Disclosures I have no financial conflicts of interest Deep: Scuba - PDF document

Disclosures • I have no financial conflicts of interest Deep: Scuba diving associated • I am a US government Employee, Risks and Complications however this lecture represents my Kyle Petersen, DO, FACP, FIDSA professional opinions and not official Director of Epidemiology & Surveillance policy of the US Government nor the Peace Corps, Peace Corps – 1 – 2 I ntroduction Objectives • 1-3 Million scuba divers in USA 2 • ~ $500 Million/year industry in USA 1 • Know fitness for diving • 1 million scuba divers in EU 2 • Know aspects and clinical symptoms of • 3-9/100,000 deaths in US alone(60% Drowning) 2 Barotrauma • Tropical destinations common • Know clinical presentation of POIS • Know clinical presentations of Decompression Sickness (DCS) • Miscellaneous: Malaria, Altitude etc. 1 http://www.prweb.com/releases/2012/1/prweb9093526.htm 2 Keystone Travel Med 2nd edition – 3 – 4 Belize, Roatan, Egypt, Jordan, Oman Cozumel, Cayman Case Islands, Bonaire, Venezuela, Bahamas • A 45 y/o lawyer presents to your office for pre-travel visit. He is going to Bonaire in the Caribbean. In addition to food and water hygiene counseling and Hep A vaccine he asks you to complete his Scuba physical exam form, he has a history of patent foramen ovale. • A: fill out the form Galapagos, Ecuador Australia, Indonesia • B: charge extra and fill out the form Kenya, Mozambique, Cocos Island, Costa Micronesia Seychelles, Maldives, • C: refer to a diving medicine physician Rica Fiji Thailand, Malaysia French Polynesia – 5 – 6 1

Medications Fitness to dive • Contraindicated- – Narcotics, antipsychotics, Anti-convulsants • Should be done by a certified diving physician – Beta blockers or vasodilators if recently started • Age, Sex, Training • Contraindications: Absolute (Seizures, Active • Relatively safe cardiac disease, active psychiatric disease, SCD, Chronic lung diseases, perforated TM, hernias, – NSAIDS, acetaminophen, Digoxin, Antibiotics, orthopedic injury) decongestants, antihistamines, scopolamine, • Contraindications: Relative (Asthma, DMII, meclizine Migraines, recent eye surgery, URI, pregnancy) • PFO controversial: 20% of population; 40% DCS cases – 7 – 8 • A 28 y/o female presents to your office after returning from Sulawesi Indonesia. She had a bad URI but traveled anyway, she went diving since she had invested so much in trip. After one dive she felt pressure in her L ear then a loud noise and felt slightly dizzy. Now “it sounds like I’m under a pillow when people talk” she stopped diving for the last 2 days. • This is • A: Barotrauma sinus squeeze • B: BarotraumaTM rupture • C: Barotrauma Oval window rupture • D: DCS (The bends) • E: Arterial Gas Embolism – 9 – 10 BAROTRAUMA BAROTRAUMA • Injury caused by changes in pressure • SQUEEZE • Boyle’s Law (Pressure inversely • barotrauma of proportional to Volume P= 1/V) descent • “Ingredients” • 10m= 1 ATM – rigid walls • damage from – gas filled space relative vacuum – enclosed space – ambient pressure change • 100% Preventable by not diving when abnormal anatomical conditions exist – 11 – 12 2

BAROTRAUMA BAROTRAUMA • REVERSE SQUEEZE • EXTERNAL EAR – barotrauma of ascent – Predisposing Factors – damage from expanding gases • obstruction of the external canal by wax • tight wet suit hood • ear plugs • otitis externa • Usually leads to reverse squeeze – 13 – 14 • BAROTRAUMA • MIDDLE EAR “MOST COMMON” – Etiology: blocked Eustachian tube – Predisposing Factors • infections (URI) • allergies (Hay Fever) • anatomic variations • inability to equalize pressure • Usually leads to ear squeeze – 15 – 16 BAROTRAUMA BAROTRAUMA • EAR SQUEEZE • CLINICAL MANAGEMENT – Clinical Manifestations: – Treatment • mild: injected TM • no diving until re-evaluated • moderate: intratympanic hemorrhage • decongestants i.e. Sudafed, Afrin • severe: hemorrhage behind TM with or w/o • If perforated consider ENT referral perforation – If perforation occur, rush of cold water into inner ear can cause vestibular symptoms (caloric vertigo) and ultimately infection – 17 – 18 3

BAROTRAUMA BAROTRAUMA • INNER EAR INJURY • INNER EAR – Clinical Manifestations – implosive or explosive injury • fullness of middle ear on descent • forceful Valsalva or – round window rupture severe ear squeeze • audible “pop” – oval window rupture • sudden onset of roaring tinnitus – intracochlear membrane rupture • sudden onset of vertigo • persistent increasing vertigo • persistent neurosensory hearing loss • visual findings (nystagmus) – 19 – 20 BAROTRAUMA Case • A 20 year old female on their 3 rd dive descends • INNER EAR INJURY rapidly to 15 meters. She had trouble Valsalva-ing on descent and experienced stabbing pain in the – Treatment forehead for 30 sec before clearing her ears, on • R/O Air Gas Embolism or Decompression arrival at surface she took off her mask and had Sickness profuse epistaxis. • This is: • strict bed rest • A barotrauma ear squeeze • avoid straining (stool softeners, antiemetics, • B: Type I DCS (the bends) antivertigo medications, sedation) • C: Barotrauma sinus squeeze • ENT REFERRAL : standard of care is surgery • D: Arterial Gas Embolism within 24 hours – 21 – 22 BAROTRAUMA BAROTRAUMA • SINUS • TOOTH – obstructed sinus – Prevention is the key! ostium (infection, – Pain in tooth on ascent allergy, anatomy) – Predisposing Factors – Pain and bleeding after squeeze or • dental disease reverse sq. • inadequate dental restorations – NO diving • recent dental work – decongestants – observe for infection Drshark2685.blogspot.com – 23 – 24 4

BAROTRAUMA BAROTRAUMA • FACE MASK SQUEEZE • ABDOMINAL SQUEEZE – failure to clear face mask on descent – usually from panic ascent – subconjunctival hemorrhages – antacid use – no treatment necessary – overbreathing and air swallowing – symptoms abate with descent Lester Quayle and Rita Barton, Duke University – 25 – 26 BAROTRAUMA Case • A 23 y/o male is diving for the 4 th time ever at 10 • PULMONARY meters, he sees a rock lobster and panics. He – Squeeze swims as fast as he can to the surface while holding his breath, on the surface he has aphasia, • deep breath-hold dive to a depth at which lung volume is an weakness in his LUE of handgrip and wrist reduced below residual volume flexion. – Over expansion • This is: • intra alveolar hemorrhage, exudate • Type II DCS(the bends) • chest pain • Arterial Gas Embolism • progressive dyspnea • Pulmonary Squeeze • progressive frothy, bloody sputum • Round window rupture – Can be accompanied by AGE and DCS – 27 – 28 PULMONARY OVERI NFLATI ON SYNDROMES (POI S) • MEDIASTINAL EMPHYSEMA – results when gas expansion forces gas into the loose mediastinal tissues in the middle of the chest – symptoms: chest pain behind the sternum (tightness, burning) – no other symptoms – symptoms generally do not get worse – no treatment is necessary – O 2 may reduce symptoms faster Univ of Maryland – 29 – 30 5

PULMONARY OVERI NFLATI ON SYNDROMES (POI S) • SUBCUTANEOUS EMPHYSEMA – results from expansion of gas which has leaked from the mediastinum into the subcutaneous tissues of the neck – symptoms: feels like “Rice Krispies” under the skin – there may be a voice change due to pressure on the larynx – no treatment is necessary – O 2 may reduce symptoms faster – 31 – 32 PULMONARY PULMONARY OVERI NFLATI ON OVERI NFLATI ON SYNDROMES (POI S) SYNDROMES (POI S) • ARTERIAL GAS EMBOLISM • PNEUMOTHORAX • THE MOST SERIOUS POTENTIAL – accumulation of gas within the pleural COMPLICATION OF DIVING CAUSED BY space EXCESS AIR PRESSURE IN THE CHEST!! – symptoms: chest pain, more likely lateral • alveolar rupture with injection of air into or apical; cough; SOB capillary so that a bolus (bubble) of air enters – Treatment: 100% O2 and chest tube prn pulmonary veins and left ventricle • Occurs suddenly, usually after a rapid ascent – 33 – 34 PULMONARY OVERI NFLATI ON Arterial Gas embolism SYNDROMES (POI S) • Presents as embolic stroke • ARTERIAL GAS EMBOLISM – A DETAILED neuro exam is critical – the brain is the most significant site of • Majority in MCA distribution embolus – Aphasia – symptoms: ANY type of neurologic sign or symptom (unconsciousness, weakness, – Apraxia paralysis, paraesthesia, etc) within 10 min – Hemiparesis of surfacing – Hemisensory loss – AGEs do not go to the spine (think DCS) • Minority Vertebral Basilar – tx: O 2 & IMMEDIATE RECOMPRESSION – Visual or cerebellar deficits – 35 – 36 6