Scuba diving emergencies

Barotrauma of Descent

1. Face Squeeze
   1. Occurs when air is not added to the facemask during descent
      1. Facial bruising, conjunctival injection or hemorrhage, retrobulbar hemorrhage (rare)
2. Otic Barotrauma ("ear squeeze")
   1. Results from inability to equalize middle ear pressure
   2. Pain, fullness, vertigo, conductive hearing loss, TM rupture
   3. Tx = decongestants, consider abx if TM ruptured
3. Sinus barotrauma ("sinus squeeze")
   1. Pain over affected sinus, possible bleeding from nare
   2. Tx = Decongestants, consider antibiotics
4. Inner ear barotrauma
   1. Results from forceful Valsalva against an occluded eustachian tube
      1. Pressure difference between middle ear and inner ear can rupture oval or round window
   2. Sudden onset of sensorineural hearing loss, tinnitus, severe vertigo
   3. Tx = Head of bed up, no nose blowing, antivertigo medications, urgent ENT consult

Barotrauma of Ascent

1. Pulmonary Barotrauma
   1. Occurs when diver breathing compressed air ascends too rapidly
   2. Symptoms occur minutes to hours after surfacing
      1. Can occur without rapid ascent in pts w/ obstructive lung disease
   3. Lung rupture can lead to pneumomediastinum, pneumothorax, or air embolism
      1. Pneumomediastinum and pneumothorax do not require recompression
2. Decompression Sickness (DCS)
   1. Dissolved inert gases come out of solution and form bubbles in blood and tissue
   2. Types
      1. Type I (Pain only DCS)
         1. Involves the joints, extremities, and skin ("cutis marmorata")
         2. Usually only single joint is involved
      2. Type II (Serious DCS)
         1. CNS (spinal cord)
            1. Ascending paralysis
            2. Signs often cannot be traced to single location in the cord (may have skip lesions)
         2. Vestibular ("staggers")
            1. Vertigo, hearing loss, tinnitus
               1. Differentiated from inner ear barotrauma which usually occurs on descent
3. Arterial Gas Embolism
   1. Results from pulmonary barotrauma (most common) and decompression sickness
   2. Symptoms develop during ascent or immediately upon surfacing
   3. Causes variety of stroke syndromes depending on part of brain affected
      1. Immediate death, loss of consciousness, seizure, blindness, hemiplegia
   4. Treatment
      1. Place in supine position
      2. 100% O2
      3. IVF (increases tissue perfusion)
      4. Rapid recompression

Source

Tintinalli