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Diving related injuries tex
- 1. DIVING RELATED INJURIES NON-LIFE THREATING
- 4. At constant temperature the volume of a flexible container depends upon the surrounding pressure and the volume is indirectly proportional to the absolute pressure. P1 V1 = P2 V2 Boyle explains Barotrauma
- 7. Squeeze Barotrauma • Space Characteristics: – Gas Filled – Rigid walls – Enclosed – Vascular Penetration • Environment – Ambient Pressure Change
- 8. Mask Squeeze AKA: Facial Barotrauma • Failure to equalize Mask Air Space during Descent • Occurrence: – as shallow as 15 ft. – Typically unexperienced divers – Not with Full Face Masks • S/Sx: – Injected Sclera – Periorbital Edema – Usually Painless – Usually No Effect on Vision • Tx: – Time (approx 2 weeks) – ANY pain or VISION problems Optho Eval STAT
- 9. OTS Full Fask Mask Mask Types VBPD Divers VBPD Dive Drill – Dredge Ops 18 MAR 2015 Half Mask
- 10. Tooth Squeeze AKA: Barodontalgia • Occurrence – Descent or Ascent – Decay, filling, abscess • S/Sx: – Pain, throbbing • What to do: – During Descent • Tooth ache = Abort Dive – During Ascent • Fracture or Rupture of tooth • Don’t swallow ! • Tx: – Pain Medication – Dentist What could change this to a life threat?
- 11. • Cause: – Air Flow from Regulators – Swallowed air • Occurrence: - ASCENT - S/sx: - Severe Abdominal Cramps and bloating - Tx: - Prevention - Extended DECO stop Stomach Squeeze
- 12. Dry Suit Squeeze
- 13. Dry Suit Squeeze
- 14. VBPD Dive Drill, Dredge Ops, 18 MAR 2015
- 15. VBPD Dive Drill, Dredge Ops, 18 MAR 2015
- 16. VBPD Dive Drill, Dredge Ops, 18 MAR 2015
- 17. Ear Squeeze “Otic Barotrauma” • Most Common Diving Related Injury • Types • Middle Ear Squeeze – Descent • Inner Ear Squeeze (Reverse Ear Squeeze) – Ascent • Occurrence: • Any Depth • Any Time • Any Diver • S/Sx: • Acute • Ear Pain • Vertigo • Tinnitis • Long Term • Can lead to permanent hearing loss
- 18. Ear Squeeze “Otic Barotrauma” • Tx: • Middle Ear Squeeze – Symptomatic • Inner Ear Squeeze • In addition to Middle Ear Tx • Bed Rest with Elevated Head of Bed • Avoidance of any Valsalva maneuvers • Stool Softeners • ENT
- 19. Anatomy of the Ear
- 20. Middle Ear Squeeze Reverse Ear Squeeze
- 21. Ear Squeeze Injected Tympanic Membrane TEED Scale What conditions could increase the risk of Ear Squeeze and possibly Ear Drum (Middle Ear) or Tympanic Membrane (Inner Ear) Rupture?
- 23. Sinus Squeeze
- 24. Other Dive related injures • Vertigo – Alternobaric Vertigo (ABV) – Caloric Vertigo • Nitrogen narcosis
- 25. VERTIGO • Function of Inner Ear Balance
- 26. Vertigo: Other Types • Alternobaric Vertigo – Transient – d/t unequal middle ear pressures on ascent • Caloric Vertigo – Stimulated by cold water in the ear
- 27. Nitrogen narcosis • Deep Dives – 100 ft or more • Breathing Compressed Air • Resolve during descent • s/sx • wooziness; • giddiness; • euphoria; • disorientation; • loss of balance; • loss of manual dexterity; • slowing of reaction time; • fixation of ideas; • and impairment of complex reasoning.
- 29. Carnival Cruise Lines Return to Norfolk Spring 2015
Editor's Notes
- Mask Squeeze
- With the Introduction of Medics to the VBPD Marine Unit, during our operations we may see injuries related to diving operations from both the Marine Unit and civilian divers. As Paramedics we will need to recognize the difference between life threatening injuries and non life threatening injuries Early recognition of these injuries will enable us to make the right treatment decision
- These two are important to know. Robert Boyle and his law explains Barotrauma and William Henry and his law explains decompression sickness or “the bends” which will be in the next lecture .
- Gas Laws and specifically Boyles Law is critical to understanding the effects scuba diving has on the body. So the technical Definition….. yep… I’m not into physics… but he is… CLICK What is important to us as providers is the concept of Boyle’s Law... so no worries, no math necessary. CLICK – here is an easy pic of how pressure affects the diver.
- This is a pic I have that I find very helpful as it gives an easy explanation and visual representation of Boyle’s Law plus I better appreciate the changes that occur in gases….. and if you notice, good thing for us.. the atm increases by 1 CLICK for every 10 meters of depth. CLICK (so easy math) but then how many meters in a foot? a little over 3… as you saw in Eric’s Lecture with the dive tables….10 m = 33 feet. For quick math and a crowded memory, I just remember a yard stick is 3 feet and for our purposes close enough…. so you can think of a meter as being equal to a yard. You can see here that this also shows absolute pressure…. which for us, not really important CLICK because we are really only concerned with the effects of additional pressure and diving, so we use the gauge pressure column CLICK. This is what is reported on diving equipment In case someone asks: at the surface we are at 1 atm of pressure already….so when you dive 1 atm…you have 2 atm of pressure in absolute terms. Each ATM equivalent to roughly 15 lbs (another factor of 3) so at about 30 feet … you have 30lbs of pressure being exerted on your body.
- Although pulmonary barotrauma and “the bends” are most often thought of a talked about when it comes to dive injuries, barotraumas in smaller spaces occur much more frequently…with the most common dive injury being ear barotrauma and least common, the GI system. While not always life threatening, they can still interfere with day to day life and lead to long term damage. In general barotrauma is referenced as “Squeeze.” It can occur d/t under-pressurization (descent) or over-pressurization (ascent)….. barotrauma occurring during ascent more often causes more severe disease. http://www.scuba-tutor.com/dive-injuries/barotrauma/tooth-squeeze.php -
- Gas Filled Space: In body or next to - Any gas-filled space within the body (such as a sinus cavity) or next to the body (such as a face mask) can damage the body tissues when the gas volume changes because of increased pressure. Space contained by Right Walls Outcome Different of Tooth Squeeze vs Stomach Squeeze When the walls are elastic like a balloon, there is no damage done by gas compression or expansion until the volume change surpasses the elasticity of the walls or vessels. ( why stomach squeeze rarely life threatening… yet it is also why a tooth can fracture or rupture Enclosed: except to blood flow, but these vessels are membrane bound and therefore “closed” If any substance (with the exception of blood in the vessels lining the space) were allowed to enter or leave the space as the gas volume changes, no damage would occur. - The space must have vascular penetration (arteries and veins) and a membrane lining the space. This allows the blood to be forced into the space and exceed the elasticity of the vessels to compensate for the change in pressure. CLICK There must be a change in ambient pressure.
- Like the air spaces in your sinuses and ears, you must also equalize the air space in your mask as you descend. When you descend, failure to equalize, or add air to the air space in the mask, by exhaling through your nose can create unequal pressure between the mask air space and the vascular pressure within the blood vessels of the face. This can result in various degrees of facial barotrauma, or injury to the soft tissues of your face contained within the mask. Imagine your face in a suction cup. The soft tissues beneath the mask and especially around the eye swell (periorbital edema) and discolor, such as redness or bruising (ecchymosis). Equalizing your mask is accomplished by exhaling a small amount of air through your nose, and this is why a nose pocket is required. Equalization usually happens automatically as you breathe, but if you feel pressure during descent you may need to consciously exhale through your nose to equalize the pressure. CLICK for AMAZING pic of MASK SQUEEZE What treatment do I need? Unless you are experiencing eye pain or visual problems, there is no treatment for facial barotrauma except time. Because it is a bruise, your body will eventually reabsorb the effect of your mask squeeze. Your physician or an eye specialist should address eye pain or visual disturbances such as blurred vision or loss of part of the visual field immediately. These symptoms would be extremely rare in mask squeeze, however. The signs and symptoms of mask squeeze can take up to two weeks or more to resolve. Unfortunately, it is one of those conditions where you will probably look worse than you'd like before it gets better. Not only will blood and edema need to be reabsorbed, but it tends to be gravity-dependent - which means it will spread downward on your face. Before you heal, you may look like a red-eyed black-and-blue marked creature in a B-grade horror flick or a boxer that took at least two too many punches. TX – None , unless you have vision distortion then seek the attention of an Ophthalmologist.
- This is a pic of one of the divers, I honestly cannot remember from one of the drills and you can see their mask wraps around their head. CLICK They wear Full Face Masks so mask squeeze doesn’t occur because they have continuous air flowing so no problem equalizing it out. Recreational divers though, who we may also be treating, most often time wear what we are likely most familiar with, the half face mask which can lead to squeeze. Point out the Communication line
- Ascent = Reverse Tooth Squeeze Air spaces inside the teeth due to decay, a filling or an abscess, change volume as pressure changes during diving. An air pocket under a filling may expand on ascent and push the filling out of the tooth. An air pocket may be distorted during descent and cause a severe toothache. The tooth can even explode. If you get a toothache during ascent, there is little you can do but continue your ascent. This results in a squeeze that's impossible to equalize during descent. If you feel pressure in a tooth while diving, abort the dive and make an appointment to see a dentist. If you ignore a tooth squeeze, the pressure may slowly equalize. This will cause a reverse block during ascent, and result in a loose filling or fractured tooth. CLICK --- This could quickly turn into an airway issue if the diver is caught by surprise and inhales leading to an airway obstruction while underwater. Now that is a difficult airway scenario I haven’t seen mentioned in training before.
- Air in the stomach at the time of ascent from a dive will expand according to Boyle's Law. Some divers swallow air, which will accumulate in the stomach during a dive. A regulator providing excess pressure at the mouthpiece can force air into the stomach. Ascent with air in the stomach will produce severe abdominal cramps. Further ascent may cause stomach rupture. Prevention is the best management of this problem. Be sure your regulator is functioning properly and avoid swallowing air while diving. If cramps do occur during ascent, stop and try to belch to remove the air from the stomach. TX – Extended DECO Stop . Rarely a Medical Emergency Very Rare…. 13 cases reported b/w 1969-1999…. most recent case published was 2003….still not a lot of cases. This case was a fit middle aged, experienced female diver… dove to depth of 23 meters, suffered a panic attack, quick ascent and ruptured her stomach. She surfaced unconscious lasting 1 min…tx for HBO tx. Upon d/c from HBO c/o abd pain. Pic of barium swallow showing leaking radioactive dye and CLICK the pic of the surgery where a 2 cm tear was fixed. The review stated in general the characteristics of people who suffer this are physically fit, the dive is deep and quick and the persons suffer a panic attack or equipment failure leading to a fast ascent and increased in the amount of air inhaled.
- Now, in general a lot of what we have had to do in our careers falls is quite true under this rule. But, when wearing a dry suit, improper fitting, too thick of under clothes, weight gain can all lead to Dry Suit Squeeze. CLICK Dry Suits are meant to be worn with a layer of clothing underneath, not bundled up in clothes underneath, but a layer. So, trying to fit into a dry suite may technically work, it isn’t “smart”
- Dry Suit users may notice painful red streaks on their skin after diving. These are caused by suit folds lying against the skin during descent. Folds containing air are compressed against the skin, the skin is forced into the folds and local injury occurs The soft tissues beneath the suit swell and discolor, becoming red or bruising (ecchymosis) TX – none / Avoidance. Wear thin garment under Dry Suit
- Office Mike Melnyk in dry suit before gear Note that it is loose compared to a wet suit. Point out the Zippers CLICK straps CLICK and where the seals are – just verbalize
- Officer Johnson in suite and tanks. Note the head cover….this is permeable to water still. They are protected everywhere else but there.
- Officer Johnson in suite and tanks. Note the head cover….this is permeable to water still. They are protected everywhere else but there. The two tanks etc
- Ear squeeze is the most common diving related injury. When the Eustachian tubes do not open to allow pressure to equalize across the eardrum, the pressure difference stretches the drum and causes injury. Enough force can tear or rupture the eardrum. The Eustachian tubes can be blocked by mucous or swelling due to colds or allergies. Middle ear squeeze causes swelling of the lining of the middle ear and fluid accumulation. Often the fluid will not clear until the swelling has subsided and normal Eustachian tube function ret
- Ear squeeze is the most common diving related injury. When the Eustachian tubes do not open to allow pressure to equalize across the eardrum, the pressure difference stretches the drum and causes injury. Enough force can tear or rupture the eardrum. The Eustachian tubes can be blocked by mucous or swelling due to colds or allergies. Middle ear squeeze causes swelling of the lining of the middle ear and fluid accumulation. Often the fluid will not clear until the swelling has subsided and normal Eustachian tube function ret
- Review of anatomy of the ear Middle ear contains the ear drum…. inner ear the bones and cochlea---- part of hearing, fluid and the eustacian tube (draining)
- When pressure outside the ear is different from the pressure in side the ear, the eardrum presses inward and blood expands the tissues of the walls of the middle ear. If the air isn’t equalied, the eardrum will eventually rupture Reverse squeeze, where the eardrum bulges outward, can occur from a too aggressive valsalva maneuver or when a tight fitting hood blocks the external ear canal…. so be easy. CLICK The increasing middle ear pressure will not be balanced by external pressure because of the blocked canal and pressure inside the middle ear will exceed the pressure in the occluded canal. TX- Descend for extended DECO stop. Note this can also present with Bells Palsy-like S&S because CN 7 & 8 Run together and if you have inner ear trauma this can affect CN 7 as well which is the facial nerve that is affected by Bell’s Palsy… difference between Bells and a Stroke? Dr A Rule When the Eye brows move you Move Also for Inner Ear Trauma… Treatment is bed rest with elevated Head
- Ear squeeze is the most common diving related injury. When the Eustachian tubes do not open to allow pressure to equalize across the eardrum, the pressure difference stretches the drum and causes injury. Enough force can tear or rupture the eardrum. The Eustachian tubes can be blocked by mucous or swelling due to colds or allergies. Middle ear squeeze causes swelling of the lining of the middle ear and fluid accumulation. Often the fluid will not clear until the swelling has subsided and normal Eustachian tube function returns. Inner ear barotrauma damages the hearing and balance mechanisms. Inner ear barotrauma during descent is caused by forceful efforts to equalize the middle ear. If the ear does not clear, the large pressure difference can lead to rupture of membranes that seal the inner ear fluid from the middle ear. Rupture is accompanied by vertigo, hearing loss, nausea, vomiting, noise in the ear and, sometimes, a feeling of weakness. If a round window rupture is suspected, remove the diver from the water. TX - Ascend until you can clear ears.
- Ironic pic I found for this… but on the DAN network case reviews, I read this story and it made me think about how our officers have a lot more going on than looking at the fish…albiet that they can actually see in the water, but a simple distraction can lead to deleterious effects and in this case, ear barotrauma. Not to mention, the scenario it occurred in can describe many of the dives our officers perform. The planned dive was in cold seawater (50-59°F, 10-15°C) using air. I was wearing a drysuit with dry gloves. During my descent I became aware that one of my dry gloves was leaking. While I attempted to rectify the problem, I was not aware that I continued to descend, and I sustained middle-ear barotrauma to my right ear. I was able to make a controlled ascent to the surface. Leaking Glove Leads to Ear Barotrauma A distracted diver lost buoyancy control and experienced ear barotrauma. Reported Story The planned dive was in cold seawater (50-59°F, 10-15°C) using air. I was wearing a drysuit with dry gloves. During my descent I became aware that one of my dry gloves was leaking. While I attempted to rectify the problem, I was not aware that I continued to descend, and I sustained middle-ear barotrauma to my right ear. I was able to make a controlled ascent to the surface. Comments The scenario that the diver describes most likely occurred due to two factors that divers frequently underestimate. The first is buoyancy control. Had the diver established neutral buoyancy, he would not have continued to descend. The consequences of this diver's situation were not serious, but in other circumstances it could have created a potentially dire situation. Whether the diver experiences an uncontrolled descent or ascent, the potential consequences of either could be catastrophic. Additionally, the diver was distracted when attempting to address the leaking dry glove. This diver could have just as easily been taking a photograph, adjusting equipment or watching the marine life. The term "situational awareness" may sound trite, but this is an example of how a simple or even familiar distraction can produce a negative outcome. It is reasonable to draw a parallel between driving a vehicle and diving. As drivers, we are consistently reminded to avoid activities such as texting or talking on a cell phone that can divert our attention from the task at hand. As a paramedic, I have personally witnessed tragic outcomes due to distracted diving. As divers, we cannot afford to be any less attentive. Proper buoyancy control is an essential safety skill that requires practice and our full concentration. — Marty McCafferty, EMT-P, DMT
- Another Common injury, both sinus squeeze and reverse sinus squeeze. If air passage into a sinus is blocked, the air trapped within will be forced to decrease in volume as pressure increases. The sinuses are air filled chambers within the skull. Although the bony structure will not collapse under the pressure changes, the lower pressure in the blocked sinus will draw blood into it. Blood vessels will engorge and leak. The squeeze results in a blood-filled sinus, which will drain during ascent when the air in the sinus expands. A bloody nose and a sinus headache after diving usually accompany a sinus squeeze TX – None, Ascend until pain goes away Happens while ascending, Expanding gas in the sinus while ascending. If tube is blocked by cysts or growths, pressure in the sinus increases relative to external water pressure . Differs from Sinus squeeze during descent. During ascent the infraorbital nerve can become affected causing numbness to the face and gums. TX – change rate of ascent , additional DECO stop may be necessary. S&S should resolve at surface. Again, with the allergy season kicking in, any congestion, blockage can increase the risk. As well as any URI.
- True vertigo, or inner ear balance disturbance, is often confused with other vague problems with balance such as dizziness, lightheadedness, fainting, swaying or over-breathing. The differentiation is sometimes difficult, even for otologic physicians who specialize in the subject. Some experts feel that vertigo is the most hazardous ear problem to occur during diving. True Vertigo is a false sense of motion that is whirling or rotational. Treatment of Vertigo Hold the diver on the dive line to prevent diver from going deeper. If vertigo occurs during ascent – descend 2 or 3 feet to help diver equalize pressure If vertigo occurs during descent – ascend 2 or 3 feet to help diver equalize pressure Vertigo multiple times –ABORT DIVE !!!!!
- Transient vertigo almost always is due to "alternobaric vertigo" due to unequal middle ear pressures during ascent with resultant unequal vestibular end-organ stimulation. Pressure differences as little as 20 mmHg can produce this. Approximately 15% -25% of all divers have been shown to have experienced ABV. TX – return to depth, clear ears Can occur any time one ear is stimulated by cold water to a greater degree that the other S&S should decrease as body temperature regulates water in ears. Side Note: Cold Calorics is one of the test used to determine brain death. Can lead to immediate vomiting, and because our divers ears are sill exposed to water, this could occur.
- Nitrogen narcosis is a condition that occurs in divers breathing compressed air. When divers go below depths of approximately 100 ft., increase in the partial pressure of nitrogen produces an altered mental state similar to alcohol intoxication Symptoms of nitrogen narcosis include: These effects are exacerbated by cold, work load, fatigue and Rx medications. The effects of nitrogen narcosis are totally reversed as the gas pressure decreases. They are typically gone by the time the diver returns to a water depth of 60 ft. Nitrogen narcosis has no hangover or lasting effects requiring further treatment. However, a doctor should be consulted whenever a diver has lost consciousness.
- Additionally as mentioned earlier, while our main focus is on the divers, part of the function of this team is to respond to calls for assistance on personal small craft, private shipping vessels, military vessels, and