Diving accident

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  • Diving accident

    1. 1. Diving accident นต . คมสัน วุฒิประเสริฐ รน . กองเวชศาสตร์ใต้น้ำและการบิน กรมแพทย์ทหารเรือ
    2. 2. Classification of Diving Injuries <ul><ul><li>Increase in atmospheric pressure (during descent) </li></ul></ul><ul><ul><li>Middle ear/ sinus barortauma of descent. </li></ul></ul><ul><ul><li>barotrauma to inner ear. </li></ul></ul><ul><ul><li>At depth </li></ul></ul><ul><ul><li>Salt water aspiration </li></ul></ul><ul><ul><li>Nitrogen Narcosis </li></ul></ul><ul><ul><li>Unconsciousness </li></ul></ul>
    3. 3. Classification of Diving Injuries <ul><ul><li>Decrease in atmospheric pressure (during ascent) </li></ul></ul><ul><ul><li>barotrauma of ascent </li></ul></ul><ul><ul><li>Decompression illness </li></ul></ul><ul><ul><li>Arterial Embolism </li></ul></ul><ul><ul><li>On surface </li></ul></ul><ul><ul><li>Salt water aspiration </li></ul></ul><ul><ul><li>Drowning </li></ul></ul><ul><ul><li>Physical injury (environment/water craft) </li></ul></ul>
    4. 4. Barotrauma <ul><li>Middle & inner ear barotrauma </li></ul><ul><li>Sinus barotrauma </li></ul><ul><li>Pulmonary barotrauma </li></ul><ul><li>Equipment Barotrauma </li></ul><ul><li>“ mask squeeze”/ facial barotrauma </li></ul><ul><li>“ suit squeeze”/ skin barotrauma </li></ul><ul><li>Dental Barotrauma </li></ul>
    5. 5. Boyle’s law <ul><li>- If the temperature remain constant , the volume of the given mass of gas is inversely proportional to the absolute pressure </li></ul><ul><li>P 1 V 1 = P 2 V 2 </li></ul>
    6. 6. Boyle’s Law <ul><li>If mass and temperature remain constant, the volume of a given mass of gas is inversely proportional to the absolute pressure </li></ul><ul><li>P 1 V 1 = P 2 V 2 </li></ul>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}
    7. 7. Middle ear barotrauma
    8. 10. Middle Ear Barotrauma of Descent <ul><li>Causes of Blockage of Eustachian Tube </li></ul><ul><li>URI and allergies (anything that can cause mucosal congestion) </li></ul><ul><li>alcohol ingestion </li></ul><ul><li>cigarette smoking </li></ul><ul><li>mucosal polyps </li></ul><ul><li>head down position </li></ul>
    9. 11. Middle Ear Barotrauma of Descent <ul><li>Management </li></ul><ul><li>Stop Diving ( temporary ) </li></ul><ul><li>avoid Valsalva manoeuvre/ straining </li></ul><ul><li>decongestants </li></ul><ul><li>serial audiometry (compare to last medical) </li></ul><ul><li>advice on ear clearing techniques </li></ul><ul><li>prevention </li></ul>
    10. 12. Middle Ear Barotrauma of Ascent <ul><li>less common - usually equalises passively </li></ul><ul><li>damage from distension by enclosed gases within the middle ear that continues to expand with ascent </li></ul><ul><li>more serious as it restricts ASCENT </li></ul><ul><li>discomfort to pain </li></ul><ul><li>alternobaric vertigo </li></ul><ul><li>avoid decongestants, diving with a cold </li></ul>
    11. 14. Grade 0 - Symptoms without signs Grade 1 - Injection of the TM (especially along the handle of the malleus)
    12. 15. Grade 2 - Injection plus slight haemorrhage within TM Grade 3 - Gross haemorrhage within the TM
    13. 16. Grade 4 - Free blood in the middle ear Grade 5 - Perforation/Rupture of the TM
    14. 17. Inner Ear Barotrauma (Perilymph Fistula)
    15. 18. Inner Ear Barotrauma <ul><li>Symptoms and Signs </li></ul><ul><li>1. Tinnitus </li></ul><ul><li>2. High frequency hearing loss </li></ul><ul><li>3. Vestibular disturbance </li></ul><ul><ul><li>nausea, vomiting, vertigo, ataxia </li></ul></ul><ul><li>Sensation of blockage in affected ear </li></ul><ul><li>+/- features of middle ear barotrauma </li></ul>
    16. 19. Inner Ear Barotrauma <ul><li>Management </li></ul><ul><li>Avoid increase in CSF pressure </li></ul><ul><li>Immediate bed rest with head elevated 30 ° </li></ul><ul><li>Consider operative intervention </li></ul><ul><li>avoid diving and flying </li></ul>
    17. 20. Sinus Barotrauma
    18. 21. Sinus Barotrauma <ul><li>pain over sinus during descent </li></ul><ul><li>may continue as dull persistent ache for several hours </li></ul><ul><li>usually frontal, less frequently retro-orbital, </li></ul><ul><li>maxillary pain uncommon but may refer to upper teeth </li></ul><ul><li>numbness over maxillary division of the trigeminal nerve is possible </li></ul>Symptoms and Signs:
    19. 22. Sinus Barotrauma <ul><li>Prevention </li></ul><ul><li>refrain from diving with URTI/sinus infections </li></ul><ul><li>discourage use of decongestants while diving </li></ul><ul><li>appropriate treatment of allergic rhinitis with topical steroids </li></ul><ul><li>cease smoking </li></ul>
    20. 23. Sinus Barotrauma <ul><li>Management </li></ul><ul><li>decongestants </li></ul><ul><li>analgesics </li></ul><ul><li>antibiotics </li></ul><ul><li>stop diving and flying until resolved </li></ul>
    21. 24. mask squeeze/ facial barotrauma
    22. 25. Facial Barotrauma of Descent <ul><li>puffy, oedematous facial tissue, especially under the eyes </li></ul><ul><li>purpuric haemorrhages </li></ul><ul><li>conjunctival haemorrhages </li></ul><ul><li>generalised bruising of skin underlying the mask </li></ul>
    23. 27. Pulmonary barotrauma
    24. 28. Pulmonary Barotrauma of Ascent <ul><li>burst lung or pulmonary overinflation syndrome </li></ul><ul><li>result of overdistension and rupture of the lungs by expanding gases during ascent </li></ul>
    25. 29. Pulmonary Barotrauma of Ascent <ul><li>Precipitating factors </li></ul><ul><li>inadequate exhalation caused by panic, faulty apparatus, inexperience </li></ul><ul><li>Predisposing factors </li></ul><ul><li>asthma , intrapulmonary fibrosis, cysts, infection, pleural adhesions, sarcoidosis, previous pneumothorax </li></ul>
    26. 31. Decompression sickness. <ul><li>The liberation of gas bubbles from solution, </li></ul><ul><li>into tissues or blood, </li></ul><ul><li>in an individual exposed to a reduction of environmental pressure. </li></ul>
    27. 32. Henry’s law <ul><li>- At a constant temperature </li></ul><ul><li>the amount of a gas that will dissolve in a liquid is proportion to the partial pressure of the gas over the liquid </li></ul>
    28. 33. 1 atm 2 atm 3 atm
    29. 34. Pathology - Bubble form first in tissue and then in venous blood - The lung are usually an effective filter for bubble ( pulmonary arterioles )
    30. 35. 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)
    31. 36. Effects of Tissue Bubbles . <ul><li>Obstruction of vascular flow </li></ul><ul><li>External compression to vascular , nerve </li></ul><ul><li>lymphatics and sensory cell </li></ul><ul><li>Mechanical damage to tissues and structures </li></ul><ul><li>Activation of inflammatory response . </li></ul>
    32. 37. Extravasations of fluid Increased hemoglobin concentration Progressive worsening of blood flow
    33. 38. 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
    34. 39. Traditional Signs & Symptoms. <ul><ul><li>Pain </li></ul></ul><ul><ul><li>Pins and needles </li></ul></ul><ul><ul><li>Paresthesia/ paralysis </li></ul></ul>
    35. 40. More commonly experienced Signs & Symptoms. <ul><ul><li>pain </li></ul></ul><ul><ul><li>paraesthesia </li></ul></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>tingling </li></ul></ul><ul><ul><li>dizziness </li></ul></ul><ul><ul><li>numbness </li></ul></ul><ul><ul><li>lethargy </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Difficulty concentrating </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul>Difficulty walking ache tired visual dist weakness vertigo chest pain dizzy itching light headed
    36. 41. DCS type 1 Bend Limb and joint pain only Skin rash
    37. 42. DCS type 2 <ul><li>- Cardiopulmonary system </li></ul><ul><li>- “ choke ” </li></ul><ul><li>Nervous system </li></ul><ul><li>- numbness </li></ul><ul><li>- “ spinal cord hit ” </li></ul><ul><li>- spinal cord DCS </li></ul>
    38. 43. Spinal cord DCS <ul><li>Venous infarction of cord </li></ul><ul><li>- Venous gas embolism block the pulmonary arterioles </li></ul><ul><li>- Rise in intra-thoracic pressure </li></ul><ul><li>( pulmonary hypertension ) </li></ul><ul><li>- Interferes drainage of venous system </li></ul><ul><li>( spinovertebral-azygos system ) </li></ul><ul><li>Autochthonous bubble </li></ul><ul><li>Embolism </li></ul><ul><li>- Spinal cord is relatively poor perfusion when compare to the brain </li></ul>
    39. 44. First Aid. <ul><ul><li>Remove from water </li></ul></ul><ul><ul><li>Lie Flat </li></ul></ul><ul><ul><li>100% O2 </li></ul></ul><ul><ul><li>oral /IV fluid </li></ul></ul><ul><ul><li>Emergency Service </li></ul></ul><ul><ul><li>Ambulance </li></ul></ul><ul><ul><li>Air (Helo/ Air Ambulance) </li></ul></ul><ul><ul><li> </li></ul></ul>
    40. 45. First Aid.
    41. 46. First Aid.
    42. 47. First Aid.
    43. 48. First Aid.
    44. 49. First Aid.
    45. 50. First Aid.
    46. 51. First Aid.
    47. 52. First Aid.
    48. 53. Patient Assessment. <ul><ul><li>Dive details. </li></ul></ul><ul><ul><li>- ascent, at depth and descent. </li></ul></ul><ul><ul><li>- contributing factors </li></ul></ul><ul><ul><li>- exclusion of alternate potential causes </li></ul></ul><ul><ul><li>- onset of symptoms </li></ul></ul><ul><ul><li>Physical assessment. </li></ul></ul><ul><ul><li>- neurological assessment </li></ul></ul>
    49. 54. Treatment . <ul><ul><li>Hyperbaric Oxygen Therapy. </li></ul></ul><ul><ul><li>Mechanical compression of bubbles. </li></ul></ul><ul><ul><li>Washout of inert gas (N2). </li></ul></ul><ul><ul><li>IV fluids. </li></ul></ul><ul><ul><li>Rehydration. </li></ul></ul><ul><ul><li>IV Lignocaine. </li></ul></ul><ul><ul><li>Stabilization of cell membranes. </li></ul></ul><ul><ul><li>NSAIDS. </li></ul></ul><ul><ul><li>Combats inflammatory response. </li></ul></ul>
    50. 57. Decompression Illness <ul><li>Prognosis </li></ul><ul><ul><li>avoid dive - 4 weeks </li></ul></ul><ul><ul><li>avoid fly 2-4 weeks </li></ul></ul><ul><ul><li>Review 4 weeks </li></ul></ul><ul><ul><li>? Further investigations </li></ul></ul>
    51. 58. Flying after diving
    52. 59. New guideline <ul><li>> Flying after a single no-decompression dive : A minimum preflight surface interval of 12 hours is suggested. </li></ul>
    53. 60. New guideline <ul><li>> 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. </li></ul>
    54. 61. New guideline <ul><li>> 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. </li></ul>
    55. 62. <ul><li>cabin altitudes of 2,000 to 8,000 feet for divers who do not have symptoms of decompression sickness (DCS). </li></ul>
    56. 63. <ul><li>The recommended preflight surface intervals do not guarantee avoidance of DCS. </li></ul><ul><li>Longer surface intervals will reduce DCS risk further . </li></ul>
    57. 64. 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
    58. 65. Emergency air evacuation <ul><li>Aircraft pressurized 1 ATA ( if possible) </li></ul><ul><li>Un-pressurized aircraft </li></ul><ul><li>- no more than 1000 feet </li></ul><ul><li>Have the patient breath 100% oxygen </li></ul><ul><li>during transport </li></ul>
    59. 66. THANK YOU

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