisms :problems unique to the sport of diving

Dysbarism

• illnesses that result directly or indirectly from exposure to
increased ambient pressure

• Pathophysiology

– volume-pressure changes within the air-filled cavities
of the body

– increased dissolution of gases, particularly nitrogen,
in body tissues

– diver needs to descend only 33 feet in seawater (34
feet in freshwater) to double the atmospheric
pressure.

Dysbarism

 Pathophysiology
 The gases in a diver’s breathing mixture are
dissolved into the body in proportion to the partial
pressure of each gas in the mixture
 The dissolved gas in a diver’s body, regardless of
quantity, depth, or pressure, remains in solution as
long as the pressure is maintained.



Decompression Illness

• Absorption and Elimination of Inert Gases
• Saturation of Tissues
• Desaturation of Tissues
• Bubble Formation

Decompression Illness

Decompression Illness

Decompression Illness

• Proposed term including all cases of reduced-pressure,
bubble-related disorders, including AGE because
distunguishing between neuro DCS and AGE can be
very difficult

• Pathologic response to the formation of bubbles from
gas dissolved in tissue due to a reduction in ambient
pressure

Pathophysiology

• Direct Bubble Effects
– Autochthonous bubbles
– Venous bubbles
– Venous bubbles carried to the lung as emboli
– Arterial bubbles can act as emboli block

Pathophysiology

• Indirect Bubble Effects
– Blood vessels become “leaky”
– The platelet system becomes active
– The injured tissue releases fats that clump
together in the bloodstream
– Injured tissues release histamine and histamine-
like substances

Decompression Sickness

• Type I DCS :

– musculoskeletal system : periarticular pain in the elbow ,
shoulder arms and legs

– Skin: pruritus (niggles), erythema ,marbling; cutis
marmorata (patchy cyanotic marbling)-- > venous stasis

– Lymphatic obstruction : extremity edema

Decompression Sickness

• Type II DCS

– CNS : particularly susceptible DCS because of its
high lipid content

• CNS DCS : mild to moderate headache, blurred vision, diplopia,
dysarthria, unusual fatigue, inappropriate behavior, Loss of
consciousness

• no imaging studies are sensitive enough to exclude DCS
• imaging should not delay transfer for definitive therapy

– The spinal cord: especially the upper lumbar

• spinal DCS : limb weakness or paralysis, paresthesias,
numbness, and low back and abdominal pain

– progressive sensory or motor loss / ascending

Decompression Sickness

• Type II DCS

– Inner ear DCS : “the staggers”

• symptoms same as IEBT : nausea, dizziness, vertigo,
nystagmus

– Pulmonary DCS : “the chokes”

• The deposition of venous gas emboli in the pulmonary
arterial circulation -- > progressive dyspnea, cough, and
chest pain

• PE : cyanosis and hypotension in association with
increased CVP and pulmonary arterial pressure

• respiratory arrest

Signs & Symptoms

pain Difficulty walking
paraesthesia ache
tired
headache
tingling visual dist
dizziness weakness
numbness
lethargy vertigo
Nausea chest pain
Difficulty concentrating
Fatigue dizzy
itching
light headed

Time of onset of symptoms in DCS

Time of onset of initial symptoms in 591 DCI
( 88% DCS) cases from 1999 Divers Alert

Network (DAN) data



Cutis Marmorata







Barotrauma

• Barotrauma

– injury caused by pressure changes, results when
a diver is unable to equalize the pressure within
air-filled structures to the ambient pressure of
the environment during ascent or descent

CLINICAL FEATURES

Middle Ear Barotrauma

• MEBT or barotitis or ears
queeze : the most common

complaint of scuba divers

• The middle ear : air-filled space
with solid bony walls except for
the tympanic membrane

• The eustachian tube : only
anatomic passage to the external
environment

Middle Ear Barotrauma



Nitrogen Narcosis

• “rapture of the deep”-- > intoxicating effects of increased
tissue nitrogen concentration at depth

– symptoms typically begin to occur at approximately 100-150 feet
– effects of nitrogen narcosis resolve with ascent to shallower depths
– the use of compressed air is not recommended for sport diving to

depths greater than 120 feet

• Symptoms

– Euphoria
– Confusion
– loss of judgment or skill
– Disorientation
– diminished motor control
– tingling and vague numbness of the lips, gums, and legs

Oxygen Toxicity

• CNS oxygen toxic

– partial pressure of oxygen > 1.6 ATA

• Symptoms of CNS oxygen -- > VENTIDC

– V: Visual symptoms (tunnel vision or blurred vision)
– E: Ear symptoms (tinnitus)
– N: Nausea or spasmodic vomiting
– T: Twitching and tingling symptoms (small facial muscles, lips, or

muscles of the extremities)
– I: Irritability, confusion, agitation, and anxiety
– D: Dizziness, clumsiness, incoordination, and unusual fatigue
– C: Convulsions
• Deep divers prevent oxygen toxicity by breathing mixed gases with
decreased oxygen content

Oxygen Toxicity

• Pulmonary oxygen toxicity

– occur after 24 hrs of exposure to partial pressures of oxygen
in excess of 0.6 ATA.

• symptoms

– a burning sensation or pain on inspiration
– Coughing
– pneumonitis & permanent fibrosis are possible

Contaminated Air

• carbon monoxide and carbon dioxide

– can contaminate the air that is compressed into a tank
– Hypercarbia increases a diver’s susceptibility to CNS oxygen

toxicity

• “soda lime”or microscopic calcium hydroxide

– dust particles can deposited in the alveoli
– contact with water-- > a caustic liquid -- >caustic burns to the

mouth, throat, and airways

Pulmonary Barotrauma

• Boyle’s law : a scuba diver who takes a full breath at
33 fsw will have twice the lung volume at the surface

• Pulmonary barotrauma can result

– AGE, pneumothorax, pneumomediastinum, subcutaneous
emphysema, and alveolar hemorrhage

• Risk factors

– fast ascent, panic, problems regulating buoyancy, or running
out of air

– asthma

Arterial Gas Embolism

• The most severe form of pulmonary barotrauma
• AGE : cause of mortality sport divers after drowning 30%

– air bubbles are forced across the alveolar-capillary membrane, escape
into the pulmonary venous circulation-- > left atrium and ventricle -- >
arterial circulation

– Emboli to the coronary arteries -- > cardiac ischemia, myocardial
infarction, dysrhythmias, or cardiac arrest

– Emboli to cerebral vascular -- > ACA & MCA -- > variety of S&S
similar in appearance to an acute stroke



DIAGNOSTIC STRATEGIES

DIAGNOSTIC STRATEGIES

DIFFERENTIAL CONSIDERATIONS

MANAGEMENT

• Diving Disorders Requiring Recompression Therapy

– Decompression sickness (DCS) type I
– DCS type II
– Arterial gas embolism
– Contaminated air (carbon monoxide poisoning)

• Immediate treatment

– administration of 100% oxygen

• This reduces the bubble size by increasing the differential pressure for nitrogen
diffusion out of the bubbles and speeds the washout of nitrogen from the tissues

– Recompression/ Hyperbaric therapy

• AGE should be initiated as soon as possible for optimal results
– within 5 minutes : mortality rate of 5%
– Delayed> 5 hr : mortality rate increases 10% & 50% morbidity

MANAGEMENT

 Diving Disorders Requiring Recompression Therapy

 IV fluid administration to ensure a urine output of 1 - 2
mL/kg/hr may facilitate tissue perfusion and washout of inert
gases

 the supine position-- > maximize arterial-venous flow

 Ground transport to a hyperbaric facility is preferred over air
transportation

 If air transportation must be used-- > maintain cabin
pressure < 1000 feet

MANAGEMENT

• Diving Disorders Requiring Recompression Therapy
– Although spontaneous resolution of symptoms may occur in
patients with AGE, all patients should be recompressed
• secondary capillary edema and swelling may result in a
delayed recurrence of symptoms
– A delay to definitive recompression treatment is associated
with a worse outcome in cases of severe DCS
• Recompression therapy for DCS may be initiated as late
as 10 to 14 days after exposure

– Recompression therapy is usually performed based on U.S.
Navy Treatment Tables

Summary of the U.S. Navy Treatment Tables

TREATMENT OF ARTERIAL GAS EMBOLISM OR DECOMPRESSION
SICKNESS

MANAGEMENT

Thank You