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Dive Medicine

Undersea and Hyperbaric Medicine
by

Shalin Patel

on 10 April 2013

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Transcript of Dive Medicine

Dive Medicine:
Undersea and Hyperbaric
Medicine Shalin Patel, MD, PGY-3 Resident
J. Willis Hurst Internal Medicine ResidencyProgram
Emory University History of SCUBA Diving
Brief Review of Physics and Dive Physiology
Medical Dive Clearance
Medical Complications of Diving
Treatment of Dive Related Complications
Other Diving Dangers 1300s- Persian divers used goggles from thinly sliced tortoise shells
1535 – First modern diving bell invented by Guglielmo de Lorena. Initially described by Aristotle
1771 – John Smeaton invented the air pump
1772 – Sieur Freminet developed a rebreathing device but died testing his own device
1825 – William James and Charles Condert carried compressed air in an iron reservoir (1832) 1865 – Rouquayrol and Denayrouze pressured diving set that regulated air pressure.
1876 – Henry Fleuss – closed circuit oxygen rebreather
1939 – Dr. Christian Lambertson designed a self contained underwater breather apparatus for U.S. Military
1943 - Emile Gagnan and Jacques Coustea invented the demand regulator and connected it to air cylinders – called the Aqua-Lung. History of SCUBA Diving
Brief review of physics & physiology of diving
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers Composition of Air
Pressure
Boyle’s Law
Henry’s Law
Archimedes' Principle What is Air?
Oxygen (O2) 21%
Nitrogen (N2) 78%
Carbon Dioxide (CO2) 0.04%
Others <1% Pressure = Force / Area
Atmospheric pressure – pressure exerted by the weight of the atmosphere- varies with altitude Pressure ATA = ATM = Bar pV = K
Volume = 1 / Pressure
At a constant temperature the volume of a given mass of gas varies inversely with the absolute pressure Boyle’s Law, 1662 At a constant temperature, the amount of a given gas that dissolves in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid Henry’s Law, 1803 Any object, wholly or partially immersed in a fluid, is buoyed up by a force equal to the weight of the fluid displaced by the object. Archimedes' Principle Underwater Physiology Immersion in water shifts peripheral venous blood centrally
Atrial natriuretic peptide and diuresis are increased
Ventilation under resistance changes preload and afterload
At high PP of O2 and nitrogen can decrease cardiac output
Increase in SVR with increasing pressure History of SCUBA and Dive Medicine
Brief review of physics & physiology
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers The Dive Medical Neurological
Epilepsy, TIA, CVA, spinal cord/brain injury,
HEENT
TM disease/surgery, inner ear disease/surgery, upper airway obstruction, blindness, eye trauma, inability to equalize
Respiratory
Asthma, COPD/Emphysema, Spontaneous PTX, ILD
Cardiovascular
HOCM, Shunt/ASD/VSD, CAD, CHF, CABG, MI, valvular disease Contraindications to Diving Contraindications to Diving Orthopedic
Aseptic necrosis, scoliosis impacting exercise and respiratory function
Endocrine and Metabolic
Diabetes requiring insulin or on hypoglycemic medications, obesity, CKD, pregnancy
Hematologic
Sickle cell disease, polycythemia vera, leukemia, impaired coagulation.
Behavioral Health
Active Psychosis, claustrophobia, panic disorder, drug/alcohol abuse History of SCUBA and Dive Medicine
Brief review of physics & physiology
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers External Ear Squeeze Ear and Sinus Most common diving related injury
Symptoms of ear fullness, pain, pressure, bleeding, TM rupture
Prevention with equalization, postpone diving if URI, sinusitis, nasal congestion Middle Ear Barotrauma Mask Squeeze
Improper equalization of mask
Results in superficial capillary rupture
Eye Squeeze
Bubbles form behind contact lenses
Symptoms of blurred vision, appearance of halo and bright lights
Can cause corneal scarring Eye and Mask Squeeze
Due to exposure to increased partial pressure of nitrogen and certain other gases
First noticed at depth of 100ft and worsens with depth
Symptoms
Impaired judgment, euphoria, lack of concern, inappropriate laughter, hallucinations, tunnel vision
Increased risk
Fatigue, anxiety, cold, alcohol, medications, increased CO2
Improves with ascent Gas Exchange Injury Martini’s Law Nitrogen Narcosis Occurs when breathing > 40% O2 at 1 ATM
With increasing depth PP of O2 increases
Caused by resuscitation, oxygen rebreathing equipment, deep diving
CNS Effects:
Initially experience nausea, tunnel vision, lightheadedness, eventually seizures
Pulmonary Effects:
Chest pain, cough, pleurisy, pneumonitis
Preventable by decreasing exposure to high PP of O2 Lack of Oxygen & Oxygen Toxicity Carbon Dioxide
Hyper and Hypoventilation
Skip breathing
Carbon Monoxide
Breathing gas contamination Other Gases Encompasses 2 diseases:
Decompression Sickness (DCS)
Arterial Gas Embolism (AGE)
Result of inadequate decompression following exposure to increased pressure
Nitrogen absorbed during depth is released on ascent
Bubbles travel through blood & deposit in tissue
Symptoms become evident 1-6 hours after ascent Decompression Illness (DCI) Depth and Duration of dive
Even shallow dives
Rapid ascent w/o safety stops
Repetitive dives
Flying after diving
Individual variation Risk Factors Minor symptoms: joint aches, fatigue
Cutaneous Marmorata
Irregular pruritic erythematous patch w/ some surrounding pallor
Resolves quickly and may be overlooked
Up to 20% have neurological symptoms DCI Type 1: “The Bends” Neurological disease
Headache, paresthesias, confusion, speech difficulty,
vision change
Progress to seizure, paralysis, LOC, coma, death
Pulmonary Disease
“The Chokes”
Chest pain, sob, hypoxia, respiratory failure DCI Type 2: Severe Symptoms Decompression Illness Second cause of death
Ascent vs Descent
Parenchyma Damage
Emphysema
Subcutaneous Pneumomediastinum
Pneumothorax
Arterial Air Embolism Pulmonary Barotrauma Merlin M. Decompression Illness in Scuba Divers. Emergency Medicine Magazine 2009.http://www.emedmag.com/PDF/041060018.pdf With repetitive dives, bubbles that precipitate can cause obstruction to blood flow
Can occur in any part of the bone
Predisposed by
Older age, inadequate decompression, History of DCI
Dept and number of of dives
Higher rate in commercial divers Dysbaric Osteonecrosis Inner ear decompression sickness
“Ear Bends”
Occurs with very deep dives
Using helium in air mixture
Symptoms: nausea, vomiting, vertigo, tinnitus Vestibular DCS Basic Life Support
Early 100% Oxygen
Promotes increasing nitrogen diffusion from the blood
Fluids
Position and Rest
Avoid Trendelenburg, sitting, or standing initially
Transport
1ATM, Pressurized aircraft
Portable recompression chamber Initial Treatment of DCS Proposed in 1854 by Pol and Wattelle
Implemented in 1896
During construction of Hudson River Tunnel
Began using 100% oxygen in 1944
Multiple sites in Georgia with several at EUH-M Therapeutic Recompression Hyperbaric Oxygen Therapy US Navy Diving Manual, Revision 6. SS521-AG-PRO-010 US NAVY: HYPERBARIC OXYGEN TREATMENT TABLE 6 Adjunct Therapy For DCI Arterial Gas
Emboli DCS Oxygen
Fluids
Euthermia Lidocaine
Decreases intracranial HTN
Anticoagulation
LE weakness or paralysis
Emboli Steroids
NSAIDS Lidocaine Complications of Therapy Reversible Myopia
Barotrauma
Oxygen toxicity
Pulmonary edema
Seizure Untreated pneumothorax
The only absolute contraindication
Relative Contraindications
Obstructive lung disease
Claustrophobia
Recent ear surgery
Chest surgery
CNS disorder Contraindications to Therapy History of SCUBA and Dive Medicine
Brief review of physics & physiology
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers History of SCUBA and Dive Medicine
Brief review of physics & physiology
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers Other Dangers
of
Diving Not including Sharks, Rays, Sea Snakes,
drowning, the ocean and getting lost History of SCUBA and Dive Medicine
Brief review of physics & physiology
Medical dive clearance
Medical complications of diving
Treatment of dive-related complications
Other diving dangers Any Questions? Acknowledgments Breath Easy Free Diving
VS
Scuba Diving Roger A. Alvarez, DO, MPH
Shahed Brown, MD
Jann Blanton, MD
Jorge L. Cabrera, DO
Francois Rollins, MD
Victor Wu, MD 10 healthy divers
Average Dive 35m for 25min
Evaluated cardiac function
Microbubbles The Issue with Bubbles
Full transcript