A review of 149 Divers Alert Network emergency call records involving diving minors.

INTRODUCTION: Minors have been scuba diving for decades, and while the initial concerns about potential long-term complications related to bone development appear to be unfounded, the incidence of scuba diving injuries among them has been poorly studied. METHODS: We reviewed 10,159 cases recorded in the DAN Medical Services call centre database from 2014 through 2016 and identified 149 cases of injured divers younger than 18 years. Records were analysed for case categorisation on the most common dive injuries. Information about demographics, level of training, risk factors, and relevant behavioural aspects were collected when available. RESULTS: While the most common reason for the call was to rule out decompression sickness, the majority of cases pertained to ear and sinus issues. However, 15% of the dive-related injuries involving minors had a final diagnosis of pulmonary barotrauma (PBt). While no reliable data is available on the incidence of PBt in adult divers, the authors' impression based on personal experience suggests that the number of cases of PBt in minors trends higher than in the general diving population. The narratives on some relevant records describe unmanageable levels of anxiety leading to panic. CONCLUSIONS: Based on the results and narratives on these cases, it is reasonable to infer that psychological immaturity, suboptimal management of adverse situations, and inadequate supervision might have led to severe injuries among these minor divers.

Pulmonary Barotrauma in a BUD/S Candidate Following Shallow Dives Using the MK 25 Rebreather.

Pulmonary barotrauma of ascent is a well-recognized risk of compressed air diving in the civilian and military diving communities. Chest imaging is a beneficial adjunct to clinical evaluation in screening select individuals for fitness to dive, evaluating dive-related injuries, and safely returning individuals to diving duty. We present a case of a 26-year-old male U.S. Navy Ensign and Basic Underwater Demolition/SEAL (BUD/S) candidate who experienced pulmonary barotrauma following two shallow dives to a maximum depth of 18 feet of seawater using the MK-25 100% oxygen rebreather. A chest radiograph showed a left upper lobe peripheral wedge-shaped opacity abutting the pleural surface. A subsequent computerized tomography (CT) scan of the chest showed multifocal areas of peripheral pulmonary hemorrhage associated with small pneumatoceles. Two months after the diving injury, chest CT showed resolution of the pulmonary hemorrhage and pneumatoceles. Diving-related pulmonary barotrauma occurs most often secondary to breath-holding on ascent by inexperienced divers and is one of the most common diving injuries seen in BUD/S candidates. The risk of pulmonary barotrauma may be decreased through adequate training and thorough medical screening to include assessing for symptoms of infection before every dive. In cases of acute pulmonary barotrauma, chest radiographs may be used to screen for thoracic injury. Chest CT with inspiratory and expiratory sequences should be used to screen dive candidates on a case-by-case basis and to evaluate lung injury and predisposing pulmonary conditions following pulmonary barotrauma.

A diving physician's experience of dental barotrauma during hyperbaric chamber exposure: case report.

Previous cases of dental barotrauma have been reported in pilots and divers. We report a case of dental barotrauma and barodontalgia in a diving physician accompanying patients during hyperbaric oxygen treatment, and due to pressure changes in the hyperbaric chamber. The physician developed sharp pain localised to the right maxillary molars but radiating to the face, ear and head during decompression from 243 kPa (2.4 atmospheres absolute). The pain intensified following completion of decompression and was consistent with irreversible pulpitis. Clinical examination and panoramic radiography suggested fracture of a heavily restored tooth due to barotrauma. This was managed by tooth extraction. The physician subsequently discontinued accompanying the patients during their hyperbaric oxygen treatment sessions. Dentists and maxillofacial surgery specialists suggest waiting for a minimum of four weeks or until the tooth socket and/or oral tissue has healed sufficiently to minimise the risk of infection or further trauma before exposure to further pressure change. Although seemingly rare, and despite the comparatively slow pressure changes, dental barotrauma can occur in hyperbaric chamber occupants.

Shallow Water Diving-Associated Alveolar Hemorrhage in an Active Duty Sailor: A Case Report.

Breath-hold diving is a common practice as a part of military dive training. An association between prior lung injury and a propensity for lung barotrauma may have the potential to impact mission readiness for combat divers, Pararescue, Combat Controllers, Army Engineer divers, and various units in Naval Special Warfare and Special Operations. Barotrauma is a common complication of diving, typically occurring at depths greater than 30 m (98.4 ft). Individuals with abnormal lung anatomy or function may be at increased risk of barotrauma at shallower depths than those with healthy lungs, rendering these service members unfit for certain missions. We describe the case of a 25-year-old male, with a remote history of polytrauma and resultant pulmonary pleural adhesions, whose dive training was complicated by lung barotrauma at shallow depths. In missions or training utilizing breath-hold diving, the association with secondary alterations in lung or thoracic anatomy and function may limit which service members can safely participate.

Balloon Eustachian tuboplasty in a professional Navy SEAL diver: case report.

Middle ear barotrauma due to dilatory Eustachian tube dysfunction (ETD) is probably the most common medical disorder related to diving. Moreover, ETD makes divers prone to other diving-related accidents, including inner ear barotrauma and alternobaric vertigo. Until the development of Eustachian tube balloon dilation no diving-compatible surgical options existed to effectively and safely prevent recurrence. We present a case of an Israeli Navy SEAL diver who dives in extreme strenuous combat-related closed-circuit rebreather (CCR) dives. Due to repeated middle ear barotrauma, the patient underwent Eustachian tube balloon dilation of the affected side. Following surgery, the patient returned to both CCR and scuba dives but still suffered from middle ear symptoms and repeated barotrauma hence was eventually disqualified from further combat diving.

Traumatic diaphragmatic rupture: delayed presentation following a SCUBA dive.

Traumatic diaphragmatic rupture (TDR) is a rare yet life-threatening occurrence that remains a diagnostic challenge for clinicians. Delayed presentation with associated strangulation of the contents, although uncommon, requires emergent management. A 42-year-old woman presented with constant, severe left-sided shoulder and chest pain, as well as associated upper abdominal pain following a self-contained underwater breathing apparatus (SCUBA) dive. A chest radiograph (CXR) and CT showed a left-sided diaphragmatic hernia containing stomach. She subsequently underwent a laparoscopic repair of the diaphragmatic defect and recovered well postoperatively.

A 20-year analysis of compressed gas diving-related deaths in Tasmania, Australia.

INTRODUCTION: This study reviews diving deaths that occurred in Tasmanian waters over a 20-year period. METHODS: Detailed analysis was undertaken of deaths that occurred from 01 January 1995 to 31 December 2014. The cases were collated from numerous sources. Utilising a chain of events analysis, factors were identified and assigned to predisposing factors, triggers, disabling agents, disabling injuries and cause of death. These were then scrutinised to ascertain regional variables, remediable factors and linkages which may benefit from targeted risk mitigation strategies. RESULTS: Seventeen deaths were identified across this 20-year period, which included one additional case not previously recorded. All were recreational divers and 15 were male. Five were hookah divers, 12 were scuba divers. Important predisposing factors identified included equipment (condition and maintenance), pre-existing health conditions, diver experience and training. These factors can now be used to promote public health messages for divers. CONCLUSIONS: This 20-year study highlighted regional variations for Tasmanian deaths and presents opportunities for strategies to prevent diving deaths in the future. Of particular concern was the diving practice of 'hookah' diving, which has no governing regulations. The study highlighted the importance of applying a structured methodology such as chain of events analysis to scrutinise diving deaths.

Inner ear barotrauma in divers: an evidence-based tool for evaluation and treatment.

OBJECTIVE: To systematically search the literature for studies evaluating the typical presentation and testing that is performed for divers with inner ear symptoms and then to create a tool for clinicians when evaluating a diver with inner ear symptoms. METHODS: Nine databases, including PubMed/MEDLINE were systematically searched through 31 January 2018. The PRISMA statement was followed. RESULTS: Three-hundred and two manuscripts were screened, 69 were downloaded and 21 met criteria to be included in this review. The articles were evaluated for symptomatic trends and initial evaluation work-up primarily focusing on inner-ear barotrauma (IEBt) and inner ear decompression sickness (inner ear DCS). The trends for IEBt were compared to typical inner ear DCS presentation based on large study inner ear DCS results consistent with the plethora of research available. Finally, the HOOYAH Tool was developed to assist the receiving provider to better determine the most likely diagnosis and thus initiate appropriate treatment. The HOOYAH Tool is comprised of the following: 1) H: hard to clear; 2) O: onset of symptoms; 3) O: otoscopic exam; 4) Y: your dive profile; 5) A: additional symptoms and 6) H: hearing. For each of these components, the typical presentation is described allowing the provider better to discern the correct diagnosis. CONCLUSION: The diagnosis of IEBt remains difficult to define short of visualization through surgical exploration. Early treatment is defined by conservative management with a subsequent observational period to determine symptomatic resolution and need for surgery. However, a similar differential diagnosis is inner ear DCS which requires early recompression. The HOOYAH tool provides a method for assisting the provider in forming a more confident decision regarding the underlying pathology and facilitation of the appropriate treatment.

Rhinologic and oral-maxillofacial complications from scuba diving: a systematic review with recommendations.

Rhinologic and oral maxillofacial complications from scuba diving are common, representing approximately 35% of head and neck pathology related to diving. We performed a systematic and comprehensive literature review on the pathophysiology, diagnosis, and treatment of rhinologic and oral maxillofacial pathology related to diving. This included complications due to sinus barotrauma, barodontalgia, odontocrexis, temporomandibular joint dysfunction, partially dentulous patients, and considerations for patients following major head and neck surgery. Of 113 papers accessed, 32 were included in the final synthesis. We created a succinct summary on each topic that should inform clinical decision making by otolaryngologists, dive medicine specialists and primary care providers when faced with pathology of these anatomic sub-sites.

Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care.

Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver's hearing and balance systems. The majority of dive-related injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.

[Spinal cord injuries resulting from diving accidents in the Canary Islands]. / Lesión medular secundaria a zambullida en Canarias.

OBJECTIVE: Diving accidents is one of the leading causes of spinal cord injury after falls and car accidents. The objective of this study was to determine the epidemiological and clinical characteristics of these patients in our setting to better prevent these injuries. MATERIAL AND METHODS: We performed a retrospective, descriptive study of patients who have suffered from a traumatic spinal cord injury after a diving accident in the Canary Islands, Spain from 2000 to 2014. These patients were admitted to the Spinal Cord Unit of Hospital Universitario Insular de Gran Canaria. RESULTS: Of the 264 patients admitted to our unit for acute traumatic spinal cord injury, 23 (8.7%) cases were due to diving. Grouping the patients into 5years periods, 56% of the injuries occurred in 2000-2005, 17% in 2006-2010 and 26% in 2011-2014. All patients were male, with a mean age of 29years. Approximately 65% were under 30years. A total of 22/23 patients had a fracture and injury most commonly occurred to the C5 vertebra. Burst fractures were the most common. A total of 86% of cases underwent surgery. All the spinal cord injuries were cervical, with C6 being the neurological level most often affected. A total of 65% of spinal cord injuries were complete injuries. CONCLUSIONS: Spinal cord injury secondary to diving accidents is the third leading cause of traumatic spinal cord injury in our setting. It affects young males and the most common clinical presentation is a complete cervical spinal cord injury. Given the irreversible nature of the injury, prevention, aimed mainly at young people, is of great importance.

[Epidemiology of traumatic spinal cord injury in Gran Canaria]. / Epidemiología de la lesión medular de origen traumático en Gran Canaria.

OBJECTIVE: To evaluate the epidemiological and clinical trends in acute traumatic spinal cord injuries. MATERIAL AND METHODS: A retrospective study was conducted of traumatic spinal cord injury patients in Gran Canaria (Canary Islands, Spain) from 2000 to 2014. Demographic and spinal injury severity trends were analysed by year of injury grouped into 3 periods: 2000-2005, 2006-2010, and 2011-2014. RESULTS: The sample included 141 patients. The mean incidence for the entire period was 12 cases/million/year. There was a decrease in cases in the second and third period. While the male/female ratio was 3.8/1 and was maintained in all periods, the mean patient age increased from 38.8 in 2000-5 to 54.5 years in 2011-4 (P<.05). Falls have been the leading cause of spinal cord injury (48.2%), followed by traffic accidents (37.6%). Falls have increased, especially in the older population. Incomplete tetraplegia has been the most prevalent group (30.5%). A vertebral fracture was suffered by 70.3% of all patients, with 93.2% of them requiring surgery. CONCLUSIONS: There has been a decrease in the incidence of traumatic spinal cord injury in recent years. The target population has changed, and the older population is currently the most affected. This reality suggests the need to change the local prevention campaigns for spinal cord injury in the elderly.

Oxygen, the lung and the diver: friends and foes?

Worldwide, the number of professional and sports divers is increasing. Most of them breathe diving gases with a raised partial pressure of oxygen (PO2 ). However, if the PO2 is between 50 and 300 kPa (375-2250 mmHg) (hyperoxia), pathological pulmonary changes can develop, known as pulmonary oxygen toxicity (POT). Although in its acute phase, POT is reversible, it can ultimately lead to non-reversible pathological changes. Therefore, it is important to monitor these divers to prevent them from sustaining irreversible lesions.This review summarises the pulmonary pathophysiological effects when breathing oxygen with a PO2 of 50-300 kPa (375-2250 mmHg). We describe the role and the limitations of lung function testing in monitoring the onset and development of POT, and discuss new techniques in respiratory medicine as potential markers in the early development of POT in divers.

Can asthmatic subjects dive?

Recreational diving with self-contained underwater breathing apparatus (scuba) has grown in popularity. Asthma is a common disease with a similar prevalence in divers as in the general population. Due to theoretical concern about an increased risk for pulmonary barotrauma and decompression sickness in asthmatic divers, in the past the approach to asthmatic diver candidates was very conservative, with scuba disallowed. However, experience in the field and data in the current literature do not support this dogmatic approach. In this review the theoretical risk factors of diving with asthma, the epidemiological data and the recommended approach to the asthmatic diver candidate will be described.

[Diving accidents]. / Tauchunfälle.

Decompression injuries occur on account of the special hyperbaric effects during the emerge phase and require superior therapeutic knowledge. Vitally important is emergency treatment with high concentrated oxygen at an early stage. Sever decompression injuries require oxygenation in a hyperbaric treatment chamber.

Perilymphatic fistula after underwater diving: a series of 11 cases.

INTRODUCTION: Onset of cochleovestibular symptoms (hearing loss, dizziness or instability, tinnitus) after a dive (scuba or breath-hold diving) warrants emergency transfer to an otology department. One priority is to investigate the possibility of the development of decompression sickness with a view to hyperbaric oxygen treatment of bubble-induced inner-ear damage. If this injury is ruled out, inner-ear barotrauma should be considered together with its underlying specific injury pattern, perilymphatic fistula. METHODS: We report on a series of 11 cases of perilymphatic fistula following ear barotrauma between 2003 and 2015, eight after scuba diving and three after free diving. All patients underwent a series of laboratory investigations and first-line medical treatment. RESULTS: Seven patients had a perilymphatic fistula in the left ear and four in the right. Eight cases underwent endaural surgical exploration. A fistula of the cochlear fenestra was visualised in seven cases with active perilymph leakage seen in six cases. After temporal fascia grafting, prompt resolution of dizziness occurred, with early, stable, subtotal recovery of hearing in seven. Of six patients in whom tinnitus occurred, this disappeared in two and improved in a further two. Two patients were not operated on because medical treatment had been successful, and one patient refused surgery despite the failure of medical treatment. Median follow-up time was 7.4 years (range 0.3 to 12). CONCLUSION: The diagnosis of perilymphatic fistula is based on clinical assessments and various laboratory findings. When there was strong evidence of this condition, surgery yielded excellent functional outcomes in all patients treated early.

Cerebrospinal fluid markers of central nervous system injury in decompression illness - a case-controlled pilot study.

INTRODUCTION: Decompression sickness (DCS) may cause a wide variety of symptoms, including central nervous system (CNS) manifestations. The main objective of this study was to examine whether DCS is associated with neuronal injury, and whether DCS could result in altered amyloid metabolism. METHODS: Seven, male divers with DCS and seven age-matched controls were included in the study. All the divers were treated by recompression but the controls did not receive hyperbaric oxygen. Cerebrospinal fluid (CSF) samples were collected 7-10 days after the diving injury and at three months follow-up. CSF biomarkers of neuronal injury, astroglial Injury/activation, and a range of markers of amyloid ß (Aß) metabolism, as well as two proinflammatory interleukins, were analysed using immunochemical methods. RESULTS: There were no significant differences in the best-established CSF markers of neuronal injury, total tau (T-tau) and neurofilament light, between DCS patients and controls or between the two sampling time points. Also, there were no significant changes in the astroglial or amyloid (Aß)-related markers between DCS patients and controls. However, the only diver with CNS symptoms had the highest levels of CSF T-tau, Aß38, Aß40 and Aß42. CONCLUSION: The results of our study speak against subclinical CNS injury or induction of inflammation or amyloid build-up in the brain among the six DCS patients without neurological symptoms. Further research, including on divers with CNS DCS, is justified.

Osteonecrosis disbárica de cabeza humeral en buzo pesquero tratado con artroplastia de superficie / Dysbaric osteonecrosis of humeral head in a diver treated with resurfacing arthroplasty

Describir osteonecrosis disbárica (ODB) en buzo pesquero y exponer la experiencia inédita de tratamiento con artroplastia de superficie (AS). Introducción ODB, forma de necrosis avascular secundaria a enfermedad por descompresión (EDC), cuyo tratamiento gold standard para estadios avanzados continúa siendo la artroplastia total (AT). Presentación de caso: Paciente de 49 años, buzo pesquero, antecedentes de EDC tratada el 2008 en cámara hiperbárica, con diagnóstico compatible con ODB de cabeza humeral derecha de 6 años de evolución; Constant score=29. Se realiza AS del hombro derecho, y luego de 18 meses de seguimiento se reporta una adecuada evolución clínica con remisión de la sintomatología; Constant score a 18 meses=72. Discusión: El uso de AT en el paciente joven es limitado, por lo que surge la necesidad de implementar nuevas técnicas quirúrgicas en este grupo de pacientes. Conclusión: La AS constituye una alternativa terapéutica en adultos jóvenes y activos con ODB...

Introduce and describe Dysbaric Osteonecrosis (DON) in a fishing diver patient, emphasising clinical features, use of imaging methods, and present a new experience of treatment with Resurfacing Arthroplasty (RA). Introduction: DON, a form of avascular necrosis secondary to Decompression Sickness (DCS). Total Arthroplasty (AT) remains the reference treatment for advanced stages. Case report: Male, 49 years old, fishing diver, with a history of DCS treated in a hyperbaric chamber (2008). Right humeral head DON Compatible with 6 years of onset. Constant Score=29. RA performed on right shoulder. Clinical remission of symptoms was observed after 18 months of follow-up. Constant Score at 18 months=72. Discussion: TA use in young patients is limited, so there is a need to implement new surgical techniques in this group of patients. Conclusion: RA is a therapeutic alternative in young and active subjects with DON...

Antioxidants, endothelial dysfunction, and DCS: in vitro and in vivo study.

Reactive oxygen species (ROS) production is a well-known effect in individuals after an undersea dive. This study aimed to delineate the links between ROS, endothelial dysfunction, and decompression sickness (DCS) through the use of antioxidants in vitro and in vivo. The effect of N-acetylcysteine (NAC) on superoxide and peroxynitrite, nitric oxide (NO) generation, and cell viability during in vitro diving simulation were analyzed. Also analyzed was the effect of vitamin C and NAC on plasma glutathione thiol and thiobarbituric acid reactive substances (TBARS), plasma angiotensin-converting enzyme (ACE) activity, and angiotensin-II and DCS morbidity during in vivo diving simulation. During an in vitro diving simulation, vascular endothelial cells showed overproduction of superoxide and peroxynitrite, obvious attenuation of NO generation, and promotion of cell death, all of which were reversed by NAC treatment. After in vivo diving simulation, plasma ACE activity and angiotensin-II level were not affected. The plasma level of glutathione thiol was downregulated after the dive, which was attenuated partially by NAC treatment. Plasma TBARS level was upregulated; however, either NAC or vitamin C treatment failed to prevent DCS morbidity. During in vitro simulation, endothelial superoxide and peroxynitrite-mediated oxidative stress were involved in the attenuation of NO availability and cell death. This study is the first attempt to link oxidative stress and DCS occurrence, and the link could not be confirmed in vivo. Even in the presence of antioxidants, ROS and bubbles generated during diving and/or decompression might lead to embolic or biochemical stress and DCS. Diving-induced oxidative stress might not be the only trigger of DCS morbidity.

A SCUBA diver with acute kidney injury.

An otherwise healthy young man was transferred to our hospital after a diving incident. He had made an uncontrolled ascent from 10 m. On arrival he appeared well. No hypotensive episodes occurred during the transfer. He denied having arthralgias, back pain, dyspnoea or neurological symptoms. Laboratory investigations revealed acutely elevated creatinine (170 µmol/L) and creatine kinase (909 U/L). Radiology was consistent with a focus of pulmonary barotrauma and intrinsic renal disease. Creatine kinase is a marker of arterial gas embolism (AGE). We determined that our patient suffered acute kidney injury as a result of gas embolisation to his renal vasculature from an area of pulmonary barotrauma. Creatinine fell the following day in response to aggressive intravenous fluids. This is the first reported case of acute kidney injury secondary to AGE. Biochemical studies should be part of the routine assessment of patients involved in diving incidents.