Dysbarism Clinical Presentation

  • Author: Stephen A Pulley, MS, DO, FACOEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 13, 2011
 

History

Any symptom or sign that appears during or following a dive is pressure-related until proven otherwise based on diagnostic or therapeutic recompression. Specifics about the dive should be elicited as follows:

  • Location - Ocean, lake, river, quarry, or cave
  • Timing - Time dives occurred, length of dives, surface intervals, safety stops, and type of timing used (eg, watch with tables, dive computer) (The diver's logbook or dive computer, along with all of his or her dive equipment, should accompany the diver each step of the way.)
  • Activities - Over the 72 hours prior to the dive (especially flying) and after the dive (including how transported)
  • Depth - Deepest point, approximate time spent at that depth, and rate of ascent
  • Work - Currents, distance swam, water temperature, and primary activity (eg, wreck diving, artifact recovery)
  • Gases and equipment - Compressed air, rebreathing equipment, and mixed gases
  • Problems - Violation of no-decompression limit dive tables, equipment, entanglement, dizziness, and marine bites or stings
  • Condition - Physical condition before, during, and after the dive (eg, fatigue, alcohol ingestion, fever, vertigo, nausea, overexertion, pulled muscles)
  • First aid received - Oxygen, positioning, medications, and fluids
  • Eyes or face - Hemorrhage and numbness
  • Ears - Pain, hearing loss, tinnitus, bloody discharge, and vertigo
  • Nose or sinuses - Pressure or pain associated with sinus locations, bloody nasal discharge, and numbness in infraorbital nerve distribution
  • Mouth - Dental pain
  • Neck - Edema, crackling, and hoarseness
  • Pulmonary - Dyspnea, hemoptysis, and chest pain
  • Gastrointestinal - Bloating, cramps, and pain
  • Musculoskeletal - Symptoms probably related to DCS
  • Skin - Rash or marks
  • Neurologic - Seizure, unconsciousness, confusion, headache, visual disturbance, paresis, and paresthesia (more likely related to DCS)
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Physical

Physical examination findings may include any of the following:

  • Distress secondary to pain
  • Eyes or face - Subconjunctival or scleral hemorrhage or edema, periorbital edema, nystagmus, facial petechiae, and red ring
  • Ears - Tympanic hemorrhage or perforation, hemotympanum, external canal blood, cerumen, mass, lack of mobility on pneumatoscopy, and evidence of sensorineural hearing loss
  • Nose or sinuses - Pain over sinuses with percussion or epistaxis
  • Mouth - Tooth tenderness to percussion
  • Neck - Subcutaneous emphysema, vocal changes, and neck vein distention
  • Pulmonary - Respiratory distress, decreased breath sounds, hyperresonance, and tracheal shift
  • Gastrointestinal - Distention
  • Skin - Subcutaneous emphysema
  • Neurologic - Unconsciousness, changes in mental status, blindness, hemiplegia, paresis, and paresthesia
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Causes

Anything that prevents free flow of air out of air-filled spaces and allows overpressurization on ascent is a cause.

  • Asthma - Bronchospasm from breathing dry compressed air, aspirating salt water or cold water, exertion, and anxiety, anything that permits local air trapping
  • Emphysema - Air trapping disease, air blebs, abnormal gas exchange
  • Infections - Mucus plugging (localized air trapping), coughing on ascent
  • Environmental allergies - Mucosal inflammations (impeded air flow), sneezing on ascent
  • Structural lesions, pathology, obstruction, or inflammation (eg, polyps, tumors) - Nasal or sinus, external auditory canal, lungs
  • Poor training or experience and panic or anxiety - Diving when conditions listed above are present, too-rapid an ascent or inadequate pressure-equalization techniques

The principle cause of dysbarism or DCS injuries is from too-rapid an ascent. The most common cause of too-rapid ascent is panic and subsequent loss of control. With scuba diving being an unfamiliar environment, beginners are more likely to panic and less experienced to deal with urgencies that occur during a dive. A diver's tendency toward stress or panic should be of concern to instructors and dive masters.[47] During instruction, major efforts should be directed toward making the students feel comfortable in the unfamiliar environment. Anxiety or panic disorders can develop in experienced divers. Poor control of anxiety or panic disorders may disqualify the individual from continued participation in diving.

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Contributor Information and Disclosures
Author

Stephen A Pulley, MS, DO, FACOEP  Assistant Professor, Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine; Attending Faculty, Emergency Medicine Residency, Albert Einstein Healthcare Network; Attending Physician, Montgomery Hospital Medical Center

Stephen A Pulley, MS, DO, FACOEP, is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven A Conrad, MD, PhD  Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary; Assistant Professor, Department of Family Medicine, McGill University

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. AIDA International. AIDA International World Records. International Association for Development of Apnea. Available at http://www.hotweb.se/aspportal1/code/page.asp?sType=wr&CountryID=4&actID=3&ObjectID=136. Accessed October 5, 2007.

  2. Gibbs JW 3rd, Piantadosi CA, Massey EW. Internal carotid artery dissection in stroke from SCUBA diving: a case report. Undersea Hyperb Med. Fall 2002;29(3):167-71. [Medline].

  3. Scuba Times. Pippin makes record breaking breath hold dive. July/Aug 1995.

  4. Bennett PB, Marroni A, Cronje FJ, Cali-Corleo R, Germonpre P, Pieri M, et al. Effect of varying deep stop times and shallow stop times on precordial bubbles after dives to 25 msw (82 fsw). Undersea Hyperb Med. Nov-Dec 2007;34(6):399-406. [Medline].

  5. Mihos P, Potaris K, Gakidis I, Mazaris E, Sarras E, Kontos Z. Sports-related spontaneous pneumomediastinum. Ann Thorac Surg. Sep 2004;78(3):983-6. [Medline].

  6. Rozali A, Sulaiman A, Zin BM, Khairuddin H, Abd-Halim M, Sherina MS. Pulmonary overinflation syndrome in an underwater logger. Med J Malaysia. Oct 2006;61(4):496-8. [Medline].

  7. Lafère P, Germonpré P, Balestra C. Pulmonary barotrauma in divers during emergency free ascent training: review of 124 cases. Aviat Space Environ Med. Apr 2009;80(4):371-5. [Medline].

  8. Yildiz S, Ay H, Gunay A, Yaygili S, Aktas S. Submarine escape from depths of 30 and 60 feet: 41,183 training ascents without serious injury. Aviat Space Environ Med. Mar 2004;75(3):269-71. [Medline].

  9. Shupak A, Guralnik L, Keynan Y, Yanir Y, Adir Y. Pulmonary edema following closed-circuit oxygen diving and strenuous swimming. Aviat Space Environ Med. Nov 2003;74(11):1201-4. [Medline].

  10. Halpern P, Gefen A, Sorkine P, Elad D. Pulmonary oedema in SCUBA divers: pathophysiology and computed risk analysis. Eur J Emerg Med. Mar 2003;10(1):35-41. [Medline].

  11. Wallace JM, Stein S, Au J. Special problems of the asthmatic patient. Curr Opin Pulm Med. Jan 1997;3(1):72-9. [Medline].

  12. Koehle M, Lloyd-Smith R, McKenzie D, Taunton J. Asthma and recreational SCUBA diving: a systematic review. Sports Med. 2003;33(2):109-16. [Medline].

  13. Sade K, Wiesel O, Kivity S, Levo Y. [Asthma and scuba diving: can asthmatic patients dive?]. Harefuah. Apr 2007;146(4):286-90, 317. [Medline].

  14. Neuman TS, Bove AA, O'Connor RD, Kelsen SG. Asthma and diving. Ann Allergy. Oct 1994;73(4):344-50. [Medline].

  15. Böhm F, Lessle M. [Round window membrane defect in divers]. Laryngorhinootologie. Apr 1999;78(4):169-75. [Medline].

  16. Ramos CC, Rapoport PB, Brito Neto RV. Clinical and tympanometric findings in repeated recreational scuba diving. Travel Med Infect Dis. Feb 2005;3(1):19-25. [Medline].

  17. Karahatay S, Yilmaz YF, Birkent H, Ay H, Satar B. Middle ear barotrauma with hyperbaric oxygen therapy: incidence and the predictive value of the nine-step inflation/deflation test and otoscopy. Ear Nose Throat J. Dec 2008;87(12):684-8. [Medline].

  18. Duplessis C, Hoffer M. Tinnitus in an active duty navy diver: A review of inner ear barotrauma, tinnitus, and its treatment. Undersea Hyperb Med. Jul-Aug 2006;33(4):223-30. [Medline].

  19. Parell GJ, Becker GD. Inner ear barotrauma in scuba divers. A long-term follow-up after continued diving. Arch Otolaryngol Head Neck Surg. Apr 1993;119(4):455-7. [Medline].

  20. Sheridan MF, Hetherington HH, Hull JJ. Inner ear barotrauma from scuba diving. Ear Nose Throat J. Mar 1999;78(3):181, 184, 186-7 passim. [Medline].

  21. Zulkaflay AR, Saim L, Said H, Mukari SZ, Esa R. Hearing loss in diving--a study amongst Navy divers. Med J Malaysia. Mar 1996;51(1):103-8. [Medline].

  22. Taylor DM, Lippmann J, Smith D. The absence of hearing loss in otologically asymptomatic recreational scuba divers. Undersea Hyperb Med. Mar-Apr 2006;33(2):135-41. [Medline].

  23. Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol Neurotol. Jun 2007;28(4):447-54. [Medline].

  24. Shupak A, Gil A, Nachum Z, Miller S, Gordon CR, Tal D. Inner ear decompression sickness and inner ear barotrauma in recreational divers: a long-term follow-up. Laryngoscope. Dec 2003;113(12):2141-7. [Medline].

  25. Uzun C, Yagiz R, Tas A, Adali MK, Inan N, Koten M, et al. Alternobaric vertigo in sport SCUBA divers and the risk factors. J Laryngol Otol. Nov 2003;117(11):854-60. [Medline].

  26. Cheshire WP. Headache and facial pain in scuba divers. Curr Pain Headache Rep. Aug 2004;8(4):315-20. [Medline].

  27. Zadik Y. Aviation dentistry: current concepts and practice. Br Dent J. Jan 10 2009;206(1):11-6. [Medline].

  28. Zadik Y. Barodontalgia. J Endod. Apr 2009;35(4):481-5. [Medline].

  29. Simon DR, Bradley ME. Adverse effects of contact lens wear during decompression. JAMA. Sep 12 1980;244(11):1213-4. [Medline].

  30. Latham E, van Hoesen K, Grover I. Diplopia due to mask barotrauma. J Emerg Med. Nov 6 2008;[Medline].

  31. Bolognini A, Delehaye E, Cau M, Cosso L. Barotraumatic orbital emphysema of rhinogenic origin in a breath-hold diver: a case report. Undersea Hyperb Med. May-Jun 2008;35(3):163-7. [Medline].

  32. Titu LV, Laden G, Purdy GM, Wedgwood KR. Gastric barotrauma in a scuba diver: report of a case. Surg Today. 2003;33(4):299-301. [Medline].

  33. Oh ST, Kim W, Jeon HM, Kim JS, Kim KW, Yoo SJ, et al. Massive pneumoperitoneum after scuba diving. J Korean Med Sci. Apr 2003;18(2):281-3. [Medline].

  34. Sporting Goods Manufacturers Association. Sports participation trends 1995. North Palm Beach Florida. Available at www.sgma.com.

  35. Sporting Goods Manufacturers Association. SGMA Sports Participation Trends Report. 1995. Available at http://www.sgma.com.

  36. Sporting Goods Manufacturers Association. Top Ten Sports/Activites With the Highest Growth In Participation. 1999. North Palm Beach Florida. Available at http://www.sgma.com.

  37. Sporting Goods Manufacturers Association. Sports Participation in America Topline Report 2004. Washington, DC, US: Sporting Goods Manufacturers Association; 2004. [Full Text].

  38. Sporting Goods Manufacturers Association. Sports Participation in America 2004. Washington, DC, US: Sporting Goods Manufacturers Association; August 2004. [Full Text].

  39. Sporting Goods Manufacturers Association. 2007 Sports and Fitness Participation Report. Washington, DC, US: Sporting Goods Manufacturers Association; 2007. [Full Text].

  40. Goldhahn RT Jr. Scuba diving deaths: a review and approach for the pathologist. Leg Med Annu. 1977;1976:109-32. [Medline].

  41. Lewis PR. Skin diving fatalities in New Zealand. N Z Med J. Jun 27 1979;89(638):472-5. [Medline].

  42. Roydhouse N. 1001 disorders of the ear, nose and sinuses in scuba divers. Can J Appl Sport Sci. Jun 1985;10(2):99-103. [Medline].

  43. Taylor DM, O'Toole KS, Ryan CM. Experienced scuba divers in Australia and the United States suffer considerable injury and morbidity. Wilderness Environ Med. 2003;14(2):83-8. [Medline].

  44. Landsberg PG. South African underwater diving accidents, 1969-1976. S Afr Med J. Dec 25 1976;50(55):2155-9. [Medline].

  45. Arness MK. Scuba decompression illness and diving fatalities in an overseas military community. Aviat Space Environ Med. Apr 1997;68(4):325-33. [Medline].

  46. Taylor DM, O'Toole KS, Ryan CM. Experienced, recreational scuba divers in Australia continue to dive despite medical contraindications. Wilderness Environ Med. 2002;13(3):187-93. [Medline].

  47. Morgan WP, Raglin JS, O'Connor PJ. Trait anxiety predicts panic behavior in beginning scuba students. Int J Sports Med. May 2004;25(4):314-22. [Medline].

  48. Reuter M, Tetzlaff K, Warninghoff V, Steffens JC, Bettinghausen E, Heller M. Computed tomography of the chest in diving-related pulmonary barotrauma. Br J Radiol. May 1997;70(833):440-5. [Medline].

  49. Oliver J, Lyons TJ, Harle R. The role of computed tomography in the diagnosis of arterial gas embolism in fatal diving accidents in Tasmania. Australas Radiol. Feb 1999;43(1):37-40. [Medline].

  50. Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ. First aid normobaric oxygen for the treatment of recreational diving injuries. Undersea Hyperb Med. Jan-Feb 2007;34(1):43-9. [Medline].

  51. Bessereau J, Coulange M, Genotelle N, Barthélémy A, Michelet P, Bruguerolle B, et al. [Aspirin in decompression sickness]. Therapie. Nov-Dec 2008;63(6):419-23. [Medline].

  52. de Watteville G. [A critical assessment of Trendelenburg's position in the acute phase after a diving accident]. Schweiz Z Sportmed. Sep 1993;41(3):123-5. [Medline].

  53. Feng LN, Chen WX, Cong R, Gou L. Therapeutic effects of eustachian tube surfactant in barotitis media in guinea pigs. Aviat Space Environ Med. Jul 2003;74(7):707-10. [Medline].

  54. MacDonald RD, O'Donnell C, Allan GM, Breeck K, Chow Y, DeMajo W, et al. Interfacility transport of patients with decompression illness: literature review and consensus statement. Prehosp Emerg Care. Oct-Dec 2006;10(4):482-7. [Medline].

  55. Capes JP, Tomaszewski C. Prophylaxis against middle ear barotrauma in US hyperbaric oxygen therapy centers. Am J Emerg Med. Nov 1996;14(7):645-8. [Medline].

  56. Carlson S, Jones J, Brown M, Hess C. Prevention of hyperbaric-associated middle ear barotrauma. Ann Emerg Med. Dec 1992;21(12):1468-71. [Medline].

  57. Brown M, Jones J, Krohmer J. Pseudoephedrine for the prevention of barotitis media: a controlled clinical trial in underwater divers. Ann Emerg Med. Jul 1992;21(7):849-52. [Medline].

  58. Jones JS, Sheffield W, White LJ, Bloom MA. A double-blind comparison between oral pseudoephedrine and topical oxymetazoline in the prevention of barotrauma during air travel. Am J Emerg Med. May 1998;16(3):262-4. [Medline].

  59. O'Connor PE. The nontechnical causes of diving accidents: can U.S. Navy divers learn from other industries?. Undersea Hyperb Med. Jan-Feb 2007;34(1):51-9. [Medline].

  60. Shupak A. Recurrent diving-related inner ear barotrauma. Otol Neurotol. Dec 2006;27(8):1193-6. [Medline].

  61. Brocks C, Wollenberg B, Graefe H. [Acute hearing loss from scuba-diving holidays: diagnosis and treatment of barotrauma of the inner ear]. HNO. Mar 2009;57(3):262-5. [Medline].

  62. Camporesi EM. Diving and pregnancy. Semin Perinatol. Aug 1996;20(4):292-302. [Medline].

  63. Lemaitre F, Carturan D, Tourney-Chollet C, Gardette B. Circulating venous bubbles in children after diving. Pediatr Exerc Sci. Feb 2009;21(1):77-85. [Medline].

  64. Bennett PB, Elliott DH. The Physiology and Medicine of Diving and Compressed Air Work. 2nd ed. William and Wilkins Company: Baltimore; 1975.

  65. Blatteau JE, Jean F, Pontier JM, Blanche E, Bompar JM, Meaudre E, et al. [Decompression sickness accident management in remote areas. Use of immediate in-water recompression therapy. Review and elaboration of a new protocol targeted for a mission at Clipperton atoll]. Ann Fr Anesth Reanim. Aug 2006;25(8):874-83. [Medline].

  66. Clendenen B. Rescue!. Alert Diver (Divers Alert Network). 1997;Nov/Dec:38-43.

  67. Davis JC, Kizer KW. Diving medicine. In: Auerbach PS, Geehr EC, eds. Management of Wilderness & Environmental Emergencies. Mosby-Year Book; 1989:879-905.

  68. DeGorordo A, Vallejo-Manzur F, Chanin K, Varon J. Diving emergencies. Resuscitation. Nov 2003;59(2):171-80. [Medline].

  69. Dickey LS. Barotrauma. In: Tintinalli JE, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York: McGraw Hill (Text); 1996:985-93.

  70. Divers Alert Network. Annual Diving Report 2006 Edition. Durham, North Carolina, US: Divers Alert Network; Oct 11, 2006. [Full Text].

  71. Goplen FK, Gronning M, Irgens A, Sundal E, Nordahl SH. Vestibular symptoms and otoneurological findings in retired offshore divers. Aviat Space Environ Med. Apr 2007;78(4):414-9. [Medline].

  72. Hsu YL, Wang HC, Yang PC. Desbaric air embolism during diving: an unusual complication of Osler-Weber-Rendu disease. Br J Sports Med. Aug 2004;38(4):E6. [Medline].

  73. Jerrard DA. Diving medicine. Emerg Med Clin North Am. May 1992;10(2):329-38. [Medline].

  74. Kalemoglu M, Keskin O. Hemoptysis and breath-holding diving. Mil Med. Jul 2006;171(7):606-7. [Medline].

  75. Kizer KW. Dysbarism. In: Rosen R, Barken RM, Brean CR, et al, eds. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1992:881-8.

  76. Masuda Y, Tanabe T, Murata Y, Kitahara S. Protective effect of edaravone in inner-ear barotrauma in guinea pigs. J Laryngol Otol. Jul 2006;120(7):524-7. [Medline].

  77. National Oceanic and Atmospheric Administration. Diving for science and technology. In: NOAA Diving Manual. Washington DC: 1990.

  78. Russi EW. Diving and the risk of barotrauma. Thorax. Aug 1998;53 Suppl 2:S20-4. [Medline].

  79. Tetzlaff K, Muth CM, Waldhauser LK. A review of asthma and scuba diving. J Asthma. Oct 2002;39(7):557-66. [Medline].

  80. Tetzlaff K, Reuter M, Warninghoff V, Bettinghausen E, Heller M. [Diving-associated pulmonary barotrauma as a rare differential diagnosis in internal medicine-pneumologic ambulatory care]. Pneumologie. Dec 1996;50(12):902-5. [Medline].

  81. Undersea Medical Society. Program and abstracts: Undersea Medical Society annual scientific meeting. 11-14 June 1985, Long Beach, California. Undersea Biomed Res. Mar 1985;12(1 Suppl):1-65. [Medline].

 
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The Boyle gas law. Every 33 ft of descent increases the pressure by 1 atm. Therefore, lung volume during a breath-hold dive at 33 ft is one half that at the surface. At 66 ft, it is one third that at the surface; at 99 ft, it is one quarter; and at 132 ft, it is one fifth.
The Boyle gas law. Descending to 33 ft decreases lung volume by one half. If an individual takes a breath from a SCUBA tank, then surfaces without venting (exhaling), pressure in the lungs, with minimal ability to further expand, increases to twice normal, which probably causes rupture. The greatest change occurs in the top 33 ft when surfacing.
 
 
 
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