Dysbarism Follow-up

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

Further Inpatient Care

  • Admission is rarely required. Pneumothorax, pneumomediastinum, or air embolism requires admission.
  • Patients with signs of other dysbaric or decompression injuries should be transferred to a facility with HBO capability.
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Further Outpatient Care

  • Consider reevaluation by an ENT specialist.
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Inpatient & Outpatient Medications

  • Topical and systemic decongestants (eg, pseudoephedrine)
  • Analgesics (eg, acetaminophen, ibuprofen, narcotics) if needed
  • If bleeding or evidence of effusion is present, an appropriate antibiotic should be prescribed (eg, amoxicillin, erythromycin, trimethoprim/sulfamethoxazole [TMP/SMX], or topical cortisporin otic if tympanic membrane is intact).
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Transfer

  • For individuals with symptoms that are more than minimal, consult a diving medicine specialist or HBO specialist to determine appropriateness of treatment with HBO. Many times, dysbaric or other injuries can mimic decompression sickness and a diagnostic HBO treatment may be warranted to help determine this.
  • DAN is an excellent resource if local support is not available.
  • If HBO treatment is advised, an important issue is transport of the patient to the closest hyperbaric facility. This is frequently accomplished by land transport; however, air transportation is occasionally required. An effort should also be made to minimize the transport time.
  • Helicopter transport requires the pilot to maintain an altitude of less than 500 ft (152 m) above the departure point (which could be more than 500 ft above sea level depending on the dive location).[54] Flight paths through mountainous regions may make this difficult. In this situation, explore options other than rotary-wing transportation to the closest chamber. Fixed-wing transport should be limited to aircraft that can maintain cabin pressure at normal surface pressure of 1 atm (eg, Lear Jet, Cessna Citation, military C-130 Hercules).
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Deterrence/Prevention

  • All patients treated for diving-related injuries should be instructed to not return to diving until they have consulted with a diving medicine specialist. The specialist will make a determination on the appropriateness of returning to the activity.
  • Future prophylaxis with decongestants along with improved instruction may decrease recurrences. As mentioned above related to middle ear barotrauma, evidence of trauma to the tympanic membrane via otoscopy after a dive may guide prophylactic treatment to help prevent future middle ear barotrauma.[17] Many HBO centers use a topical vasoconstrictor nasal spray for this purpose (oxymetazoline).[55] However, studies have shown that there is minimal benefit to this approach, whereas predive treatment with oral pseudoephedrine (60 or 120 mg) at least 30 minutes prior to a dive decreased pain and evidence of tympanic membrane injury.[56, 57, 58]
  • The culture of diving, at least in military naval diving, may have some impact upon prevention of diving accidents. The two most common causes of diving accidents, or near misses, were leadership failures and decreased situational awareness. These came into play when the overall risk was underestimated and the time was not closely monitored. In addition, the need for junior divers to ask questions was rebuffed by the posture of the senior divers not being interested in providing answers.[59] While this was found in the US Navy, correlations could be considered in the average dive situation, namely daily dive charters. A lack of leadership, in the form of a divemaster, and the generally isolated situation of a number of divers not knowing each other, could lead to the same overall environment.
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Prognosis

  • With early recognition of diving-related injuries, most individuals have good outcomes and minimal residual problems.
  • ENT disorders, even inner ear barotrauma, do not automatically contraindicate future diving when proper education is given and followed.
  • A common misconception exists that there are no efficacious treatment options for inner ear barotrauma. The first step is a full neurotological evaluation, including high-resolution CT of the temporal bones, by an ENT specialist with experience with diving-related cochleovestibular (middle and inner ear) dysbaric injuries.[60] Treatment options can range from conservative, to acute high-dose steroid administration (started within 3 wk of the injury), to surgery for perilymphatic fistula repair.[61]
  • The diver commonly asks when he or she can return to scuba diving. The decision is partly dictated by the presence of a significant residual sensorineural hearing loss, evidence for noncompensated vestibular damage, and CT findings of possible enhanced cerebrospinal fluid–perilymph connection. The decision is not an easy one and requires a specialist with the appropriate experience in treating diving injuries to determine the risk for recurrent inner ear injury and to communicate that adequately to the scuba diver. In addition, animal studies suggest that the use of a free radical scavenger greatly decreases symptoms.
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Patient Education

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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.

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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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