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Diving and Hyperbaric Medicine

Diving and Hyperbaric Medicine

Diving and Hyperbaric Medicine

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ISSN 1833 - 3516 Volume 37 No. 4 ABN 29 299 823 713 December 2007

Diving expeditions: from Antarctica to the Tropics

Diving deaths in New Zealand Epilepsy and diving – time for a change? Mechanical ventilation of patients at pressure

Print Post Approved PP 331758/0015 9^k^c\VcY=neZgWVg^XBZY^X^cZKdajbZ(,Cd#)9ZXZbWZg'%%,

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Dg^\^cVaVgi^XaZh Diving-related deaths in New Zealand 2000–2006 Andrew McClelland

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Diving expedition medicine – the Coral Cay Conservation experience Karen E Richardson

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All encounters 540

Sea-based Land-based 271 (50.2%) 269 (49.8%)

Marine Diving Medical 87 (16.1%) 215 (39.8%) 56 (10.4%) x Resp. infections 63 (11.7%) x Eye infections 13 (2.4%) x Other 11 (2.0%)

Gastrointestinal 61 (11.3%) Medical 195 (36.1%) Barotrauma 51 (9.9%) x Infective gastro 37 (6.9%) x Ear 143 (26.5%) x Ear 43 (8.0%) x Food poisoning 17 (3.1%) x Skin 52 (9.6%) x Sinus 6 (1.1%) x Abdominal pain 6 (1.1%) x Tooth 2 (0.4%) x Alcoholic gastritis 1 (0.2%) Animal 15 (2.8%) x Sea urchin 9 (1.7%) Decompression- 3 (0.6%) Orthopaedic/Injury 44 (8.1%) x Jellyfish 6 (1.1%) related x Soft-tissue injury 22 (4.1%) x DCI 1 (0.2%) x Back/muscle pain 10 (1.9%) x Possible DCI 1 (0.2%) x Laceration 10 (1.9%) Environmental 5 (0.9%) x Rapid ascent 1 (0.2%) x Minor head injury 1 (0.2%) x Coral cuts 4 (0.7%) x Fracture 1 (0.2%) x Fuel ingestion 1 (0.2%) Other 2 (0.4%) Foot 38 (7.0%) x Diving incident 1 (0.2%) x Soft-tissue trauma 16 (3.0%) x SWAS 1 (0.2%) x Infection 10 (1.9%) x Ingrown toenail 6 (1.1%) x Blisters 5 (0.9%) x Burns 1 (0.2%) Animal 22 (4.1%) x Insect bite 12 (2.2%) x Mosquito 9 (1.7%) x Centipede 1 (0.2%) Surgical/Dental 9 (1.7%) x Dental 8 (1.5%) x Surgical 1 (0.2%) Environmental 6 (1.1%) x Sunburn 3 (0.6%) x Climate adjustment 2 (0.4%) x Dehydration 1 (0.2%)

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A lot of protection at a very small cost! Photo by Christopher Ross &.- 9^k^c\VcY=neZgWVg^XBZY^X^cZKdajbZ(,Cd#)9ZXZbWZg'%%,

SPUMS ASM 2007, Tutukaka, the Poor Knights Islands & Fiordland

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Mike Davis and Sarah Webb wish all readers a Happy Christmas and a healthy and successful 2008 9^k^c\VcY=neZgWVg^XBZY^X^cZKdajbZ(,Cd#)9ZXZbWZg'%%, &..

Ventilator performance under hyperbaric conditions: a study of the Servo 900C ventilator Gordon Bingham, Bill Koch, Geraldine Lee and Ian Millar

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Critical Review Epilepsy and Recreational Scuba Diving: An Absolute Contraindication or Can There Be Exceptions? A Call for Discussion

Maria do Rosario G. Almeida, Gail S. Bell, and Josemir W. Sander

Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom; and †Epilepsy Institute of The Netherlands, SEIN, Achterweg, Heemstede, The Netherlands

Summary: Recreational scuba diving is a popular sport, and creases with increasing time in remission, but the risk is never people with epilepsy often ask physicians whether they may en- completely abolished. We suggest that people with epilepsy who gage in diving. Scuba diving is not, however, without risk for wish to engage in diving, and the physicians who certify fitness anyone; apart from the risk of drowning, the main physiological to dive, should be provided with all the available evidence. Those problems, caused by exposure to gases at depth, are decom- who have been entirely seizure-free on stable antiepileptic drug pression illness, oxygen toxicity, and nitrogen narcosis. In the therapy for at least 4 years, who are not taking sedative antiepilep- United Kingdom, the Sport Diving Medical Committee advises tic drugs and who are able to understand the risks, should then that, to dive, someone with epilepsy must be seizure free and off be able to consider diving to shallow depths, provided both they medication for at least 5 years. The reasons for this are largely and their diving buddy have fully understood the risks. Key theoretical. We review the available evidence in the medical lit- Words: Epilepsy—Recreational scuba diving—Seizure. erature and diving websites. The risk of seizures recurring de-

Recreational scuba diving (using “self-contained under- ter. Essentially, the diver carries a tank of high-pressure water breathing apparatus”) is a popular sport and it is not air (or suitable gas mixture), and this is delivered to the uncommon for neurologists to be asked by their patients diver at ambient pressure by means of a regulator. The with epilepsy whether they may dive. People in the United diver also carries a weight system and a buoyancy con- Kingdom, taking antiepileptic drugs (AEDs) for epilepsy, trol device (BCD). Diving associations advise people to whether or not experiencing seizures, have been banned dive with a “buddy,” a diving partner who shares mutual from scuba diving (Hallenbeck, 1984; Millington, 1985; responsibility for safety. Sykes, 1994; Bove, 1996; Taylor et al., 2002). The UK Apart from the hazards caused by the marine environ- Sport Diving Medical Committee considers that the re- ment and the risk of drowning, there are three main phys- quirements that someone with epilepsy must fulfill before iological problems that may occur as a result of exposure being passed as able to dive are “5 years free from fits and to gases at depth. These are decompression sickness or ill- off medication” (UK Sport Diving Medical Committee, ness (DCI), oxygen toxicity, and nitrogen narcosis. These 2004). Both the Professional Association of Diving Pro- problems can all occur in any diver; each therefore needs fessionals and the National Association of Underwater In- to assess the risk/benefit ratio before diving. Questions structors regard a history of seizures as contraindications that need to be addressed include: to diving (NAUI, 2005; PADI, 2006). Scuba diving is a hazardous sport, as it requires mechanical aids to support respiration, and is performed under wa- 1. What are the physiological risks for anyone scuba Accepted December 13, 2006. diving? Address correspondence and reprint requests to Prof. Ley Sander, De- 2. Are these risks any greater for a person with a his- partment of Clinical and Experimental Epilepsy, Box 29, National Hos- tory of seizures? pital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK. E-mail: [email protected] 3. Do AEDs themselves pose a risk for someone scuba doi: 10.1111/j.1528-1167.2007.01045.x diving? 9^k^c\VcY=neZgWVg^XBZY^X^cZKdajbZ(,Cd#)9ZXZbWZg'%%, '&,

4. Are seizures likely to be induced by recreational lungs (Newton, 2001) (although mediastinal emphysema scuba diving in people with epilepsy controlled by or pneumothorax are more likely), as can patent foramen AEDs? ovale and other causes of right to left shunt, (Madsen et 5. Is recreational diving by a person with controlled al., 1994; DeGorordo et al., 2003) as bubbles are able to epilepsy likely to endanger the life of others? pass from the venous to the arterial circulation. CAGE 6. What benefits may people with epilepsy derive accounts for almost one in four fatalities in recreational from scuba diving? divers (Newton, 2001). Patients with CAGE may present A further physiological problem that could be consid- with alteration of consciousness, seizures, (Newton, 2001) ered is carbon dioxide toxicity. This is most likely to occur “stroke”-like symptoms, or paralysis (Bove, 1996). Ex- in divers using a closed or semiclosed circuit rebreath- cess nitrogen can remain for hours in the body, and, al- ing apparatus (DeGorordo et al., 2003); most recreational though the initial effects of bubbles are mechanical, there scuba divers use open circuit apparatus. It may also occur may also be secondary biochemical effects of activation when exercising at depth, or due to breath holding, nei- of leukocytes, platelets, complement, and the clotting cas- ther of which is recommended for recreational divers. It cade (Barratt et al., 2002). will therefore not be considered further. Carbon monoxide DCI can, to a large extent, be prevented by avoiding poisoning may also affect any diver after a “bad fill,” and rapid ascent and by use of decompression tables or diving vomiting from whatever cause could prove fatal. computers. It is, however, a probabilistic event, and could We looked for evidence about diving and epileptic occur on any dive (Madsen et al., 1994). Other risk factors seizures within the medical literature and by accessing include deep/long dives, cold water, and hard exercise at diving websites. A PubMed search of English language depth (Thalmann, 2004). DCI can occur even when no articles published between 1984 and 2006 was conducted rules have been violated, and this is referred to as “unde- using the following search terms: (1) epilepsy and diving; served” or “unexpected” DCI. It is said that DCI is “still a (2) seizures and diving; (3) diving fatalities; (4) diving mystery in many ways” (Almon and Uguccioni, 1997). It injuries; (5) diving accidents; (6) diving morbidity; (7) used to be thought that it was possible to spend an unlim- diving mortality; (8) diving physiology; and (9) drugs and ited amount of time at depths of9morless (Barratt et al., diving. We found a paucity of evidence on this subject. 2002); while this is no longer held to be true, dive tables We also investigated the epidemiology of diving in peo- indicate that the risk of DCI at depths of less than 10 m ple with epilepsy, to see whether any theoretical risks are is very small, provided the dive is not prolonged (Spira, borne out in practice. 1999). Oxygen toxicity PHYSIOLOGICAL RISKS INHERENT Hyperbaric oxygen (O2) exposure is known to cause TO RECREATIONAL SCUBA DIVING CNS O2 toxicity, usually manifested by seizures (com- Decompression sickness/illness monly focal, but generalized seizures may occur in 5– Decompression illness results from the reduction in the 10% patients (Newton, 2001)); the mechanism is unknown ambient pressure surrounding a body (Thalmann, 2004). (Chavko et al., 1998). It has been suggested that it may As the diver submerges, and the surrounding pressure in- be due to changes induced in cerebral blood flow (Chavko et al., 1998) or to the formation of free radicals from molec- creases, more nitrogen (N2) is forced into solution in the ular O during metabolism (Green and Leitch, 1985; New- body tissues as the partial pressure of N2 increases (Barratt 2 ton, 2001; DeGorordo et al., 2003). It is also known that et al., 2002). The tissues become saturated and as N2 is inert it is removed only by diffusion or blood flow. When GABA falls after exposure to increased pressures of O2 the pressure decreases as the diver later surfaces, the dis- (Green and Leitch, 1985). The risk of O toxicity increases with the pressure of solved N2 returns to the gaseous state faster than the blood 2 can remove it. Rapid ascent is considerably more danger- O2 experienced and the duration of exposure (Emerson, ous than a controlled ascent, which allows more time for 2002). It occurs more often at depths of 50 m or more when breathing compressed air (Green and Leitch, 1985), but the N2 to be removed by the blood flow. The N2 not removed is liable to form bubbles in the musculoskeletal may occur at 2 atmospheres pressure (approximately 10-m system (causing “the bends”), and in the marrow of long depth) or less when pure oxygen is being breathed (Spira, bones, although whether or not the bubble formation is 1999). The overall incidence of O2 induced convulsions the cause of the symptoms of DCI is not proved (Hamil- is extremely low (around 0.03% in a hyperbaric chamber) (Hampson and Atik, 2003). ton and Thalmann, 2003). If N2 cannot escape through the airways, usually because of breath-holding, it can rupture Nitrogen narcosis into the pulmonary venous system [leading to cerebral Nitrogen narcosis is the narcotic-like effect precipi- arterial gas embolism (CAGE)], the perivascular sheaths tated by increased partial pressure of inspired N2 at depth or the pleural cavity (Barratt et al., 2002). Asthma and (Emerson, 2002). Although it can happen to any diver bronchitis can also facilitate CAGE by trapping gas in the (Worf, 2002) and is not entirely predictable, it usually

Epilepsia, Vol. 48, No. 5, 2007 '&- 9^k^c\VcY=neZgWVg^XBZY^X^cZKdajbZ(,Cd#)9ZXZbWZg'%%,

occurs at deeper depths and with more rapid descent, perbaric chamber, but the patient had recently had surgery (Emerson, 2002) and resolves with return to the shallows for frequent seizures secondary to radiation necrosis fol- (Worf, 2002). The symptoms increase with depth, starting lowing treatment for an anaplastic astrocytoma (Doherty as light-headedness and euphoria from 30 m, through poor and Hampson, 2005). No other recent histories are avail- judgment and overconfidence, and hallucinations, to loss able of people with known epilepsy being treated in a of consciousness at great depths (Royal Naval Medical hyperbaric chamber. A study in the 1940s found no cor- Service, 2004). The behavioral disturbances manifested relation between preexisting EEG abnormalities and time seem to occur regardless of which inert gas is breathed, to convulsion in people exposed to high partial pressures and, although the mechanism is not yet elucidated, it is as- of O2. Indeed, two patients with gross EEG abnormali- sumed to be similar to those of general anesthetics (Turle- ties who were diagnosed with epilepsy had no increased Lorenzo et al., 1999). It may be, however, that nitrogen tendency to convulse (quoted in Green and Leitch, 1985). acts directly by potentiating GABA neurotransmission at One study is reported as showing hyperbaric O2 treatment the GABAA receptor, thus producing its narcotic effect producing reduction of seizures in children with epilepsy, (Abraini et al., 2003). but the scientific nature of this study is questioned (quoted in Hardy et al., 2002). ARE THESE RISKS INCREASED IN SOMEONE Nitrogen narcosis WITH CONTROLLED EPILEPSY? There is no reason to suspect that people with a history Decompression sickness/illness of seizures would be more likely to suffer from Nitrogen There is no published literature to support an associ- Narcosis than anyone without such a history. ation between DCI and epilepsy. Uncontrolled epilepsy could, however, predispose to the development of DCI ARE THESE RISKS INCREASED IN SOMEONE if a seizure occurred while underwater, thus precipitating TAKING AEDS? an acute ascent (Madsen et al., 1994). It is therefore un- Decompression illness likely that someone with fully controlled epilepsy would The secondary biochemical effects of DCI could po- be more at risk of DCI than someone without epilepsy. It tentially interact with AEDs. These effects are secondary is possible, however, that CAGE could be precipitated by to the formation of bubbles, however, and are therefore a fast ascent from as shallow as 10 m if breath holding unlikely to take effect until the diver is safely on land. during a convulsive seizure occurred. Anyone suffering from DCI should not dive again for one Oxygen toxicity month (Emerson, 2002) by which time the biochemical It is important to try to establish whether people with effects should also have cleared. There is no other rea- controlled epilepsy are more likely to suffer from O2 son why DCI should preferentially affect anyone taking toxicity, and hence from its seizures, than those without AEDs. epilepsy. Two case histories have been reported which may Oxygen toxicity suggest that people with epilepsy are more likely to have There is no reason to suppose that AEDs would increase such seizures in a hyperbaric chamber than those with- the risk of O toxicity. Indeed, in rats, carbamazepine out epilepsy (Emerson and Oxer, 1998). One, an experi- 2 has been shown to exhibit a dose-related protective effect enced diver, developed DCI after a “dive” in the chamber. against hyperoxic seizures (Reshef et al., 1991), so people On recompression with O she had a generalized seizure 2 with epilepsy controlled by carbamazepine could poten- preceded by a simple partial seizure, and afterwards an tially also be protected. A case report of CAGE causing EEG was reported as being abnormal, showing gener- seizures in a hyperbaric environment showed that pheny- alized epilepsy. This was reported as “unmasking latent toin also appeared to inhibit seizure activity (Weaver, epilepsy.” However, as the EEG changes were general- 1983). ized, and the seizure was of partial onset, it is unclear whether the two were closely related. The second was Nitrogen narcosis a female having a therapeutic compression, who had a Some drugs, particularly alcohol and sedatives, are “grand mal” seizure. She had, however, been treated with thought to have an additive effect on N2 narcosis (Royal high doses of pethidine, a metabolite of which may be Naval Medical Service, 2004). As stated above, the mech- proconvulsive. Thus it seems unlikely that either of these anism of N2 narcosis is assumed to be similar to that of cases had an intrinsically altered seizure threshold which anesthesia with nitrous oxide. The British National For- was affected by hyperbaric oxygen (and therefore unlikely mulary (Joint Formulary Committee, 2004) does not list that these case reports show that people with controlled any AEDs as having interactions with nitrous oxide anes- epilepsy are more likely to suffer from O2 toxicity and thetics, although it states that nitrous oxide produces an in- seizures than someone without). A recent case report decreased sedative effect when general anesthetics are given scribes partial seizures developing in a man treated in a hy- with anxiolytics and hypnotics. Clearly, if any particular

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AED is shown to have a sedative effect, then it would be bation, and causes relative suppression of EEG abnormal- inappropriate for someone sedated by that AED to dive; ities (Fountain and May, 2003). However, inexperienced this may be difficult to ascertain objectively. divers tend to hyperventilate more than those who have It is possible that AEDs acting on the GABAA receptor dived more often, although this is often an indication that (clonazepam, diazepam, phenobarbital, primidone, topira- further training is required. Tiredness and lack of sleep mate, valproic acid that act directly; tiagabine that inhibits have also long been recognized as potential seizure pre- the neuronal reuptake of GABA) may interact with high cipitants (Spector et al., 2000; Nakken et al., 2005). If any partial pressures of nitrogen. This could produce unex- person with epilepsy knows that any of these factors are pected side effects, perhaps including nitrogen narcosis. likely to lower their own seizure threshold, then clearly that person should not scuba dive. OTHER RISKS DUE TO AEDS Regular physical exercise induces hepatic microsomal enzymes, and the release of fatty acids into the blood It has been argued that people with epilepsy will have stream may compete with protein binding, leading to a impaired performance and reaction time due to AEDs higher free fraction of AEDs with important protein bind- (Millington, 1985); those affected in this way by their ing, such as phenytoin, valproate, tiagabine, and benzo- AEDs and those taking AEDs known to be sedative prob- diazepines. Theoretically it could be advisable to adjust ably should not dive. AED doses in patients engaged in regular exercise, but Biochemical and hematological changes occur in peo- a prospective study found no effects of exercise on the ple who dive (Philp et al., 1975), and in people who de- blood levels or rate of metabolism, and no correlation be- velop DCI (Jacey et al., 1976). The significance of these tween minor fluctuations in the blood levels and seizure changes on AEDs, or indeed on any other prescription or occurrence (Fountain and May, 2003). nonprescription drugs, is unknown. While the secondary effects of DCI include biochemical changes, they would be unlikely to provoke a seizure. ARE SEIZURES LIKELY TO BE INDUCED BY SCUBA DIVING IN PEOPLE WITH EPILEPSY IS DIVING BY A PERSON WITH CONTROLLED CONTROLLED BY AEDS? EPILEPSY LIKELY TO ENDANGER THE LIFE A large questionnaire study showed that approximately OF OTHERS? 50% of people with epilepsy report seizure-precipitating The person with completely controlled epilepsy may be factors, such as emotional stress (21%), sleep depriva- able to decide that the benefits of diving outweigh the small tion (12%) and physical exercise (3%) (Nakken et al., risks of having a seizure. It is imperative, however, that 2005). Consequently several factors operating during a the health and safety of the diving buddy be considered. dive may be associated with an increased risk of seizures If a diver has a seizure at depth, the buddy would need to underwater, because they may alter the seizure thresh- reach the surface quickly, putting himself at risk of DCI old. These factors include the seizure-precipitating factors (Emerson, 2002). One author quotes “several instances of above, as well as hypothermia, hyperventilation, breath- divers having seizures under water who went onto drown, ing oxygen under increased pressure (see above) (Milling- but in addition a diving buddy also drowned while trying ton, 1985), and changes in drug metabolism (Fountain and to rescue the convulsing diver” (Bove, 1996), but it is not May, 2003). Many of these are only important during diver clear whether the divers who had seizures did so because training. of epilepsy or because of O toxicity. An Australian study Up to 30% people with epilepsy may experience stress 2 of 100 consecutive scuba diving fatalities found that in as a seizure trigger, and some report that the stress of only 14% of the fatalities did a buddy remain with the participating in sports may exacerbate seizures (Fountain person who died, although a further 20% only separated and May, 2003). Aerobic exercise may occasionally because of the problem causing the fatality (Edmonds and cause seizures, but is more likely to reduce seizure fre- Walker, 1989). quency; those whose seizures are exacerbated by exercise generally recognize the association (Fountain and May, BENEFITS OF SCUBA DIVING FOR PEOPLE 2003). Interictal epileptiform activity has been shown WITH EPILEPSY to remain unchanged or decreased during or immedi- ately after exercise, even in some people with exercise- People with epilepsy tend to be less active, less phys- associated seizures (Fountain and May, 2003). Hyperven- ically fit and less likely to participate in sports than the tilation performed at rest may trigger absence seizures and general population and to have more psychological prob- epileptiform activity on EEG, by producing hypocapnia lems (Fountain and May, 2003). A study of a regular ex- and cerebral vasoconstriction. During exercise, however, ercise program on a small number of people with epilepsy hyperventilation is a compensatory response to avoid hy- showed that behavioral outcomes were positively influ- percapnia, is usually not associated with seizure exacer- enced by moderate exercise with no impact on seizure

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frequency; 10 of 14 randomized to exercise were seizure- on the swim back to shore, in a man with severe coronary free before starting the study and remained so throughout artery disease and type I diabetes) (Divers Alert Network, the study (McAuley et al., 2001). It is important to realize, 2002, 2003). The South Pacific Underwater Medical Soci- however, that this study involved a regular, frequent and ety records show that, between 1972 and 1999 there were supervised exercise regimen. People with epilepsy who four fatalities in divers with a history of epilepsy (Douglas wish to engage in recreational scuba diving should build Walker, personal communication, 2006). up their exercise tolerance, while remaining seizure-free, The British Sub-Aqua Club (BSAC) publishes annual before considering scuba diving. reports of diving incidents (Cumming, 2005) in the interest of promoting diver safety. In the last 9 years 3,744 incidents have been recorded, including 161 fatalities. There is EPIDEMIOLOGY OF DIVING DEATHS IN often very little information available on the incidents. In PEOPLE WITH EPILEPSY this nine-year period the reports of three deaths (of 161) As diving is currently banned for people on AEDs for have mentioned convulsions or “fits.” One was using a epilepsy, any epidemiological data will be biased, as the mixture of gases usually employed by technical divers numbers of people with epilepsy who dive will neces- and therefore probably not relevant to recreational scuba sarily be very small. People with medical conditions for diving. One collapsed while on land, but was said to have which diving is contraindicated are, however, known to had a fit while in the water. In the other, postmortem ex- dive. One study sent anonymous questionnaires, which amination showed that he had suffered “something akin included a list of medical conditions, to members of 29 to an epileptic fit” while underwater. There is no data to Australian diving clubs; 346 replies were received (Taylor determine whether or not any of these three people had a et al., 2002). For each condition individuals completing the previous history of seizures. A fourth fatality was related questionnaire could answer “never,” “in the past,” or “now to an oxygen toxicity convulsion. and I dive with it.” Almost half the divers were overweight Nonfatal incidents included 22 with mention of convul- (a risk factor for DCI), and 8% had asthma or chronic sions or fits. Eleven of these were probably oxygen toxicity obstructive airways disease (both of which could precipi- seizures. Three had a previous history of seizures, but had tate arterial gas embolism) in their history, with 3% with not declared them. One was due to anaphylaxis, and in the current symptoms. Although none had current seizures, 2 other cases it is not possible to establish whether or not the of 346 respondents had a history of epilepsy. Other au- person had a history of seizures. In total, therefore, 3 of thors note that divers have commented on how easy it is to 161 fatalities and up to 10 of 3,583 nonfatal incidents may avoid the detection of medical conditions during the diving possibly have been related to epilepsy. Thus there is very medical examination (quoted in Taylor et al., 2002). Addi- little reliable epidemiological evidence to suggest that a tionally, once medical certification is received, no further past history of seizures does, or does not, imply increased assessments are required to continue diving (Strauss and risk to recreational scuba divers. Borer, 2001). The survey of 100 consecutive scuba diving fatalities in Australia and New Zealand found that 9% of DIVING AND PEOPLE WITH EPILEPSY victims had been specifically advised by a diving medical expert or dive instructor that they were unfit for scuba There is little doubt that seizures under water are ex- diving (Edmonds and Walker, 1989). Altogether 25% had tremely dangerous, particularly if consciousness is lost. preexisting medical contraindications, including one per- Even if consciousness is not lost, the regulator could son with epilepsy (which probably did not contribute to the be dislodged, and the subject drown (Fountain and May, death) and nine with asthma (which may have contributed 2003). The consequences of a seizure could potentially be to the death in eight cases). reduced by using a full face mask, as used by police and In 2000 and 2001, the Divers Alert Network (DAN) technical divers (Hamilton and Thalmann, 2003), instead received notification of 2,212 injured divers who were re- of the usual separate device kept in the mouth by clench- compressed. Only eight patients were reported to have ing the teeth. A full-face mask would be more likely to preexisting central nervous system disease (including remain on the face than the usual regulator if a seizure seizures, migraine, or central nervous system injury). In should occur. the same period, DAN was able to obtain records of 168 A seizure involving only loss of awareness could pose diving fatalities in the United States and Canada. Only problems, as maintenance of position in the water requires three of the deaths occurred in patients with a history of subtle changes to be made to the air in the BCD. If these seizures (including one recently hospitalized for seizures); changes are not made there is a risk of accelerated ascent the presumed causes of death were “air embolism” (in or descent, causing problems with DCI and risking loss of a subject who ascended rapidly, and in whom no AEDs contact with (and therefore rescue by) the dive buddy. were found), “drowning” (in a new diver, who struggled DCI should not otherwise occur more frequently in at the surface) and “cardiac” (shortness of breath noted people with epilepsy, but the treatment may involve

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hyperbaric oxygen. There appears to be little evidence would be one in over forty thousand. Although this that O2 toxicity, either during the dive or during recom- risk may be increased by an unknown amount in some- pression, is more likely to occur in people with controlled one under stressful hyperbaric conditions, this could be seizures. It would seem prudent, however, that people with compared with the risk of DCI occurring in any dive, controlled seizures should not use Nitrox (an oxygen en- which is said to be one in five to ten thousand (Newton, riched mixture, including less N2 than air and sometimes 2001). used to prevent DCI), in case their propensity to have hy- Data on diving in people with epilepsy who are seizure peroxic seizures was increased. free (whether or not on medication) are not available in the literature. Objections to diving by people who have been seizure-free for a long time are largely theoretical. DISCUSSION The situation is similar to that which was the case for peo- In 1985 the Professional Advisory Board of the ple with diabetes mellitus until the early 1990s. In 1991, Epilepsy Foundation of America wrote that they “strongly however, in response to advances in diabetes care, the UK believe that persons with epilepsy whose seizures are con- diving authorities changed their recommendations and al- trolled can and should lead full lives without any personal lowed certain people with well-controlled diabetes to dive restrictions” and that they should therefore be allowed to (UK Sport Diving Medical Committee, 2004). The Diving dive, but not teach diving, as long as they are fully aware Diseases Research Centre conducted a preliminary open, of the risks (Dreifuss, 1985). The flurry of letters in reply crossover, controlled study in a hyperbaric chamber to ex- to this suggested that many people did not agree (Meck- amine the effects of diving on serum glucose levels (Edge elnburg, 1985; Millington, 1985). Twenty years later, the et al., 1997), and is conducting a further study using ques- situation has not changed. tionnaires on divers with diabetes doing “real life” diving. Risk taking is an integral part of life and people with Although it would not be advisable to try to make people epilepsy, like everybody else, should be allowed to make with epilepsy have seizures in a hyperbaric chamber, it informed decisions about risk. In the United Kingdom could theoretically be possible to try to elucidate some of people with epilepsy, including those on AEDs, are al- the presumed affects of pressure on AEDs. lowed to drive a motor vehicle provided they have been There is anecdotal evidence from many practitioners seizure free for a year. A seizure while driving at speed that people with epilepsy may go to areas of the world could potentially injure far more disinterested people than where diving regulations are less stringent in order to a seizure at depth, although the latter would most likely avoid the diving ban. This is clearly very bad practice, kill the diver and endanger the life of the diving buddy. and fatalities are far more likely to occur in these con- People with epilepsy may decide that the risk is worth ditions. The BSAC data also confirms that people with taking. The chance of seizure recurrence after a period known seizures may deny having epilepsy to avoid a ban of remission is difficult to quantify, and is dependent on (Cumming, 2005). several factors; a history of tonic–clonic seizures, the oc- It is not possible to rule out an increased risk in peo- currence of further seizures after starting AED treatment ple with epilepsy who are seizure free on medication, and and use of more than one AED all increased the risk of the current data do not allow a precise assessment of the seizures in a randomized study comparing continued AED magnitude of any risk. Therefore, we recommend caution treatment with slow withdrawal in people who had been when evaluating and advising a patient with controlled seizure free for at least 2 years (Medical Research Council seizures who requests permission for scuba diving. For Antiepileptic Drug Withdrawal Study Group, 1993). The each individual, all risk factors for recurrence or for pos- risk of seizures recurring decreases with increasing time sible complications should be considered. It is important without seizures, but the risk is never completely abol- that the person is aware of all the possible risks, and ca- ished; people with epilepsy who wish to scuba dive must pable of making the decision. No person should dive if be aware of this. In the MRC AED withdrawal study, of sedated by their drugs, and perhaps diving should be lim- 510 patients who had been seizure-free for at least 2 years ited to depths no greater than 10 m, as the risks of DCI are and who were randomized to continue AED treatment, minimal at this depth unless breath holding occurs. It has 22% had had seizures within 2 years, but the risk declined been suggested that diving would be safer if the diving steadily thereafter (Medical Research Council Antiepilep- buddy was a fully qualified rescue diver, fully aware of tic Drug Withdrawal Study Group, 1991). We suggest that the history of seizures. Anyone who has not been seizure- until more information about the risk is available, an em- free for at least 4 years should be strongly advised not to pirical approach would be to delay scuba diving in people dive. People with epilepsy are at higher risk if they dive on stable AED therapy until at least 4 years have elapsed than those without epilepsy; however, many people with since the last seizure. The chance of a seizure happening epilepsy will dive regardless of rules and regulations, of- in a subject seizure free for 4 years by chance during a ten concealing their condition. We suggest potential divers 60-min period under normal, nonstressful conditions be given the best individualized advice available and that

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they should be warned of the risks and dangers, so they Edmonds C, Walker D. (1989) Scuba diving fatalities in Australia and can make an informed decision. New Zealand. Part 1. The human factor. SPUMS J 19:94–104. Emerson GM. (2002) What you need to know about diving medicine but There may, of course, be legal implications for prac- won’t find in a textbook. Emergency Medicine 14:371–376. titioners in agreeing that individual people with epilepsy Emerson GM, Oxer HF. (1998) Unusual causes of convulsions in a may be able to consider recreational scuba diving. It is hyperbaric chamber. Undersea and Hyperbaric Medicine 25:128– 129. important that physicians should be aware of the legal Fountain NB, May AC. (2003) Epilepsy and athletics. Clinics in Sports implications, and should discuss these with their insur- Medicine 22:605–609. ers, particularly in countries with a litigious environment. Green RD, Leitch DR. (1985) Head injury and diving: a review. Journal of the Royal Naval Medical Service 71:144–149. All discussions with patients who wish to dive should be Hallenbeck JM. (1984) Seizure disorder in a scuba diver. JAMA 252:565. carefully documented, and it may be appropriate to ask Hamilton RW, Thalmann E. (2003) Decompression Practice. In Brubakk the patient to sign a statement that the risks have been A, Neuman T (Eds) Bennett and Elliotts’ physiology and medicine of diving, 5th ed. Saunders, London, pp. 453–498. discussed. Hampson N, Atik D. (2003) Central nervous system oxygen toxicity This is still a controversial issue, and more research during routine hyperbaric oxygen therapy. Undersea and Hyperbaric is needed to evaluate the risks. The practitioner can only Medicine 30:147–153. Hardy P, Collet JP, Goldberg J, Ducruet T, VanasseM, Lambert J, Marois give the patient the best currently available information, P, Amar M, Montgomery DL, Lecomte JM, Johnston KM, Lassonde and then the decision as to whether to dive has to be the M. (2002) Neuropsychological effects of hyperbaric oxygen ther- result of a consensus between the person with controlled apy in cerebral palsy. Developmental Medicine and Child Neurology 44:436–446. seizures, the diving buddy, the insurer, and the family. Jacey MJ, Heyder E, Williamson RA, Tappan DV. (1976) Biochemistry and hematology at decompression sickness: a case report. Aviation Acknowledgments: This work was supported by the UK Na- Space and Environmental Medicine 47:657–661. tional Society for Epilepsy and University College London Hos- Joint Formulary Committee. (2004) British National Formulary, 48th pitals NHS Foundation Trust. The authors would like to thank ed. British Medical Association and Royal Pharmaceutical Society Professors John Duncan, Philip Patsalos, Robert Fisher, and Dr. of Great Britain, London. Khalid Hamandi for helpful comments on the manuscript. Dr. Madsen J, Hink J, Hyldegaard O. (1994) Diving physiology and patho- John King of the London Dive Chamber gave invaluable assis- physiology. Clinical Physiology 14:597–626. tance. We are also grateful to Mr. Bob Davies (Scuba Bob) for McAuley JW, Long L, Heise J, Kirby T, Buckworth J, Pitt C, Lehman KJ, many useful discussions on diving in practice. We are also very Moore JL, Reeves AL. (2001) A prospective evaluation of the effects grateful to the anonymous reviewers of this paper for Epilepsia, of a 12-week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy. Epilepsy and Behavior 2:592– for their most useful comments and suggestions. 600. Meckelnburg RL. (1985) Should epileptics scuba dive? JAMA 254: 3183. 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Taylor DM, O’Toole KS, Ryan CM. (2002) Experienced, recreational performing a fixed-ratio test. Physiology and Behavior 67:321– scuba divers in Australia continue to dive despite medical contraindi- 325. cations. Wilderness and Environmental Medicine 13:187–193. UK Sport Diving Medical Committee. (2004) Standards. Available at: Thalmann ED. (2004) Decompression illness: what is it and what is www.uksdmc.co.uk/standards. Accessed 5-10-2004. the treatment? Available at: www.diversalertnetwork.org. Accessed Weaver LK. (1983) Phenytoin sodium in oxygen-toxicity-induced 5-10-2004. seizures. Annals of Emergency Medicine 12:38–41. Turle-Lorenzo N, Zouani B, Risso JJ. (1999) Narcotic effects pro- Worf N. (2002) Scuba-diving injuries. Emergency Medical Services duced by nitrous oxide and hyperbaric nitrogen narcosis in rats 31:147–149.

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First-aid normobaric oxygen for the treatment of recreational diving injuries [Abstract] Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ

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Alveolar gas composition before and after maximal breath-holds in competitive divers [Abstract] Lindholm P, Lundgren CEG

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SPUMS $QQXDO6FLHQWL¿F0HHWLQJ Dates: May 24 – 31 Venue: Liamo Resort, Kimbe WNB, Papua New Guinea Guest speakers: Professor Alf Brubakk Associate Professor Richard Moon Dr David Williams

Themes: The Treatment Tables Tropical/Envenomation Medicine Update Resuscitation Update

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',9,1*5(/$7(')$7$/,7,(65(6285&( The coronial documents relating to diving fatalities in Australian waters up to and including 1998 have been de- posited by Dr Douglas Walker for safe keeping in the National Library of Australia, Canberra. Accession number for the collection is: MS ACC 03/38. These documents have been the basis for the reports in this Journal as Project Stickybeak. They are available free of charge to ERQD¿GH researchers attending the library in person, subject to an agreement regarding anonymity. It is hoped that other researchers will similarly securely deposit documents relating to diving incidents when they have no further immediate need of them. Such documents can contain data of great value for subsequent research.

DISCLAIMER $OORSLQLRQVH[SUHVVHGLQWKLVSXEOLFDWLRQDUHJLYHQLQJRRGIDLWKDQGLQDOOFDVHVUHSUHVHQWWKHYLHZVRIWKHZULWHU DQGDUHQRWQHFHVVDULO\UHSUHVHQWDWLYHRIWKHSROLF\RI63806 8DCI:CIH Diving and Hyperbaric Medicine Volume 37 No. 4 December 2007

Editorial SPUMS notices & news 211 Diploma of Diving and Hyperbaric 173 The Editor’s offering Medicine requirements 212 Minutes of the SPUMS Executive Committee Telephone Conference Meeting held on Original articles 01 September 2007 213 Notice of the SPUMS Annual 174 Diving-related deaths in New Zealand 2000–2006 General Meeting 2008 Andrew McClelland 214 Minutes of AGM of ANZHMG, 189 Diving expedition medicine – the Coral Cay Conservation 11 August 2007 experience $1=&$&HUWLÀFDWHLQ'LYLQJDQG Karen E Richardson Hyperbaric Medicine 199 Ventilator performance under hyperbaric conditions: a study of the Servo 900C ventilator Gordon Bingham, Bill Koch, Geraldine Lee and Ian Millar

Review article Letters to the Editor

 6FLHQWLÀF GLYLQJ LQ $QWDUFWLFD KLVWRU\ DQG FXUUHQW 226 Diving medical education practice David Elliott Neal W Pollock 226 Recognition of diving medicals in Queensland Jürg Wendling

Articles reprinted from other sources Book reviews

216 Epilepsy and recreational scuba diving: an absolute 227 PFO and the diver contra-indication or can there be exceptions? A call for Constantino Balestra, Frans J Cronjé, discussion Peter Germonpré and Alessandro Maria do Rosario G Almeida, Gail S Bell and Josemir W Sander Marroni (Commentary: Michael Davis) 228 The oxygen revolution 224 First-aid normobaric oxygen for the treatment of Paul G Harch and Virginia McCul- recreational diving injuries [Abstract] lough Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ 224 Alveolar gas composition before and after maximal breath-holds in competitive divers [Abstract] Lindholm P, Lundgren CEG

Critical appraisal Courses and meetings

225 Hyperbaric oxygen therapy reduces muscle tenderness 229 Courses and meetings and raises pain threshold in patients suffering from ÀEURP\DOJLD Yildiz S, Kiralp MZ, Akin A, Keskin I, Ay H, Dursun H, Cimsit M Appraised by Gibbens A, Bennett M Instructions to authors

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