Diving Related Emergencies

Question 1

Which patients have a high probability of CAGE?

Answer 1

Pts with:

1. GCS <15 and/or onset of symptoms <10-15mins after surfacing
2. Any seizure
3. LOC or ALOC

Question 2

If cerebral arterial gas embolism suspected, consider…?

Answer 2

Air transport, preferably by helicopter at <300m.

Question 3

List the signs and symptoms associated with DCI.

Answer 3

1. Musculoskeletal pain
2. Itching
3. Any neurological changes
4. Any respiratory complaint

Question 4

What are the 8 elements of specific history taking that are important to ascertain for Diving Related Emergencies?

Answer 4

1. Number of dives
2. Surface interval between dives
3. Maximum depths and bottom times
4. Type of ascent (controlled/rapid)
5. Decompression or safety stops
6. Breathing gas mixture used
7. Level of exertion during and after dive
8. Presenting symptoms, first aid provided.

Question 5

What needs to be done with divers computers/gauges from the dive?

Answer 5

Transport with pt to the facility.

Question 6

What is the management for pts who have a GCS 15 and have been experiencing DCI symptoms for >12-24hrs?

Answer 6

Tx with a simple face mask with their gear to a recompression facility - they do not need high flow O2 via a NRB.

Question 7

Where are the two proximal recompression facilities?

Answer 7

The Alfred Hospital and Royal Adelaide Hospital.

Question 8

What are the primary goals for patients with a diving related injury?

Answer 8

Allow nitrogen to off-gas, increase O2 delivery and rehydrate.

Question 9

What is the best way to remove nitrogen pre-hospitally?

Answer 9

High flow O2 delivery.

Question 10

Unconscious and intubated pts must be ventilated using?

Answer 10

A BVM with 15L O2 if possible.

Question 11

Post-immersion patients can have isolated hypotension. How is this managed?

Answer 11

Titrate fluid admin to pt response.

Question 12

What is the issue with warming tissues in ?DCI?

Answer 12

Can result in dissolution of undissolved nitrogen. Pts should be warmed to less than 32 degrees only to avoid arrhythmia risk.

Question 13

What position should potential CAGE pts be kept in?

Answer 13

Supine or lateral - do not allow to sit or stand.

If respiratory concerns, semi-recumbent is acceptable.

Question 14

If there is an indication for opioid analgesia for ?DCI, consultation with the Alfred needs to occur - why?

Answer 14

Opioids may mask the symptoms for the receiving physician when assessing potential recompression Rx.

Question 15

Which drug can mask the symptom of vertigo in ?DCI?

Answer 15

Stemetil.

Question 16

What is a stable vs. unstable DRE pt?

Answer 16

GCS 15 or GCS <15.

Question 17

What is the management for a symptomatic, stable DRE pt?

Answer 17

1. Position supine/lateral
2. Mx nausea
3. O2 15L/min via NRB regardless of symptoms
4. Avoid rapid body temp increases
5. Tx to recompression chamber
6. Mx other signs and symptoms
7. Monitor for deterioration of GCS (Mx unstable)
8. Fluid rehydration based on perfusion status

Question 18

What is the management for a symptomatic, unstable DRE pt?

Answer 18

1. Position supine/lateral
2. Mx nausea
3. O2 15L/min via NRB regardless of symptoms
4. Avoid rapid body temp increases
5. Tx to recompression chamber
6. Mx other signs and symptoms
7. Monitor for deterioration of GCS (Mx unstable)
8. Fluid rehydration based on perfusion status
9. Be aware of high risk of chest injuries
10. Consider need for MICA/HEMS

Question 19

When are MICA required for DRE pts?

Answer 19

If GCS <10, may require RSI.

Question 20

What are the 2 fluid administration pathways under the DRE guidelines?

Answer 20

If adequately perfused and chest clear admin 20ml/kg of Normal Saline over 15-20mins. Continue at 1L per 4hrs.

If less than adequate perfusion, administer ambient Normal Saline 40ml/kg, titrate to response.

Consult the Alfred for further fluids, or if no consult avail. admin 20mL/kg Normal Saline.