What is the acute care for diving-related injuries?

Acute Care for Diving-Related Injuries

For any suspected diving injury, immediately administer 100% high-flow oxygen and arrange urgent transport to a hyperbaric facility, as this is the definitive treatment for both arterial gas embolism and decompression illness, which can be fatal if untreated. 1

Immediate Assessment and Stabilization

When evaluating a diver with acute symptoms, rapidly determine the type of injury based on timing and presentation:

Three Primary Diving Emergencies

Pulmonary Barotrauma (Burst Lung)

• Most serious and potentially fatal - occurs during ascent when expanding gas cannot escape from lungs 1
• Presents with: central chest discomfort, hoarseness, dyspnoea, subcutaneous emphysema 1
• Can lead to pneumomediastinum, pneumothorax, or arterial gas embolism 1
• Arterial gas embolism manifests with major neurological symptoms, impaired consciousness, convulsions, or sudden death from coronary embolism 1
• Risk factors include airway narrowing, lung bullae, rapid uncontrolled ascent, or running out of air at depth 1

Decompression Illness

• Symptoms range from joint pain ("the bends") to focal neurological deficits, collapse, and death 1, 2
• Can occur up to 24 hours after diving 3
• Severity depends on bubble location in systemic circulation and nitrogen tissue content 1

Ear/Sinus Barotrauma

• Most common diving injury overall 4
• Ear barotrauma presents with pain, hearing loss, vertigo 5, 6
• Less immediately life-threatening but requires prompt treatment 5, 6

Acute Management Protocol

Immediate Actions (All Suspected Diving Injuries)

1. Administer 100% oxygen via non-rebreather mask at highest flow rate 2, 3, 7

   • Continue oxygen during transport
   • This is therapeutic, not just supportive

2. Position patient supine (not Trendelenburg) 3

   • Avoid head-down positioning which was previously recommended

3. Maintain hydration with IV fluids 3

   • Avoid overhydration which may worsen pulmonary edema

4. Contact Divers Alert Network (DAN) immediately for physician consultation and hyperbaric facility location 2

   • Available 24/7 for emergency consultation
   • Can assist with diagnosis and transfer arrangements

5. Arrange urgent transport to hyperbaric chamber 2, 3, 7

   • Recompression therapy is definitive treatment for decompression illness and arterial gas embolism
   • Do not delay transport for diagnostic testing

Specific Management by Injury Type

For Arterial Gas Embolism/Severe Barotrauma:

• Immediate hyperbaric oxygen therapy is mandatory 2, 3, 7
• Supportive care for neurological symptoms
• Avoid air transport at altitude if possible (increases gas expansion) 3

For Ear Barotrauma:

• Decongestants and analgesics for mild cases 5
• Toynbee maneuver (swallowing with pinched nostrils) to prevent recurrence 5
• Short-term corticosteroids if laryngeal edema present 5
• Severe cases may require myringotomy or surgical repair 5

For Immersion Pulmonary Edema:

• Presents with cough, breathlessness, haemoptysis during or after dive 1
• Chest radiograph shows patchy alveolar infiltrates 1
• Supportive care with oxygen and diuretics
• Advise against future diving due to high recurrence risk 1

Critical Pitfalls to Avoid

• Do not perform Valsalva maneuver in acute ear barotrauma as it may worsen injury 5
• Do not use high-pressure oxygen insufflation which can cause further barotrauma 5
• Do not delay hyperbaric referral for imaging or other diagnostics in suspected decompression illness or gas embolism 2, 3
• Recognize that symptoms may be delayed up to 24 hours post-dive 3
• Be aware that 32% of injured divers never seek help, leading to potential complications 4
• Even shallow dives can cause significant barotrauma, particularly in patients with asthma or airway disease 5

When to Suspect Diving Injury

Any diver presenting with symptoms during or within 24 hours of diving should be assumed to have a diving-related injury until proven otherwise 3. The most common presentations include:

• Neurological symptoms (confusion, focal deficits, seizures) 1
• Respiratory distress (dyspnoea, chest pain, haemoptysis) 1
• Ear pain or hearing loss 4, 6
• Joint pain or skin changes 1

Physicians in non-coastal areas must maintain awareness as injured divers may present hours after traveling from diving locations 3.