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)

Physical Examination

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

Differential Diagnoses

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Media Gallery

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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