DIVE EMERGENCIES

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DIVE EMERGENCIES
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OBJECTIVES

• Recognize Signs and Symptoms of Patients with a
  Dive Related Complaint
• Discuss Treatment Considerations for Patients
  with a Suspected Dive Emergency
• Review Destination Decisions for Patients with a
  Decompression Emergency.

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Scuba Diving

• S - Self
• C Contained
• U Underwater
• B Breathing
• A - Apparatus

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MEDICAL ISSUES OF DIVERS

• Environmental Exposures
• Hazardous Marine Life
• Pressure/Squeeze Injuries
• Gas Related Issues

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Barotrauma

• Descent Barotrauma
• Ascent Barotrauma

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GAS RELATED ISSUES

• Decompression Sickness

• Nitrogen Narcosis

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Distribution of Cases According to Diagnosis
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Cause of Death in Dive Fatalities 1999-2002
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BAROTRAUMA OF DESCENT

• Tissue Distortion
• Vascular Engorgement
• Mucosal Edema
• Hemorrhage and Damage

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THE EARS
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Barotrauma

• Barotitis Externa
• Barotitis Media
• Barotitis Intera
• Sinus Barotrauma
• Pulmonary Barotrauma

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Barotrauma Risk Factors

• URI
• Allergies
• Smoking
• Mucosal Polyps
• Prior Maxillofacial trauma/surgery
• Excessive Auto inflation maneuvers

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Pulmonary Barotrauma

• Air Embolism
• Subcutaneous emphysema
• Pneumothorax
• Mediastinal emphysema

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Air Embolism

• Gas entry into the circulation from ruptured
  pulmonary veins
• Air bubbles travel into the arterial blood supply
  and into the body tissues
• Air bubbles become lodged in tissues blocking
  blood flow

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Air Embolism

• Signs and Symptoms
• Most occur within 2-3 minutes
• Cardiac Cardiac arrest, arrhythmias
• Neurological focal paralysis, sensory
  disturbance, deafness, vertigo, seizures, altered
  mental status

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Subcutaneous Emphysema

• Expanding air accumulates under the skin
• around the neck and clavicle
• Signs and Symptoms
• Fullness in the neck
• Voice changes
• Neck swelling
• Crackling under the skin

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Mediastinal Emphysema

• Air accumulates in the
• mediastinum pressing on the
• heart and major vessels
• interfering with circulation
• Signs and Symptoms
• Sub-Sternal Chest Pain
• Shortness of Breath
• Syncopal
• Shock
• Cyanosis

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Pneumothorax

• Air in the pleural cavity
• causing partial or
• complete collapse of the
• lung
• Signs and Symptoms
• Chest Pain
• Difficulty Breathing
• Unequal Breath Sounds

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Decompression Sickness

• DCS Type I
• 30 of the cases reported to Diving Alert Network
• Mild - skin, lymphatic, musculoskeletal
• DCS Type II
• 70 of reported cases to Diving Alert Network
• Moderate to severe - pulmonary, cardiovascular,
  neurological

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DCS Type I

• Cutaneous
• pruritis, SQ emphysema, rashes
• Musculoskeletal
• joint pain, numbness

• Lymphatic
• Localized obstruction

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DCS Type II

• Pulmonary
• Venous Air Embolism
• Signs and Symptoms
• Chest Pain, cough, dyspnea, shock, pulmonary
  edema
• Often rapidly fatal

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DCS Type II

• Cardiovascular
• Dizziness
• Chest Pain
• Shortness of Breath
• Myocardial Infarction

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DCS Type II

• Neurological
• Blurred vision, headache
• Numbness to extremities
• Paralysis in lower extremities
• Stroke symptoms

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DCS Percentage in Hours of Onset of Symptoms
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Nitrogen Narcosis

• Usually occurs at depths gt100ft
• Euphoria
• Drowsy
• Lack of Coordination
• Poor Judgment/Memory
• Symptoms Recede at Shallow Depths

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Heart Disease

• The 1 cause of death in the United States.
• The cause of 20 -30 of deaths while scuba
  diving.
• The direct cause of death for 26 of diver
  fatalities over 35 years of age.
• 25 of divers involved in diving fatalities were
  taking heart medications.
• DAN Fatality Report 2006

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Patient Assessment

• BSI
• Scene Size-up
• Initial Assessment
• Focused History and Physical

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Scene Size-Up

• Personal Safety
• Patient Safety
• Environment
• Number of Patients
• Additional Resources/Equipment

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Initial Assessment

• Airway/Spinal Immobilization
• Breathing
• Circulation
• Major Disabilities
• Determine Chief Complaint
• Expose
• Transport Decision

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Focused History and Physical

• Vital Signs
• Neurological Status
• Dive History
• Rapid Trauma Assessment
• Manage specific problems/injuries
• Rapid Head to Toe Exam

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Dive History

• Number Depth/Time of Dive
• Rapid ascent
• Uncontrolled/Panic Ascent
• Decompression Stop

• Dive Computer/Tables
• Dive Buddy/Solo
• Tank Pressure
• Type of Compressed breathing gas

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Dive Equipment

• Regulator
• Tank
• Buoyancy Compensator
• Weight Belt
• Computer

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Decompression EmergenciesPatient Destination

• Policy Reference 518
• To provide a procedure for transporting
• patients with potential decompression
• emergencies to the most accessible
• medical facility appropriate to their needs

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Provider Agency Responsibilities

• Contact Base Hospital or designated dispatch
  center for any patient with a suspected
  decompression emergency
• Obtain a dive incident history of patient and
  dive partner
• Coordinate patient transport to the appropriate
  facility
• Retrieve patients dive equipment

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Medical Control

• Contact the Medical Alert Center
• Base Hospital Contact
• Standing Field Protocols

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Transport Considerations

• Patient with a history of
• recent underwater
• compressed air
• Immediate
• Emergent
• Non-emergent

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Immediate

• Patients presenting
• Unconscious or
• Apneic or
• Pulseless
• Transport to an approved hyperbaric
• chamber

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Emergent

• Patients presenting
• Severe Neurological symptoms, or
• Severe dyspnea, or
• Chest discomfort
• Transport to a hyperbaric chamber and/or
• the MAR after consult with the hyperbaric
• Camber MD

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Non-Emergent

• Patients presenting
• Minor neurological symptoms, or
• Delayed symptoms after flying, or
• Delayed minor symptoms after 24 hours
• Transport to MAR with potential secondary
• Transfer to hyperbaric chamber after
• Consultations with hyperbaric MD

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Air Transport Considerations

• Early Deployment
• Equipment
• Weather
• Landing Zone

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Los Angeles CountyHyperbaric Chambers

• USC - Catalina Island
• (only 24 hour emergency receiving)
  
• UCLA Westwood
• Long Beach Memorial
• Beverly Hills Hyperbaric
• Know the Location of YOUR closest Hyperbaric
  Chambers

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• DELAYS IN TRANSPORT MAY RESULT IN PERMENENT
  DISABLITY OR DEATH!!!

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Scenario 1

• You are call to the beach to a 25
• old female complaining of
• numbness in both hands with
• bilateral knee pain. Patient is
• A O X 3, BP 110/74, P 104,
• Resps 32, Pulse Oximetry 98
• What other questions would assist
• you in your focused history and
• physical examination?

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Scenario 1

• What is the possible cause of this patients signs
  and symptoms?
• What would be the treatment and transport
  considerations for a patient with this
  presentation?

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Scenario 2

• You respond to a dive boat, you
• find a man with no pulses, no
• respirations.
• His dive buddy tells you that they
• were at 40 ft depth. He
• witnessed his friend rush to the
• surface without stopping.
• What is the probable cause of this
• patients loss of consciousness?

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Scenario 2

• What additional information may be useful
• to obtain in your focused history and
• physical?
• What are the treatment and transport
• priorities for this patient?

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Scenario 3

• You respond to the beach
• where you find a 40 year
• old female supine, crying.
• She complains of severe
• pain in her right ear.
• What questions may assist you in
• your evaluation of this patient?

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Scenario 3

• On further evaluation you notice that the patient
  
• has blood draining from her ear with continued
• pain. She tells you that she has a car available
  
• and will drive herself to the hospital 10 minutes
• away.
• What advice should you give to this patient?

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Scenario 4

• You find a 20 year old male on the beach wearing
• a wet suit. He responds only to verbal stimuli.
• BP 100/50, P 110, R 24 with a GCS of 4-5-4.
• He is uncooperative and complaining of pain in
  his
• right ankle.
• What further information could assist you in the
  assessment of this
• patient?

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Scenario 4

• On scene size up several beer cans are found
• next to the patients surf board. His friends
  tell
• you that they were surfing after heavy intake of
• alcohol. The patient was hit on his ankle by his
• board. He continues to be uncooperative with an
• ALOC.
• What are your transport considerations for this
  patient?

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Scenario 5

• You are called to the beach where you find a 55
  year old
• man, sitting on the sand, wearing a wet suit. He
  weighs
• 280 lbs and is complaining of sub-sternal chest
  pain. Your
• assessment reveals that he has a BP 108/60 P. 120
  R 28.
• He has a history of angina and is non compliant
  with his
• medications. His SCUBA diving equipment is next
  to him
• on the beach.
• What additional information would be useful to
  your
• assessment?

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Scenario 5

• The patient tells you that his chest pain started
  prior to the
• dive but he thought it was indigestion. 10
  minutes after
• descent the pain became worse. He made a
  controlled slow
• ascent and swam to shore.
• What are your treatment and transport
  considerations for
• this patient?

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• QUESTIONS?

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