Dive Injuries PDF

Dive Injuries Objectives Learn to recognize dive injuries Learn how to treat various diving injuries/incidents Understand how to prevent injuries from occurring Drowning and near-drowning Caused by: Inhaling water Suffocation following water leaking into the lungs once unconsc...

Dive Injuries Objectives Learn to recognize dive injuries Learn how to treat various diving injuries/incidents Understand how to prevent injuries from occurring Drowning and near-drowning Caused by: Inhaling water Suffocation following water leaking into the lungs once unconscious Water in the lungs results in low blood oxygen because diffusion cannot occur, starving the tissues of oxygen and causing hypoxia. Once the brain does not receive enough oxygen, the victim often losses consciousness Drowning and near-drowning Treatment: CPR Rescue breaths AED Oxygen Transport to medical care Anyone who suffers a near drowning but is resuscitated must be examined at a clinic or by a doctor immediately, even if the patient feels fine This is because of “secondary drowning” which can occur hours later and is a result of water damage in the lungs Hypercapnia Elevated CO2 in the bloodstream Occurs: When breathing resistance is too high or the partial pressure of oxygen is very high. Both of which are scenarios that can occur while diving. During “skip breathing”, holding one's breath slightly between inhalation and exhalation, or during shallow breathing while diving. The lack of longer exhalations inhibits CO2 venting from the body. During very rapid descents which promote a build-up of CO2 due to the decreased minute volume (amount of gas that can be inhaled/exhaled in one minute -> at increasing depth pressures). Can occur during rebreather dives, if the scrubber materials is improperly packed or not working correctly to remove CO2 from the divers exhalations Hypercapnia The consequences of hypercapnia in divers include unpleasant and dangerous symptoms such as: Dyspnea (difficult or labored breathing) Headache Nausea Unconsciousness as well as potentiation of nitrogen narcosis, oxygen toxicity and decompression illness. Important considerations for CO2 transport The number of molecules of carbon dioxide that are produced remains constant for a given workload, irrespective of depth. Transport of the carbon-dioxide load from tissues to lungs, however, may be less efficient in the hyperbaric environment, where an increased partial pressure of oxygen causes a fall in Hemoglobin (Hb) in venous blood. Reduced Hb forms carbamino compounds with carbon dioxide and buffers the hydrogen ion resulting from the hydration of carbon dioxide in red blood cells. Going to Extremes of Lung Physiology–Deep Breath- Hold Diving. Tetzlaff et alt. Frontiers in Physiology July 2021, Volume 12, p 8 Pulmonary barotrauma General symptoms: General Treatment: Cough Hemoptysis (coughing up blood) Administration of 100% Oxygen Chest pain Basic life support Pink frothy sputum Transport to medical facility Vocal changes Discomfort swallowing A feeling of fullness in the throat Difficulty breathing AGE (Arterial Gas Embolism) General symptoms: General Treatment: Loss of consciousness Confusion Contact emergency medical Headache services and request immediate Convulsions response Bloody froth from the mouth or nose Administer 100% Oxygen Weakness or paralysis in the extremities Basic life support Cardiac arrest or stroke symptoms DCS (Decompression Sickness) DCS manifests for a diver may vary drastically depending on where the bubble(s) are usually manifests between 15 minutes to 12 hours after surfacing from a dive General symptoms: Unusual fatigue Numbness, tingling and Skin itch paralysis Pain in joints and / or muscles of the Shortness of breath arms, legs or torso Denial!!! Dizziness, vertigo, ringing in the ears DCS (Decompression Sickness) Signs of DCS: Skin may show a blotchy rash Staggering Paralysis, muscle weakness Coughing up bloody, Difficulty urinating frothy sputum Confusion, personality changes, bizarre Collapse or behavior unconsciousness Amnesia, tremors General Treatment: Administration of 100% Oxygen and transport to recompression chamber (paying attention to altitude. DCS follow up from Week 7 slides In water recompression: Using oxygen vs air is preferred method For air: Follow Air Treatment Table 1A as closely as possible Use of full face mask or helmet is preferred to regular mouthpiece if available Keep at least one diver with the patient at all times and maintain good communication Best to have several topside support people and rotate water and surface people safely Recompress patient to the maximum available depth (if deep not available) Remain at max depth for 30 minutes  Elapsed time (h:mm) 0 0:30/1 0:43/4 0:56/7 1:09/10 1:22/3 1:53/4 2:24/5 2:55/6 3:56 0 30 12 12 12 12 30 30 30 60 5 Interval (minutes) 30 (9) 40 (12) 50 (15) 60 (18) Pressure in fsw (msw) Oxygen 80 (24) Air 100 (30) 120 (37) Time between stops 1 minute Time at 165 fsw includes compression at 25fsw per minute 140 (43) US Navy Recompression Treatment Table 2 165 (50)  Elapsed time (hours:minutes) after reaching maximum pressure 0:25 0:45 1:15 1:45 3:15 4:45 0:00 0:20 0:50 1:10 2:00 3:00 4:14 0 3 20 5 20 5 20 5 30 15 60 15 60 30 Interval (minutes) Pressure in fsw (msw) 30 (9) 1 fsw per minute ascent Oxygen 60 (18) Air 20 fsw per minute descent U.S. Navy Recompression Treatment Table 6  Elapsed time (hours:minutes) after reaching maximum pressure 4:05 4:20 5:20 0:00 0:25 0:30 2:15 2:20 2:50 3:05 5:50 1:05 1:25 1:30 1:50 1:55 0 8:15 25 5 35 20 5 20 5 20 5 30 15 60 15 60 30 Interval (minutes) 30 (9) 1 fsw per minute ascent 60 (18) Oxygen Air Option of Air or treatment gas with ppO2 not exceeding 3 ata Pressure in fsw (msw) U.S. Navy Recompression Treatment Table 6a 20 fsw per minute descent 3 fsw per minute ascent 165 (50) Maximum treatment Elapsed time (hours:minutes) from start of decompression time at 225 fsw = 0:30 0:00 65:29 0 Stop times 120 minutes every 2 fsw (0.6 msw) 20 (6) Stop times 60 minutes every 2 fsw (0.6 msw) 40 (12) Stop times 40 minutes every 2 fsw (0.6 msw) 60 (18) Stop times 30 minutes every 2 fsw (0.6 msw) 80 (24) Stop times 25 minutes every 2 fsw (msw) 100 (30) Pressure in fsw (msw) Stop times 20 minutes every 2 fsw (0.6 msw) Patient is recompressed to depth of symptomatic relief. 120 (36) Breathing gas mixture depends on depth. Heliox may be used as breathing gas to reduce nitrogen narcosis at pressures greater than 165 fsw. Preferred gas is Heliox 64/36 Stop times 15 minutes every 2 fsw (0.6 msw) Heliox or Nitrox with oxygen partial pressure not exceeding 3 ata or air may be used at pressures less than 165 fsw 140 (42) Oxygen may be used at pressures less than 60 fsw. For all treatment gases periods of 25 minutes on gas with 5 minute air breaks Stop times 12 minutes every 2 fsw (0.6 msw) 165 (50) Treatment time is limited depending on maximum depth 3 hours at 165 fsw 5 hours at 140 fsw 8 hours at 120 fsw 11 hours at 100 fsw Stop times 5 minutes every 2 fsw 15 hours at 80 fsw US Navy Treatment Table 8 (for 225 fsw) 225 (68) In Water Recompression using Oxygen For Oxygen Treatment at depth: Use 100% oxygen if available Make sure to purge the oxygen delivery device at least 3 times with pure oxygen prior to treatment Descend to a depth of 30 feet with a standby diver. Remain at 30 feet, at rest, for 60 minutes for Type I symptoms and for 90 minutes for Type II symptoms Ascend to 20 feet even if symptoms are still present Perform 60 minute stops at both 20 feet and 10 feet At surface, breathe 100% oxygen for an additional 3 hours Hyporthermia Reduction of core temperature below 95F Prevention: wear proper exposure protection Symptoms: Treatment: Uncontrollable shivering Remove wetsuit/wet clothing Behavioral changes Cover with blankets and towels Inability to speech Avoid aggressive warming techniques Loss of coordination because this may cause additional problems Potential loss of consciousness Contact EMS Hyperthermia - Too hot, core temperature over 100F Prevention: Drink before thirsty, especially while diving (which further dehydrates the body from breathing dry air and water immersion). Minimize time spent standing around in the sun in exposure suits. Set up in the shade Maintain above average fitness levels for best cardio-vascular health. Symptoms: Hot, red, wet, or dry skin. Initially, the body will try sweating, but once the issue is severe this control will be lost Extremely fast or slow pulse Headache Nausea Dizziness Hyperthermia - Too hot, core temperature over 100F Treatment of Hyperthermia: If mild symptoms apply fluids and cooling mechanisms (ice packs, cool water) and potentially activate EMS. If severe (no sweating, hot/dry skin, temps above 105º) activate EMS, cool patient aggressively. Marine Life Encounters/Injuries Don’t touch marine life If you are collecting for science purposes, know what you are dealing with. Educate yourself before diving in and take proper precautions Be aware of your surroundings and the conditions which may put you at risk for the following types of injuries Assume you will probably get an infection with any of these wounds. Extra care must be given to these injuries and consult professional if signs of infection  Box Jellyfish - Hawaii Typically observed monthly (8-10 days after full moon) on the south facing shores Nematocysts deliver toxin upon contact Results in burning sensation and red skin with welts common Treatment of Stings: Rinse well with salt water and ensure jelly not stuck to patient Use vinegar if available Contact EMS if allergic reaction occurs  Man-o-war Jellyfish - Hawaii Most often found on windward facing shores and nearshore water Nematocysts deliver toxin upon contact Results in burning sensation and red skin with welts common Treatment of Stings: Rinse well with salt water and ensure jelly not stuck to patient Use vinegar if available (although debated heavily) Contact EMS if allergic reaction occurs (but NO epipen)  Urchins Found in nearshore waters Only a few species in Hawaii that are problematic so be aware and avoid! Treatment of Spine puncture wounds: Use tweezers or pliers to extract whatever you can Soak in hot water (with a slight mixture of iodine if not allergic to penicillin) Don’t allow to scab/scar over Use plenty of antibiotic ointment Vinegar soak? Seek medical treatment if signs of infection Mooray Eels Found in holes along the reef or free swimming Problems occur when sticking hands in holes Be sure to inspect occupants of hole prior to reaching inside Teeth have a slight angle backwards down the throat Eels will bite and not release Don’t shake and freak out as it will cause a greater injury Use your other hand to grab aggressively at its eyes and it will release and swim away. Not known to go for a second bite. Seek medical advice and will likely need antibiotics to avoid infection Fish (not eel) bites Happens occasionally with ulua, baraccuda, or groupers when attracted by shiny gear Will most likely result in a series of punctures Irrigate and clean very well and pack with antibiotic ointment. Seek medical attention Coral scrapes Very abrasive surface that can easily cut/scrape human skin Be aware of surroundings, especially in surge Don’t touch coral! Treatment: Scrub aggressively with soap and water Flush wound with 50:50 hydrogen peroxide and water solution Apply antibiotic ointment Repeat wound flush and antibiotic ointment twice a day Most common Pacific fire coral Cone Snails Attractive shells that often catches the eye of divers Be an observer and not a collector Don’t touch! Snails have a proboscis that comes out of the pointed end and can deliver a potent toxin If you were collecting cone snails as part of your scientific dive, use tongs and be very careful Injury can be comparable to a bee sting but occasionally fatal with some species Seek medical attention if stung Crown of Thorns Starfish Very sharp spikes on upward facing surface Spikes carry a toxin which is difficult to combat with over the counter medications/treatments If skin irritation is only injury, treat with cortisone May need antibiotics if gets infected If a spine breaks off in your skin, seek medical treatment Monk Seals Look all cute, but can cause serious problems Don’t corner them or approach closely They are far more agile in the water than us! They bite when scared Bites are severe puncture wounds and require medical attention! Control bleeding and transport to medical facility  Sharks Look all cute, but can cause serious problems Not something to worry about, but to respect Odds are that only two species would ever exhibit aggressive behavior (Grey reef and Tiger) Methods for dealing with If a bite did occur, activate EMS, control bleeding and monitor basic life support. Give Oxygen. Posturing Grey Reef Sharks Diver’s Alert Network (DAN) Every diver should be a DAN member! Go forth and preach that! Emergency medical hotline and transport is priceless! Read the DAN publication Alert Diver (comes with membership) Read the countless articles and pamphlets on Dan.org Most comprehensive library/resource for all things dive medical related for the non-physician Summary Become familiar with the Emergency Action Plan Be prepared with necessary support equipment Know your options for medical assistance Maintain current CPR/First Aid/Oxygen administration certifications If ever have questions or need a refresh, the Divers Alert Network (dan.org) has a ton of good material to reference for dive related injuries Summary For the less serious wounds listed or cuts and scrapes, clean aggressively and use a lot of antibiotic ointment Clean to the point of it hurting, otherwise unlikely to get clean enough Attempt to dry the wounds and redress as often as you can to promote healing Tegaderm works wonders but good adhesion is critical