Diving accident
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Diving accident

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Diving accident Diving accident Presentation Transcript

  • Diving accident นต . คมสัน วุฒิประเสริฐ รน . กองเวชศาสตร์ใต้น้ำและการบิน กรมแพทย์ทหารเรือ
  • Classification of Diving Injuries
      • Increase in atmospheric pressure (during descent)
      • Middle ear/ sinus barortauma of descent.
      • barotrauma to inner ear.
      • At depth
      • Salt water aspiration
      • Nitrogen Narcosis
      • Unconsciousness
  • Classification of Diving Injuries
      • Decrease in atmospheric pressure (during ascent)
      • barotrauma of ascent
      • Decompression illness
      • Arterial Embolism
      • On surface
      • Salt water aspiration
      • Drowning
      • Physical injury (environment/water craft)
  • Barotrauma
    • Middle & inner ear barotrauma
    • Sinus barotrauma
    • Pulmonary barotrauma
    • Equipment Barotrauma
    • “ mask squeeze”/ facial barotrauma
    • “ suit squeeze”/ skin barotrauma
    • Dental Barotrauma
  • Boyle’s law
    • - If the temperature remain constant , the volume of the given mass of gas is inversely proportional to the absolute pressure
    • P 1 V 1 = P 2 V 2
  • Boyle’s Law
    • If mass and temperature remain constant, the volume of a given mass of gas is inversely proportional to the absolute pressure
    • P 1 V 1 = P 2 V 2
    Surface 10 m 20 m 30 m 2 ATA 3 ATA 4 ATA 1 ATA 1/2 1/3 1/4 6 L 3 L 2 L 1.5 L 3 L 6 L 4 L {12 L}
  • Middle ear barotrauma
  •  
  •  
  • Middle Ear Barotrauma of Descent
    • Causes of Blockage of Eustachian Tube
    • URI and allergies (anything that can cause mucosal congestion)
    • alcohol ingestion
    • cigarette smoking
    • mucosal polyps
    • head down position
  • Middle Ear Barotrauma of Descent
    • Management
    • Stop Diving ( temporary )
    • avoid Valsalva manoeuvre/ straining
    • decongestants
    • serial audiometry (compare to last medical)
    • advice on ear clearing techniques
    • prevention
  • Middle Ear Barotrauma of Ascent
    • less common - usually equalises passively
    • damage from distension by enclosed gases within the middle ear that continues to expand with ascent
    • more serious as it restricts ASCENT
    • discomfort to pain
    • alternobaric vertigo
    • avoid decongestants, diving with a cold
  •  
  • Grade 0 - Symptoms without signs Grade 1 - Injection of the TM (especially along the handle of the malleus)
  • Grade 2 - Injection plus slight haemorrhage within TM Grade 3 - Gross haemorrhage within the TM
  • Grade 4 - Free blood in the middle ear Grade 5 - Perforation/Rupture of the TM
  • Inner Ear Barotrauma (Perilymph Fistula)
  • Inner Ear Barotrauma
    • Symptoms and Signs
    • 1. Tinnitus
    • 2. High frequency hearing loss
    • 3. Vestibular disturbance
      • nausea, vomiting, vertigo, ataxia
    • Sensation of blockage in affected ear
    • +/- features of middle ear barotrauma
  • Inner Ear Barotrauma
    • Management
    • Avoid increase in CSF pressure
    • Immediate bed rest with head elevated 30 °
    • Consider operative intervention
    • avoid diving and flying
  • Sinus Barotrauma
  • Sinus Barotrauma
    • pain over sinus during descent
    • may continue as dull persistent ache for several hours
    • usually frontal, less frequently retro-orbital,
    • maxillary pain uncommon but may refer to upper teeth
    • numbness over maxillary division of the trigeminal nerve is possible
    Symptoms and Signs:
  • Sinus Barotrauma
    • Prevention
    • refrain from diving with URTI/sinus infections
    • discourage use of decongestants while diving
    • appropriate treatment of allergic rhinitis with topical steroids
    • cease smoking
  • Sinus Barotrauma
    • Management
    • decongestants
    • analgesics
    • antibiotics
    • stop diving and flying until resolved
  • mask squeeze/ facial barotrauma
  • Facial Barotrauma of Descent
    • puffy, oedematous facial tissue, especially under the eyes
    • purpuric haemorrhages
    • conjunctival haemorrhages
    • generalised bruising of skin underlying the mask
  •  
  • Pulmonary barotrauma
  • Pulmonary Barotrauma of Ascent
    • burst lung or pulmonary overinflation syndrome
    • result of overdistension and rupture of the lungs by expanding gases during ascent
  • Pulmonary Barotrauma of Ascent
    • Precipitating factors
    • inadequate exhalation caused by panic, faulty apparatus, inexperience
    • Predisposing factors
    • asthma , intrapulmonary fibrosis, cysts, infection, pleural adhesions, sarcoidosis, previous pneumothorax
  •  
  • Decompression sickness.
    • The liberation of gas bubbles from solution,
    • into tissues or blood,
    • in an individual exposed to a reduction of environmental pressure.
  • Henry’s law
    • - At a constant temperature
    • the amount of a gas that will dissolve in a liquid is proportion to the partial pressure of the gas over the liquid
  • 1 atm 2 atm 3 atm
  • Pathology - Bubble form first in tissue and then in venous blood - The lung are usually an effective filter for bubble ( pulmonary arterioles )
  • Pathology - The ability of lung to filter the bubble which then resolve by gas diffusion to the alveoli - Bubble can also be bypassed through anatomical defect  patent foramen ovale ( PFO)
  • Effects of Tissue Bubbles .
    • Obstruction of vascular flow
    • External compression to vascular , nerve
    • lymphatics and sensory cell
    • Mechanical damage to tissues and structures
    • Activation of inflammatory response .
  • Extravasations of fluid Increased hemoglobin concentration Progressive worsening of blood flow
  • Decompression sickness Type 1 - limb or joint pain ( bends ) Type 2 - sign or symptom ,cause by involvement of CNS , cardiopulmonary system Type 3 - DCS + AGE
  • Traditional Signs & Symptoms.
      • Pain
      • Pins and needles
      • Paresthesia/ paralysis
  • More commonly experienced Signs & Symptoms.
      • pain
      • paraesthesia
      • headache
      • tingling
      • dizziness
      • numbness
      • lethargy
      • Nausea
      • Difficulty concentrating
      • Fatigue
    Difficulty walking ache tired visual dist weakness vertigo chest pain dizzy itching light headed
  • DCS type 1 Bend Limb and joint pain only Skin rash
  • DCS type 2
    • - Cardiopulmonary system
    • - “ choke ”
    • Nervous system
    • - numbness
    • - “ spinal cord hit ”
    • - spinal cord DCS
  • Spinal cord DCS
    • Venous infarction of cord
    • - Venous gas embolism block the pulmonary arterioles
    • - Rise in intra-thoracic pressure
    • ( pulmonary hypertension )
    • - Interferes drainage of venous system
    • ( spinovertebral-azygos system )
    • Autochthonous bubble
    • Embolism
    • - Spinal cord is relatively poor perfusion when compare to the brain
  • First Aid.
      • Remove from water
      • Lie Flat
      • 100% O2
      • oral /IV fluid
      • Emergency Service
      • Ambulance
      • Air (Helo/ Air Ambulance)
  • First Aid.
  • First Aid.
  • First Aid.
  • First Aid.
  • First Aid.
  • First Aid.
  • First Aid.
  • First Aid.
  • Patient Assessment.
      • Dive details.
      • - ascent, at depth and descent.
      • - contributing factors
      • - exclusion of alternate potential causes
      • - onset of symptoms
      • Physical assessment.
      • - neurological assessment
  • Treatment .
      • Hyperbaric Oxygen Therapy.
      • Mechanical compression of bubbles.
      • Washout of inert gas (N2).
      • IV fluids.
      • Rehydration.
      • IV Lignocaine.
      • Stabilization of cell membranes.
      • NSAIDS.
      • Combats inflammatory response.
  •  
  •  
  • Decompression Illness
    • Prognosis
      • avoid dive - 4 weeks
      • avoid fly 2-4 weeks
      • Review 4 weeks
      • ? Further investigations
  • Flying after diving
  • New guideline
    • > Flying after a single no-decompression dive : A minimum preflight surface interval of 12 hours is suggested.
  • New guideline
    • > Flying after multiple no-decompression dives in a single day or multiple days of no-decompression diving : A minimum preflight surface interval of 18 hours is suggested.
  • New guideline
    • > Flying after dives requiring decompression stops : There is little experimental or published evidence on which to base a recommendation for decompression dives. A preflight surface interval substantially longer than 18 hours appears prudent.
    • cabin altitudes of 2,000 to 8,000 feet for divers who do not have symptoms of decompression sickness (DCS).
    • The recommended preflight surface intervals do not guarantee avoidance of DCS.
    • Longer surface intervals will reduce DCS risk further .
  • Emergency air evacuation -Aircraft pressurized 1 ATA ( if possible) -Un-pressurized aircraft - no more than 1000 feet -Have the patient breath 100% oxygen during transport
  • Emergency air evacuation
    • Aircraft pressurized 1 ATA ( if possible)
    • Un-pressurized aircraft
    • - no more than 1000 feet
    • Have the patient breath 100% oxygen
    • during transport
  • THANK YOU