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PLONGEE AU MELANGE TERNAIRE Bilan Des Accidents Entre 1998 Et 2008 En Région Provence-Alpes-Côte D’Azur

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PLONGEE AU MELANGE TERNAIRE Bilan Des Accidents Entre 1998 Et 2008 En Région Provence-Alpes-Côte D’Azur FFESSM Paris- 2010 PLONGEE AU MELANGE TERNAIRE Bilan des accidents entre 1998 et 2008 en région Provence-Alpes-Côte d’Azur Docteur Jean-Michel Pontier Docteur Eric Bergman Docteur Bruno Grandjean Ecole de Plongée de la Marine Nationale [email protected] Introduction (1) Plongée à l’air: limites physiologiques * NARCOSE À L’AZOTE (Pp N2 3,5 b 3535--4040 M) 60 mètres * HYPEROXIE (Pp O22 2 b 90 M) * SATURATION EN AZOTE (PROFONDEUR / TEMPS) * MECANIQUE VENTILATOIRE (POIDS MOLÉCULAIRE N2 = 28) Introduction (2) Plongée à l’air: limites légales 60 mètres * MINISTÈRE DE LA DÉFENSE IPA Tome 1, Circulaire 280280--COMISMERCOMISMER / ADG / NP 01.01.10.9610.96 * MINISTÈRE DU TRAVAIL Décret nn°°9090--277277 DU DU 28.03.90 28.03.90 Titre Titre III, III, article article 5 * MINISTÈRE DE LA JEUNESSE ET DES SPORTS Décret nn°°9393--11011101 DU DU 03.09.93, 03.09.93, Arrêté Arrêté du du 22.06.9 22.06.988 Introduction (3) Plongée aux mélanges gazeux * NITROX : Azote / Oxygène : moindre saturation, limité * HELIOX : Hélium / Oxygène : + léger, - narcotique, + saturant * ARGOX : Argon / Oxygène : pouvoir isolant * NEOX : Néon / Oxygène : absence d’effet narcotique, onéreux * HYDROX : Hydrogène / Oxygène : dangereux * HYDRELIOX : Hydrogène / Hélium / Oxygène : dangereux * TRIMIX : Hélium / Azote / Oxygène : plongée profonde > 60 m ARRETE DU 28.08.2000 (JO N° 221 du 23.09.00) Introduction (3) Plongée aux mélanges gazeux en pratique •MÉLANGES SUROXYGÉNÉS : NITROX (AZOTE/OXYGÈNE) - Moindre saturation et risque ADD - temps de plongée et temps de palier - Profondeur moyenne: 20 – 40 M = Risque ACCIDENT HYPEROXYQUE * MÉLANGES AVEC ADJONCTION D’HÉLIUM - Binaire : HELIOX (HELIUM/OXYGENE) - Ternaire : TRIMIX (HELIUM/AZOTE/OXYGENE) - Profondeur moyenne: 60 – 120 M = Risque ACCIDENT DE DESATURATION Introduction (4) Appareil respiratoire de plongée CIRCUIT OUVERT CIRCUIT SEMISEMI--FERMEFERME Protocole de décompression avec table spécifiques Introduction (4) Intérêts des appareil à recyclage de gaz * MOINDRE CONSOMMATION DE GAZ - Autonomie augmentée - Coût ? * ERGONOMIE - Encombrement réduit - Poids réduit * DISCRETION (militaires, photographes) Introduction (4) Risques des appareil à recyclage de gaz ACCIDENTS BIOCHIMIQUES * GAZ RESPIRABLE * CONTRÔLE DE LA PpO22 * EPURATION DU CO22 * LIMITATION DES RÉSISTANCES RESPIRATOIRES Introduction (5) Risques des plongées aux mélange TRIMIX ACCIDENTS BIOCHIMIQUES * PERTE DE CONNAISSANCE * SURPRESSION PULMONAIRE * NOYADE EN PLONGEE ACCIDENTS DE DESATURATION ACCIDENTS BAROTRAUMATIQUES (idem a Air) PATIENTS et METHODE · 39 DOSSIERS D’ACCIDENT DE PLONGEE au TRIMIX · PERIODE 1998 - 2008 · 3 CENTRES HYPERBARES - TOULON HIA St Anne n = 15 Hôpital Font-Pré n = 18 - NICE n = 6 - MARSEILLE Résultats (1): Population des plongeurs étudiée Sexe masculin Age : 37 ±±± 8 ans (moy ±±± sem) min. 22 et max. 48 Niveaux en plongée (FFESM) - niveau III n = 11 - niveau IV n = 10 - moniteur fédéral n = 18 Résultats (2) Répartition du nombre des Accidents de Plongée au mélange TRIMIX entre 1998 et 2008 8 7 6 5 4 3 2 Nombre d'accidents de de plongée plongée Nombre Nombre d'accidents d'accidents 1 0 1998 - 2008 Résultats (3): Caractéristiques de la plongée · Plongée de loisir dans 80 % · Type d’appareil de plongée: 2/3 Recycleur · Paramètres de la plongée (FFESM) - Profondeur max: 83 ± 23 m (moy ± sem) - Durée de travail: 17 ± 5 min (moy ± sem) - Procédure de décompression: ordinateur - Plongée non successive Résultats (4): Classification des Accidents de Plongée Accidents barotraumatiques n = 0 Accidents biochimiques n = 0 ADD de type II n = 39 Neurologique Cochléo-vestibulaire - Ostéo-myo-articulaire n = 29 Ostéo-myo-articulaire Mixte (OMA et ADD type 1) 7% 11% - Cochléo-vestibulaire n = 8 18% - Neurologiques n = 5 64% - Mixte (OMA et ADD type 1) n = 3 Résultats (5): Prise en charge sur les lieux de la plongée · Délai moyen de survenue des symptômes · Traitement initial (ONB MHC 15l/min) · Thérapeutique hyperbare - sur les lieux n = 0 - RTI n = 2 - Centre hyperbare n = 39 Résultats (6): Thérapeutique hyperbare hospitalière · Délai de prise en charge 13 h (3-21 h) · Séance initiale - Table 2.8 ATA (ADD OMA aggravation) - Table 1.5 ATA (ADD OMA amélioration) - Table 4 ATA (ADD cochléo-vestibulaire et neuro) · Séances de consolidation selon évolution Discussion (1): Plongée TRIMIX en pratique · Plongeur sportif, entrainé, 37 ans · Plongée d’exploration - Appareil à recyclage - Profondeur moyenne 80 mètres - Profil de décompression conforme · Absence de facteur favorisant ADD Discussion (2): Plongée TRIMIX et Accident biochimique · Difficultés de déclaration · Problème technologique en plongée · Décès par noyade avec obstacle médico-légal Effect of in-water recompression with oxygen to 6 msw versus normobaric oxygen breathing on bubble formation in divers. (Blatteau & Pontier, Eur J Appl Physiol, 2009) Méthode temps (min) Détection de bulles 0 10 20 30 40 50 60 70 80 90 100 110 120 130 0 ONB 5 19 plongeurs militaires OHB 10 Age 34 ± 7 ans 15 Chaque plongeur a réalisé 3 plongées : ±±± -2 20 - une plongée contrôle IMC 24,2 1,4 kg. m profondeur (mètres) (mètres) (mètres) profondeur profondeur 25 - 2 plongées suivies d’oxygénation normo-(ONB) ou hyperbare (OHB) 30 30 25 20 15 10 Résultats KISS bulles de score * 5 0 ** control ONB OHB Phénomène bullaire et agrégation plaquettaire Discussion (3): Plongée TRIMIX et Accident de désaturation · Formes mixtes · Formes neurologiques · Formes cochléo-vestibulaire · Formes Ostéo-Myo-Articulaire Discussion (4): Plongée TRIMIX et Accident de désaturation · Traitement initial de l’ADD · Délai de prise en charge · Thérapeutique hyperbare - Table 4 ATA: formes type II déficitaire - Table 2.8 ATA: formes OMA reçues tardivement - Table 1.5 ATA: formes assymptomatiques à l’arrivée · Bilan complémentaire (IRM à distance) Discussion (5): Plongée TRIMIX et Aptitude médicale 1 Recherche d’un shunt droitdroit--gauchegauche 2 Evaluer l’importance du phénomène bullaire 3 Prévenir le risque d’ oedême pulmonaire d’immersion 4 Susceptibilité individuelle à l’l’hyperoxiehyperoxie: EEG 5 Bilan radiologique des grosses articulations 6 Evaluation psychologique ? Surveillance des effets à long terme Conclusion PLONGEE TRIMIX: une activité à risque Risques technologiques Risques biochimiques et toxiques en plongée Risques physiologiques lors de la décompression Conclusion PLONGEE TRIMIX et Protocole de décompression MERCI POUR VOTRE ATTENTION.
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