DIVE EMERGENCIES

2. DIVEEMERGENCIES

3. OBJECTIVES • Recognize Signs and Symptoms of divers with a Dive Related Complaint • Discuss Treatment Considerations for divers with a Suspected Dive Emergency • Describe methods that divers can prevent dive related emergencies

4. Scuba Diving S - Self C – Contained U – Underwater B – Breathing A - Apparatus

5. MEDICAL ISSUES OF DIVERS • Environmental Exposures • Hazardous Marine Life • Pressure/Squeeze Injuries • Gas Related Issues

6. Barotrauma • Descent Barotrauma • Ascent Barotrauma

7. GAS RELATED ISSUES • Nitrogen Narcosis • Decompression Sickness

8. BAROTRAUMA OF DESCENT • Tissue Distortion • Vascular Engorgement • Mucosal Edema • Hemorrhage and Damage

10. Distribution of Cases According to Diagnosis

11. Cause of Death in Dive Fatalities 1999-2002

12. THE EARS

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

14. Barotrauma Risk Factors • URI • Allergies • Smoking • Mucosal Polyps • Prior Maxillofacial trauma/surgery • Excessive Auto inflation maneuvers

15. Pulmonary Barotrauma • Air Embolism • Subcutaneous emphysema • Pneumothorax • Mediastinal emphysema

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. DCS Type I Cutaneous • pruritis, SQ emphysema, rashes Musculoskeletal • joint pain, numbness Lymphatic • Localized obstruction

23. DCS Type II Pulmonary • Venous Air Embolism • Signs and Symptoms: Chest Pain, cough, dyspnea, shock, pulmonary edema • Often rapidly fatal

24. DCS Type II Cardiovascular • Dizziness • Chest Pain • Shortness of Breath • Myocardial Infarction

25. DCS Type II Neurological • Blurred vision, headache • Numbness to extremities • Paralysis in lower extremities • Stroke symptoms

26. DCS – Percentage in Hours of Onset of Symptoms

27. Nitrogen Narcosis • Usually occurs at depths >100ft • Euphoria • Drowsy • Lack of Coordination • Poor Judgment/Memory • Symptoms Recede at Shallow Depths

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

29. Scene Size-Up • Personal Safety • Patient Safety • Environment • Number of Patients • Additional Resources/Equipment

30. Initial Assessment • Airway/Spinal Immobilization • Breathing • Circulation • Major Disabilities • Determine Chief Complaint • Expose • Transport Decision

31. Focused History and Physical • Vital Signs • Neurological Status • Dive History • Manage specific problems/injuries • Rapid Head to Toe Exam

32. 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

33. Treatment of the Injured Diver Remove from Water ABC’s Lay flat if tolerated Determine need for oxygen Remove Dive Equipment (do not interfere with settings) Remove Wet/Dry Suit Keep Diver Warm Monitor until help arrives Prepare for Transport of Diver and Equipment

34. Dive Equipment • Regulator • Tank • Buoyancy Compensator • Weight Belt • Computer

36. Immediate Patients presenting: • Unconscious or • Apneic or • Pulseless Transport to an approved hyperbaric chamber

37. 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

38. 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

39. Los Angeles CountyHyperbaric Chambers • USC - Catalina Island (only 24 hour emergencyreceiving) • UCLA – Westwood • Long Beach Memorial • Beverly Hills Hyperbaric Know the Location of YOUR closest Hyperbaric Chambers

41. 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?

42. 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?

43. 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?

44. 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?

46. 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?

47. 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?

49. 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?

50. 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?