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Dysbarism Clinical Presentation

  • Author: Stephen A Pulley, DO, MS, FACOEP; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Oct 20, 2015
 

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, such as the following:

  • 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.[79] 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, DO, MS, FACOEP Clinical Professor, Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine; Attending Physician, Mercy Suburban Hospital; Costin Scholar, Midwestern University

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

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

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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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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