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Home , Barotrauma

Disclosures

• I have no financial conflicts of interest Deep: 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

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Introduction Objectives • 1-3 Million scuba divers in USA2 1 • Know fitness for diving • ~$500 Million/year industry in USA • 1 million scuba divers in EU2 • Know aspects and clinical symptoms of • 3-9/100,000 deaths in US alone(60% )2 • Tropical destinations common • Know clinical presentation of POIS • Know clinical presentations of Sickness (DCS) • Miscellaneous: Malaria, Altitude etc.

1http://www.prweb.com/releases/2012/1/prweb9093526.htm 2 Keystone Travel Med 2nd edition –3 –4

Belize, Roatan, , Cayman Egypt, Jordan, Oman Islands, Bonaire, Case 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.

Galapagos, Ecuador Australia, Indonesia • A: fill out the form Cocos Island, Costa Kenya, Mozambique, Micronesia • B: charge extra and fill out the form Rica Seychelles, Maldives, Fiji • C: refer to a physician Thailand, Malaysia French Polynesia

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1

Fitness to dive • Contraindicated- • Should be done by a certified diving physician – Narcotics, antipsychotics, Anti-convulsants • Age, Sex, Training – Beta blockers or vasodilators if recently started • Contraindications: Absolute (Seizures, Active cardiac disease, active psychiatric disease, SCD, • Relatively safe Chronic diseases, perforated TM, hernias, – NSAIDS, acetaminophen, Digoxin, Antibiotics, orthopedic injury) , antihistamines, scopolamine, • Contraindications: Relative (, DMII, Migraines, recent eye surgery, URI, pregnancy) meclizine • PFO controversial: 20% of population; 40% DCS cases

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• 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 in her L 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

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BAROTRAUMA BAROTRAUMA • Injury caused by changes in pressure • Boyle’s Law (Pressure inversely • SQUEEZE proportional to Volume P=1/V) • barotrauma of •“Ingredients” descent – rigid walls • 10m=1 ATM – gas filled space • damage from – enclosed space relative – change • 100% Preventable by not diving when abnormal anatomical conditions exist

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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

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• BAROTRAUMA

• “MOST COMMON” – Etiology: blocked – Predisposing Factors •infections (URI) • (Hay Fever) • anatomic variations • inability to equalize pressure • Usually leads to ear squeeze

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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 perforation • If perforated consider ENT referral – If perforation occur, rush of cold water into inner ear can cause vestibular symptoms (caloric ) and ultimately infection

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3 BAROTRAUMA BAROTRAUMA

• INNER EAR INJURY • INNER EAR – Clinical Manifestations • fullness of middle ear on – implosive or explosive injury descent • forceful Valsalva or – round window rupture severe ear squeeze • audible “pop” – oval window rupture • sudden onset of roaring – 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 3rd dive descends • INNER EAR INJURY rapidly to 15 meters. She had trouble Valsalva-ing –Treatment on descent and experienced stabbing pain in the forehead for 30 sec before clearing her , on • R/O Air Gas Embolism or Decompression arrival at surface she took off her mask and had Sickness profuse epistaxis. • strict bed rest •This is: • avoid straining (stool softeners, antiemetics, • A barotrauma ear squeeze antivertigo medications, sedation) • B: Type I DCS (the bends) • ENT REFERRAL: standard of care is surgery • C: Barotrauma sinus squeeze within 24 hours • D: Arterial Gas Embolism

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BAROTRAUMA BAROTRAUMA

•SINUS • TOOTH – obstructed sinus – Prevention is the key! ostium (infection, , anatomy) – Pain in tooth on ascent – Pain and bleeding – Predisposing Factors after squeeze or •dental disease reverse sq. • inadequate dental restorations –NO diving • recent dental work –decongestants – observe for infection Drshark2685.blogspot.com

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4 BAROTRAUMA BAROTRAUMA

• FACE MASK SQUEEZE • ABDOMINAL SQUEEZE – failure to clear face mask on descent – usually from 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

•PULMONARY • A 23 y/o male is diving for the 4th time ever at 10 meters, he sees a rock lobster and . He – Squeeze swims as fast as he can to the surface while • deep breath-hold dive to a depth at which lung volume is holding his breath, on the surface he has aphasia, reduced below residual volume an weakness in his LUE of handgrip and wrist –Over expansion flexion. •This is: • intra alveolar hemorrhage, exudate •chest pain • Type II DCS(the bends) • progressive dyspnea • Arterial Gas Embolism • progressive frothy, bloody sputum • Pulmonary Squeeze – Can be accompanied by AGE and DCS • Round window rupture

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PULMONARY OVERINFLATION SYNDROMES (POIS) • MEDIASTINAL EMPHYSEMA – results when gas expansion 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

–O2 may reduce symptoms faster Univ of Maryland

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5 PULMONARY OVERINFLATION SYNDROMES (POIS) • – results from expansion of gas which has leaked from the into the subcutaneous tissues of the neck – symptoms: feels like “Rice Krispies” under the – there may be a voice change due to pressure on the larynx – no treatment is necessary

–O2 may reduce symptoms faster

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PULMONARY PULMONARY OVERINFLATION OVERINFLATION SYNDROMES (POIS) SYNDROMES (POIS) • • ARTERIAL GAS EMBOLISM – accumulation of gas within the pleural • THE MOST SERIOUS POTENTIAL space COMPLICATION OF DIVING CAUSED BY – symptoms: chest pain, more likely lateral EXCESS AIR PRESSURE IN THE CHEST!! or apical; cough; SOB • alveolar rupture with injection of air into – Treatment: 100% O2 and chest tube prn capillary so that a bolus () of air enters pulmonary veins and left ventricle • Occurs suddenly, usually after a rapid ascent

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PULMONARY Arterial Gas embolism OVERINFLATION SYNDROMES (POIS) • Presents as embolic stroke • ARTERIAL GAS EMBOLISM – A DETAILED neuro exam is critical – the is the most significant site of • Majority in MCA distribution embolus –Aphasia –symptoms: ANY type of neurologic sign or –Apraxia symptom (unconsciousness, weakness, – Hemiparesis paralysis, paraesthesia, etc) within 10 min – Hemisensory loss of surfacing • Minority Vertebral Basilar – AGEs do not go to the spine (think DCS) – Visual or cerebellar deficits –tx: O2 & IMMEDIATE RECOMPRESSION

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6 (DCS)

•Inert Gas (N2) saturated in on dive • As diver ascends gas comes out of • Gas forms bubbles-causes vascular obstruction, ischemia, cell death • Bubbles activate clotting system, cause plt clumping etc. also activate cytokines • Onset of sx is delayed unlike AGE

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Decompression Sickness (DCS) Decompression Sickness (DCS) •Risk factors • Mitigators –Obesity – Being physically fit –Age reduces risk of – – Injuries Decompression Sickness (DCS) – – Excessive exercise –Dehydration

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Decompression sickness (DCS)- Classification Decompression sickness (DCS) •Type I •Spinal – Usually sensory level, lower motor neuron sx, – PMS-Pain, Marbling, Swelling bowel bladder dysfunction • “Cutis marmarata” • Cerebral • Bone/joint pain – Fatigue, upper motor neuron sx, • Not life threatening • Pulmonary (chokes) •Type II – Cough, chest pain – Serious neurological symptoms • Inner ear (staggers) • Cerebral, Spinal cord, Pulmonary, Inner ear – Vertigo, N&V, tinnitus, hearing loss – Most common with diving

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7 Treatment

•Type I- – Can be managed with Non Steroidal Anti-Inflammatory Drugs and observation if remote from a chamber –Hydration – USN Treatment Table 5 •Type II – Needs emergent recompression, USN TT6 or higher – IV hydration and is paramount – Medevac is by pressurized jet (3000 feet max)

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Nitrogen Narcosis / • Rapture of the Deep • Issue with • Generally > 100 fsw Diving and •Martini’s Law • Loosened inhibitions •Hypoxia • Agitation – Similar to Narcosis • Tunnel Vision •Hyperoxia • Tinnitus/Rushing Sound –VENTID-C • Poor Judgement •Visual • Simple Tasks Become •Ear Difficult • Nausea/Vomitting •LOC • Twitching/tingling • Resolves with ascent or • Irritability He • Dizziness • Convulsions

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Carbon Dioxide/Monoxide Malaria and Diving Poisoning • Usually from bad air •Increased RR • Mosquitoes can fly 2 miles offshore source • Irritability – Both live-aboard boats and shore facilities at risk • Medications are Completely Unstudied – Compressor intakes •Sweating/N/V near exhausts – Mefloquine-likely unsafe. Study in Swiss Aircraft pilots •Drowsiness found tolerated well but neuro sx and seizure risk •CO2 also from over- •HA – Doxycycline equipment • May have GI side effects (mimic Abd squeeze, DCS) – Hyperventilation • Difficulty • Photosensitivity(marine environment) – Primaquine-no data –CO2 Scrubber Failure Concentrating (Rebreathers) • GI side effects(see above), maybe less effective agent • Seizures (CO2 ) – Atovaquone/Proguanil-My personal preference •LOC • No data on safety, recommended by military aviation community –Petersen K Regis DP Trop Dis Travel Med Vaccines. 2016 Oct 11;2:23

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8 Altitude and Diving

• Ascent from sea level mimics conditions of ascent from dive – Adds DCS risk if recently dove • Do NOT fly for 24h after diving (cabin is 8000 foot equivalent, rapid ascent) • Ascending to altitude after diving – http://www.supsalv.org/manuals/diveman5/13512- 001H/css/vol2/chap9.pdf – Table 9-6 provides guidance on surface time required before climbing – Only for climbs of 10K feet or less • Diving at altitude – Special tables and adjustments are required

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Summary Summary

• Pulmonary overinflation runs from • DCS is best prevented by adequate common (ear squeeze) to deadly (AGE) hydration, and fitness as well as • Not diving while ill markedly reduces adherence to dive tables and computer chances for POIS algorithms • Symptoms are usually immediate on • DCS usually needs recompression as dive or ascent and immediately after soon as possible surfacing • Decompression sickness runs from pain, •O2 and IVF are helpful in stabilizing to life threatening patient until they can get to a chamber

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Resources Questions? • [email protected] • emergency hotline – +1-919-684-9111 • DAN Medical Information Line – +1-919-684-2948 • http://www.diversalertnetwork.org/medical/faq/

–Lago Querococha, Huaraz 3980 meters –53 –54

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