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Br J Sports Med: first published as 10.1136/bjsm.16.2.102 on 1 June 1982. Downloaded from 102 Brit. J. Sports Med. - Vol. 16, No. 2, June 1982, pp. 102-106 IMMEDIATE MANAGEMENT OF DIVING EMERGENCIES A. J. Whitaker G. G. Bodiwala A. J. WHITAKER, LRCP, MRCS, FFARCS (3rd Class Diver BSAC)* and G. G. BODIWALA, MS, FICS, FICA** *Senior Registrar in Anaesthetics, Leicester Royal Infirmary and University of Leicester **Consultant in Accident and Emergency, Leicester Royal Infirmary and University of Leicester Underwater activities are undoubtedly one of the growth shallower dive for a longer period than is desirable, or sports of the 20th century. Such activities, in the well- multiple dives. With few exceptions he will either not trained person, are remarkably safe. The majority of have followed any decompression schedule or will have casualties are due to trauma or poor seamanship. How- carried it out inadequately. However, he will almost copyright. ever, there are a few hazards peculiar to underwater invariably claim that he has behaved safely. One must activities which are unfamiliar to the average doctor. not take his word. Decompression tables are not com- The dangers will not decrease and the mere fact that one pletely foolproof, so it is possible though rare that even does not work at a coastal site does not mean that one if he has dived within their limits he may still develop will not see the results. The amateur SCUBA (Self Con- a bend. tained Underwater Breathing Apparatus) diver uses compressed air delivered to him by a valve system that Symptoms http://bjsm.bmj.com/ supplies air at the same pressure as his surroundings. As These can be delayed for many hours (up to 24) and are pressure increases by 1 atmosphere for every 10 metres usually considered in two groups, Type I and Type II. one descends in water, it can be seen that the deeper one goes the greater the pressure of the gas respired. Type / Thus the partial pressures of the air components in the alveoli are increased and more gas diffuses into the Pain - is the most common symptom, being present in circulation and thus to the tissues. When the pressure is 9096 of all cases of decompression sickness. It often starts as fleeting pains in the limbs (known as "niggles") reduced by ascending, this process is reversed. However, on September 30, 2021 by guest. Protected if the ascent is too rapid or the volume of gas taken up and progresses as a slowly developing deep ache In or by the circulation is too large, bubbles will form in the near a joint. It may be preceded by tenderness or numb- blood and tissues and these will increase in size as more ness in the area and there may be pallor of overlying gas diffuse into them. This is the mechanism behind the skin. This severe joint pain is what divers call "the first of the conditions that must be considered (Brit. Bends". Subaqua Manual). Cutaneous Manifestation - a mottled eruption on the upper trunk accompanied by a burning pain, a DECOMPRESSION SICKNESS (THE BENDS) "cutaneous bend". In itself it is not serious and fades in History a few hours, but it can be a precursor of much worse to come, so any patient who develops it should be observed The patient will have carried out either one very deep closely. dive (more than 30 metres) or have carried out a Type li *Presen t address: The onset of this type of bend is often more vague epi- Consultant Anaesthetist, gastric pain, headache, angina, vertigo or actual signs of Mansfield District General Hospital, organic malfunction. However, they are mostly central Mansfield, Notts. nervous system or pulmonary effects. Br J Sports Med: first published as 10.1136/bjsm.16.2.102 on 1 June 1982. Downloaded from 103 CNS Effects stretch receptor reflexes are weak in man the diver will This is quite rare, about 5% of decompression sickness, probably not be aware of this effect and as the chest and is usually caused by grossly inadequate decom- wall has only very limited capacity for expansion the pression from a considerable depth. The symptom may pressure within the lungs will rise. This effect can also be mild dizziness, transient deafness or visual distur- occur in a localised segment of lung, if for any reason bances but can range to para or tetraplegia, uncon- the bronchus or bronchiole is obstructed, especially if sciousness, convulsions and death. Immediate decom- that obstruction is of the "Ball valve" type. pression is mandatory if permanent sequelae are to be avoided. The phenomenon can lead to two possible sequalae both covered under the heading of Pulmonary baro- trauma. Chest Acute shortness of breath, retrosternal pain especially 1. Pneumothorax on inspiration and coughing, may herald collapse, shock This severe and potentially fatal condition may and asphyxia. With the increasing dyspnoea the pulse, arise with or without accompanying surgical emphy- at first rapid, becomes feeble and increasing cyanosis sema. If the diver is ascending from considerable leads to unconsciousness and death supervenes. This may depth the pneumothorax may be of the lesion type. well occur in conjunction with other symptoms and is Occasionally however, surgical emphysema may arise probably due to virtually complete blockage of pul- in the absence of an obvious pneumothrax. Treat- monary capillaries with gas bubbles. It could be con- ment of the pneumothorax is by closed chest drain- fused in the early stages with a myocardial infarction. age. In the absence of neither conditions, re-com- The treatment is immediate recompression. Fortunately pression therapy is not necessary. such a disastrous picture occurs in only about 2% of cases (Miles and Mackay, 1976). 2. Air Embolism The other troubles which occur in divers are of a The cause of this phenomenon is internal damage copyright. mechanical nature and affect the ears and sinuses. to the lung structure. The hyperinflation of the alveoli caused by the expansion of the gas pro- duced disruption to the pulmonary micro circu- Ears and Sinuses lation. However, as the pressure within the thorax Pain in the sinuses on descent or a small epistaxis at increases, venous return is considerably obstructed the end of a dive are very common, especially in the first and cardiac output may fall drastically. Therefore dives of a season. However, more severe ear damage at the time of the damage to the pulmonary capill- can be caused. As one descends the external pressure on aries these are largely closed and air does not at http://bjsm.bmj.com/ the tympanic membrane increases and it becomes this time enter them. However, when the diver stretched. Insufflating the Eustacian tubes by swallowing reaches the surface, exhales and then inhales (usually or blowing gently against the pinched nose will dear forcibly), the large negative intra-thoracic pressure this pressure. If it does not and the person continues to thus causes a massive increase in venous return and dive ignoring the pain in the ears, the tympanic therefore a large increase in cardiac output, air will membrane will rupture, allowing water (usually very then enter the pulmonary capillaries via the damaged cold around the British Isles) to enter the middle ear, walls and pass in large amounts through the lungs into causing vertigo, tinnitus and nausea. The person usually the left-hand side of the heart and circulation, where on September 30, 2021 by guest. Protected returns to the surface immediately. Excessively vigorous it produces havoc. Air embolism of this type is attempts to dear the ears can result in a rupture of the extremely lethal and has produced many fatalities. round window which leads to immediate complete deaf- ness on the affected side. This may not be noticed until History after surfacing at the end of a dive and could be con- fused with the start of a Type II bend. Either of these If available at all, it will be of a person having taken conditions should be referred to an ENT specialist as a breath from an aqualung and surfaced while holding soon as possible (Strauss, 1979). the breath, or of exceptionally rapid ascending from considerable depth e.g. in emergency with an inflated Lungs life jacket. It should be noted that the person concerned may not have been diving with aqualung equipment, as As was previously explained, SCUBA apparatus supplies occasionally a snorkel diver has borrowed a mouth piece breathing air at the same ambient pressure as the from a SCUBA diver and taken a few breaths in order to surroundings. Therefore if a person takes a breath from spend a time submerged. Such a practice is extremely an aqualung at depth and then surfaces while holding the dangerous and is discouraged by all responsible regula- breath the gas contained within the lungs will expand as tory authorities throughout the world. It should also be the depth and pressure decreases, (Boyle's Law). As the noticed that this phenomenon may occur in an ascent Br J Sports Med: first published as 10.1136/bjsm.16.2.102 on 1 June 1982. Downloaded from 104 from an extremely shallow depth, as little as 3 metres Recently dry suits have reappeared on the market has been reported, and this is well within the depth of for amateur divers. As the name suggests these are many municipal swimming pools. designed to exclude water completely and the amount of thermal protection provided depends on Symptoms the under clothing worn by the diver and the insula- These include central or pleuritic chest pain, uncon- ting properties of the suit material.

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