Uniformed Services University Department of Preventive Medicine and Biometrics

Undersea Medicine
LTC(P) Michael Lewis, MD, MPH, MBA, FACPM Assistant Professor, Epidemiology, PMB
Borrowed heavily from: Michael Jacobs MD MPH Undersea Medical Officer Occupational/Preventive Medicine Physician Naval Hospital Great Lakes michael.jacobs@nhgl.med.navy.mil

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Learning Objectives
Understand the scope of undersea medicine practice Understand basic principles of diving physiology Recognize symptoms and signs of decompression

illness
Understand principles of treatment for

decompression illness
Identify medical contraindications for diving

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What is Undersea Medicine?

Also known as Diving Medicine Field of medicine that deals with the effects of the undersea environment on health Prevention and treatment of diving-related injuries/illnesses

Pre-employment/Pre-placement examinations
Fitness-for-diving evaluations NOT management of chronic medical conditions

Undersea and Hyperbaric Medicine board certification offered by the American Board of Preventive Medicine

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Examples of Diving-Related Injuries/Illnesses

Decompression Sickness (The Bends) Arterial Gas Embolism Sinus/Aural barotrauma

Pneumothorax
Nitrogen Narcosis Drowning/Near Drowning Hypothermia Bites/Envenomations

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Who sees a diving doctor?

Recreational divers

Professional/Commercial divers
Dive instructors/Dive Masters Military/Police/Technical divers Inshore professionals Oceanographers, Marine biologists, Engineers, Salvors

Offshore professionals Saturation welders, Mixed-gas construction teams

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Diving Physics

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Pressure
Pressure force applied per unit area Atmosphere (atm): pressure exerted on all bodies/structures by earths atmosphere Sea Level = 1 atm = 14.7 psi (lb/in2) Pressure under water Every 33 ft of depth (sea water) = 1 atm or 14.7 psi Example: Diver at depth of 66 ft

1 atm (sea level) + 2 atm (water depth) = 3 atm Diver at 66ft is under 3 atm pressure
P (atm) = D (fsw) + 1 33 fsw P = Pressure D = Depth fsw = Feet of sea water

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Buoyancy
Object in liquid floats or sinks depending on density of object relative to liquid Your pet rock will sink in water Your rubber ducky will float State of neutral buoyancy object neither floats nor sinks Divers use various methods to maintain neutral buoyancy throughout a dive If it feels like you are sinking negatively buoyant If it feels like you are floating up - positively buoyant Both cause extra effort and potential injuries

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Gas Laws
Boyles Law: P1V1 = P2V2 A rubber balloon with a volume of 1 cf at the surface is submerged to a depth of 33 fsw. What is the volume of the balloon now?
P1V1 = P2V2 1 atm x 1 cf = 2 atm x V2 0.5 cf = V2 P1 = atmospheric press. V1 = volume at P1 P2 = press at 33 fsw V2 = volume at 33 fsw

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Sea Level

1 atm

Vol=1

Volume 100%

33 fsw 66 fsw 99 fsw

2 atm 3 atm 4 atm

Vol=1/2 Vol=1/3

50%

33%

Vol=1/4
25%

As a diver descends, atmospheric pressure increases and the volume of compressible tissues/gases decreases (e.g. gas bubbles, lung tissue)

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Daltons Law
Ptotal = pPa + pPb + pPc + . . . pPn (P = pressure, pP = partial pressure) pPa = PtotalFa (F = % gas by volume) What is the partial pressure of oxygen when breathing air at sea level? At 99 fsw? pPO2 = 1 atm (0.21) = 0.21 atm pPO2 = 4 atm (0.21) = 0.84 atm

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Henrys Law
The amount of gas that will dissolve in a liquid is almost directly proportional to the partial pressure of that gas
N2 N2 N2 N2 N2 N2 N2 N2 N2

BLOOD
High pPN2 Dissolve

As a diver descends, inspired gases are more soluble in blood

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Gas Diffusion
The difference between the partial pressure of a gas inside a liquid and its outside partial pressure will cause the gas to diffuse in or out of the liquid and will also control the rate of diffusion Example: At 66 fsw, pPN2 = 3 atm * 0.79 = 2.4 atm Blood pPN2 = 2.4 atm Diffusion Direction Tissue pPN2 = 0 atm

As a diver descends, inspired gases diffuse into tissues; as a diver ascends, gases diffuse out of tissues and into the blood

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Diving Gases
Most recreational divers use compressed air: 79.1% Nitrogen 20.9% Oxygen 0.033% Carbon Dioxide Various inert and trace gases Other options include: Nitrox (Nitrogen/Oxygen) reduces nitrogen narcosis Heliox (Helium/Oxygen) reduces DCS Trimix (Nitrogen/Helium/Oxygen) 100% Oxygen eliminates DCS (special ops use with scrubber system to eliminate bubbles)

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Diving Gases
Nitrogen colorless, odorless, tasteless, inert under pressure

soluble in body tissues Anesthetic/intoxicant on CNS

Nitrogen Narcosis: (50 ft = 1 martini) Oxygen Colorless, odorless, tasteless Too little (low Partial Press.) = hypoxia Too much (high Partial Press.) = CNS toxicity (seizures)

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Diving Gases
Carbon Dioxide Principal stimulant for respiration Slight elevations cause headache, dizziness High concentrations cause unconsciousness, death Carbon Monoxide Product of incomplete combustion Toxic, asphyxiant Helium Inert and nontoxic Often used as a nitrogen substitute for deep-diving divers to prevent nitrogen narcosis Associated with High Pressure Nervous Syndrome (HPNS)

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In 1900, a Royal Navy diver descended to 150 fsw in 40 minutes, spent 40 minutes at depth searching for a torpedo, and ascended to the surface in 20 minutes with no apparent difficulty. Ten minutes later he complained of abdominal pain and fainted. His breathing was labored, he was cyanotic, and he died after seven minutes. An autopsy the next day revealed the organs to be healthy, but gas was present in the liver, spleen, heart, cardiac veins, venous system, subcutaneous fat, and cerebral veins and ventricles. By present U.S. Navy Standard Air Decompression Tables, this diver should have had 174 minutes of decompression time before reaching the surface.

Diagnosis: Decompression Sickness (DCS)

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History
DCS recognized in divers and compressed air workers since late 1800s Prevailing guideline was to ascend slowly Standards ranged from 1.5 ft/min to 5 ft/min

DCS still occurred but less frequently

Bert*: DCS associated with nitrogen bubbles Haldane: Shorter/shallower dives associated with less frequent/less severe DCS
*Bert P. Barometric pressure. Researches in experimental physiology. Bethesda, MD. Undersea Medical Society, 1878.

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Decompression Theory
Body tissues absorbs nitrogen at depth Each tissue type absorbs nitrogen at different rate Slow, staged ascent (decompression) releases nitrogen harmlessly and is exhaled Stages determined by time/depth of each dive Ascent without adequate decompression causes nitrogen bubble formation Clinical manifestations = Decompression Sickness Origin of bubbles is controversial Form in extra vascular spaces, such as skin and joints (including spine) Reach venous circulation through lymphatics

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Decompression Illness (DCI)

Decompression Sickness (DCS)

Typically presents minutes to hours after dive

95% within 6 hours Nitrogen bubble formation from inadequate decompression Onsite treatment: ABCs, Oxygen Definitive treatment: Recompression

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Type I DCS
Musculoskeletal pain (Limb bends)

Most common manifestation of DCS

Dull pain, not well localized; no change with movement Knees, elbows, or shoulders most commonly involved Cutaneous DCS (Skin bends) Pruritis and erythema of trunk Cutis marmorata (mottling appearance of skin) Treatment: Recompression

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Type II DCS
Risk of permanent disability or death

Pulmonary DCS (Chokes)

Venous gas emboli clog pulmonary arterial circulation Rare; occurs with rapid ascent from deep dive Substernal discomfort, cough; worse with deep inspiration May lead to right-sided heart failure and cardiovascular collapse

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Type II DCS (cont)

Neurologic DCS Predilection for spinal cord Recreational divers doing short, deep dives Syndrome over minutes to hours after ascent

Tingling in trunk Progressive numbness and paresthesias Ascending motor weakness Bowel/bladder incontinence Severe cases may present with LOC/paraplegia Cerebral Sx: memory impairment, aphasias, visual disturbances, personality changes

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Type II DCS (cont)

Vestibular DCS (Staggers) Sudden onset of dizziness, nausea, vomiting, nystagmus, +/- hearing loss and tinnitus Not common in recreational divers Confused with middle ear barotrauma Treatment of Type II DCS: Rapid recompression with hyperbaric oxygen Supportive care: Fluids, pressors

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You and your dive buddy are out on the Great Barrier Reef. Your dive buddy is a novice diver on his first real diving trip. Your first dive is planned to a depth of 60 fsw for 45 minutes. Thirty-five minutes into your dive, your dive buddy points frantically toward a beautiful nine foot reef shark. After observing the shark for a few moments, you turn back to see your dive buddy swimming quickly for the surface. By the time you reach him on the surface, he is unconscious. The boat crew brings him on board and finds him unresponsive with a weak pulse. A review of your diving profile reveals that the dive was well within the decompression limits for a 60 ft dive. All other divers on the boat had no complications from their dives. What is the most likely diagnosis?

Diagnosis: Arterial Gas Embolism

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Arterial Gas Embolism (AGE)

2nd only to drowning as most common cause of death in recreational divers More common in novice divers Pathophyisiology Usually secondary to pulmonary barotrauma (PBT) Lung overinflation from diving activities Breath holding, bronchospasm, intrinsic abnormality Excessive pressure disrupts lung parenchyma and allows gas into interstitium Gas can cause mediastinal/subcutaneous emphysema, pneumothorax, or it can enter arterial circulation Extraalveolar gas enters left side of heart and can embolize (to cerebral/coronary vessels, etc.)

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AGE (cont)
Presents immediately or within minutes of ascent

Group 1 (5%)
Apnea, unconsciousness, cardiac arrest AGE to coronary/cerebral circulation

Group 2 (95%)
Varying systemic neurologic signs but vital signs preserved Typical: LOC/stupor/confusion, hemiparesis, seizures, vertigo, or headache Treatment: Rapid recompression

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Evaluation of DCIs
Obtain accurate history Dive profile (depth, time, previous dives), rate of ascent, time of onset of symptoms Physical Exam Vital signs, evidence of pulmonary barotrauma (PTX), thorough neurologic exam Diagnostic tests may not be time Differential Diagnosis Pain, rash, dyspnea, or neurologic changes after a dive should be assumed to be a diving-related illness Consider other dx for symptoms >6 hours after dive

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DCI Treatment
Emergency treatment ABCs first priority Oxygen administration (100%)

enhances washout of inert gas (Nitrogen)

May resolve Sx or improve outcome Definitive treatment Recompression Reduce bubble size Promote bubble resolution

Delays lead to inflammatory changes, cell death, and poorer recovery

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Recompression Chamber

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Recompression
Increased ambient pressure shrinks bubbles Can often reduce symptoms Controlled decompression allows dissipation of bubbles Breathing gases Air: Acceptable, but leads to additional nitrogen uptake and potential for additional DCS Oxygen: Enhances diffusion of nitrogen out of tissues (Oxygen window)

Oxygenates ischemic tissue Reduces cerebral edema Probably inhibits endothelial leukocyte accumulation

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Treatment Tables
Designed to allow 100% oxygen breathing at

highest practical ambient pressure

Oxygen toxicity occurs above 3 atm Typical treatments max depth = 60 ft (2.8 atm) Minimize nitrogen absorption

Type of treatment depends on type/severity

of DCI

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U.S. Navy Dive Table 5*

*U.S. Navy Diving Manual Revision 4, March 2001

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Example: Treatment Table 5

Used for Type 1 DCS (pain only) All symptoms must resolve within 10 minutes of reaching 60 ft in chamber Other cases treated with similar tables, but longer duration

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Effectiveness of Recompression for DCS

Workman1 Military divers: 110 of 114 cases (96.3%) completely resolved Civilians divers: 70% resolution

Divers Alert Network (DAN) 19942

Recreational divers: 56% resolution 30-90 days later: residual Sx in 33% pain-only DCS; 46% in mild neurologic DCS; 75% in severe neurologic DCS
1.
2.

Workman RD, Aerospace Medicine 1968.

DAN, 1996.

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Other injuries and illnesses are

much more common during a

typical dive

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Potential problems during a dive

1) Descent Aural/Sinus barotrauma Injury 2) On bottom Nitrogen Narcosis Injury 3) Ascent Aural/Sinus barotrauma CO poisoning Injury AGE PTX 4) After surfacing DCS AGE (within 10 min) PTX (within 10 min) Injury

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Medical Evaluation of Divers

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Contraindications to Diving (Recreational Divers)

Relate to pressure changes and need to be completely comfortable in surroundings (underwater, heavy gear, away from land/medical treatment) Absolute (typically): Neuro: Severe brain damage (e.g. following head injury), seizure disorders, illnesses causing significant neurological deficits (stroke) Endocrine: Diabetes with end-organ disease or symptomatic hyper/hypoglycemia Gastrointestinal: Achalasia, symptomatic hernias, gastricoutlet syndrome, SBO Pulmonary: Uncontrolled asthma, COPD, spontaneous PTX Cardiac: Unstable angina, Septal defects Medications: Decision usually relates to underlying condition Relative contraindications are numerous and may require thorough evaluation/discussion with specialist

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Commercial Divers
Initial/periodic exams usually required

Very thorough evaluation (neurologic,

pulmonary) Functional testing may be required (Exercise Treadmill Test, Pulmonary Function Test)

Contraindications similar but much more

strict than for recreational divers

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Related topics
Other diving-related disorders Nitrogen narcosis, High pressure nervous syndrome, gas toxicity, hypothermia, marine animal injuries Mixed gas diving (Nitrox, Trimix, 100% oxygen) Hyperbaric Oxygen Therapy (HBOT) Non diving injuries/illnesses Poor wound healing CO poisoning Necrotizing fasciitis Radiation necrosis Benefit derives from increased oxygen delivery to tissues Area of active research

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Resources
Bove AA. Bove and Davis Diving Medicine, 4th edition. WB Saunders, Philadelphia, 2004. Navy Diving Manual, 4th edition. 2001. (www.vnh.org/DivingManual/DMTOC.html)

www.dive.noaa.gov (NOAA)
www.scubamed.com (Underwater Medicine Associates) www.diversalertnetwork.org (DAN)

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Questions?