1

Barotrauma/Decompression Sickness Overview

Barotrauma refers to medical problems that arise from the pressure differences between
areas of the body and the environment and is a particular concern for scuba divers.

Certain laws of physics apply to this topic. Boyle's law states that the product of the
multiplication of pressure and volume remains a constant. As the pressure increases, the
volume decreases and vice versa. As you dive deeper when scuba diving, pressure increases
and this volume change in gas-filled spaces and organs within your body accounts for the
distortion and damage to surrounding tissues.

 Decompression sickness, or "the bends," is related more to Henry's Law, which

states that more gas will be dissolved in a liquid when the gas is pressurized. Because
of the water pressure, body tissue absorbs nitrogen gas faster as a diver descends
than when ascending to the surface. However, if a diver ascends too quickly,
nitrogen gas bubbles will form in body tissue rather than being exhaled. The nitrogen
bubbles cause severe pain.

 External ear squeeze occurs when your ear canal is blocked by something such as
earplugs or earwax. As the water pressure increases while you descend, the air
pocket between the obstruction and the tympanic membrane (eardrum) shrinks.
This can damage the tissue in the ear canal, usually your eardrum.

 Middle ear squeeze occurs when you cannot equalize the pressure in your middle
ear. The eustachian tube is a small canal that connects the middle ear to the back
part of the nasal cavities and allows pressure to equalize. When there is a problem
with the tube, the middle ear volume decreases and pulls the eardrum inward,
creating damage and pain. You can try certain maneuvers, called Valsalva
maneuvers, such as yawning or trying to blow with your nose and mouth closed, to
open the tube and equalize the pressure.

 Inner ear barotrauma occurs from the sudden development of pressure differences
between the middle and inner ear. This can result from an overly forceful Valsalva
maneuver or a very rapid descent. The result is usually ringing in the ear, dizziness,
and deafness. This injury is less common than a middle ear squeeze.

 Less common types of barotrauma include the following. All involve air trapped in an
enclosed area where pressure cannot equalize during descent causing a vacuum
effect where it occurs.

o Sinus squeeze: When air becomes trapped in the sinuses because of

congestion or cold symptoms, a sinus squeeze can occur.

o Face mask squeeze: This occurs if you do not exhale through your nose into
the dive mask while descending (equalizing).
 2

o Suit squeeze: A dry diving suit tightly encloses an area of skin.

o Lung squeeze: This occurs when you are free-diving, but very few divers can
hold their breath to depths that cause this injury to occur.

o Tooth squeeze: This occurs during an ascent while scuba diving and air
becomes trapped in a filling or cavity.

o Gastric squeeze (aerogastralgia): This occurs when gas swallowed during

diving expands during ascent. This happens more often with novice divers
and causes temporary pain but rarely significant damage.

 Barotrauma can occur during ascent also. A reverse squeeze occurs in the middle ear
or sinus when a diver has an upper respiratory infection (cold) and has used nasal
spray to open the breathing passages. As the spray wears off during diving, tissues
swell and cause obstruction, resulting in a pressure difference and damage. During
"bounce diving" the eustachian tube may become inflamed and lead to a middle ear
squeeze.

 Pulmonary barotrauma (pulmonary overpressurization syndrome, POPS, or burst

lung) can occur if the diver fails to expel air from the lungs during ascent. As the
diver rises, the volume of the gas in the lung expands and can cause damage if the
excess is not exhaled.

 Air embolism is the most serious and most feared consequence of diving.

o While scuba diving, gas bubbles can enter the circulatory system through
small ruptured veins in the lungs.

o These bubbles expand during ascent, following Boyle's Law, and can pass
through the heart to obstruct blood flow in the arteries of the brain or heart.

 This most commonly occurs when a diver ascends rapidly because of

air shortage or panic.

 The diver then passes out, experiences a stroke, or has other nervous
system complaints within minutes of surfacing.

 The brain is affected more than other organs because gas rises, and
most divers are in a vertical position while ascending.
 3

 Decompression sickness (DCS, "the bends") involves gases diffusing into the tissues
and getting trapped there. The diver now has gas bubbles in places where there
should be none. Nitrogen is the usual culprit.

o During descent and while on the bottom, the diver absorbs nitrogen into the
tissues until they reach a pressure balance.

o When the diver ascends at the right rate, the gas diffuses from the tissues.
However, if the diver ascends too rapidly to allow diffusion, the nitrogen
bubbles will expand in the tissues as pressure decreases.

o Different body parts can be affected, depending on where the bubbles are
located.

Barotrauma/Decompression Sickness Causes

Two different phenomena cause barotrauma:

 The inability to equalize pressures

 The effect of pressure on an enclosed volume

 Decompression sickness is caused by the elevated pressures of the gas mixture

inhaled underwater that diffuse into the body tissues, and then the inadequate
diffusion of the gas from the tissues if the diver surfaces too quickly.

 Middle ear squeezes occur because of obstruction of the eustachian tube.

o The most common cause is an upper respiratory infection (cold), creating

congestion.

o Other causes of obstruction include congestion caused by allergies or

smoking, mucosal polyps, excessively aggressive Valsalva attempts, or
previous facial injuries.

 Factors that trigger sinus squeezes include a cold, sinusitis, or nasal polyps.

 Contributing factors to aerogastralgia (swallowing air) include performing Valsalva

maneuvers with the head down (which allows air swallowing), consuming
carbonated beverages or heavy meals prior to diving, or chewing gum while diving.

 Pulmonary barotrauma occurs from the diver holding their breath during ascent,
which allows pressure to rise in the lungs.

o The pressure increase results in rupture.

o Air also may penetrate into the tissue around the lungs.
 4

 The classic description of a dive causing an air embolism is rapidly ascending to the
surface because of panic.

 Failure to make recommended decompression stops during ascent usually causes

decompression sickness. Stops are based on diving tables or charts, which factor into
account the depth, duration of the dive, and previous dives completed and give you
guidelines on the proper rate of ascent.

Barotrauma/Decompression Sickness Symptoms

You should consider the signs and symptoms of diving injuries with regard to your overall
dive plan, including what part of the dive you were performing when the problems
occurred.

 The history of the dive is very important to medical personnel and should always be
included when assistance is required.

o Barotrauma such as squeezes will commonly occur during descent, and the
symptoms will frequently prevent a diver from reaching the desired depth.

o You will notice symptoms of aerogastralgia, pulmonary barotrauma, air

embolism, and decompression sickness both during and after ascent.

The following are symptoms for specific pressure problems:

 External ear squeeze: Pain in your ear canal and blood from your ear

 Middle ear squeeze: Ear fullness, pain, eardrum rupture, disorientation, nausea, and
vomiting

 Inner ear barotrauma: Feeling that your ear is full, nausea, vomiting, ringing in the
ear, dizziness, and hearing loss

 Sinus squeeze: Sinus pressure, pain, or nasal bleeding

 Face mask squeeze: "Bloodshot" eyes and redness or bruising of the face under the
mask

 Lung squeeze: Chest pain, cough, bloody cough, and shortness of breath

 Aerogastralgia (gastric squeeze): Abdominal fullness, colicky pain (severe pain with
fluctuating severity), belching, and flatulence (gas expelled through the anus).

 Pulmonary barotrauma: Hoarseness, neck fullness, and chest pain several hours after
diving. Shortness of breath, painful swallowing, and loss of consciousness also may
occur.
 5

 Air embolism: Sudden loss of consciousness within 10 minutes of surfacing. Other

symptoms include paralysis, numbness, blindness, deafness, dizziness, seizures,
confusion, or difficulty speaking. The paralysis and numbness can involve several
different parts of the body at the same time.

 Decompression sickness: Rashes, itching, or bubbles under your skin

o Lymphatic obstruction which can cause localized swelling

o Musculoskeletal symptoms include joint pain that worsens with movement

and commonly involves the elbows and shoulders

o Nervous system after-effects include paralysis, sensory disturbances, and

bladder problems, usually the inability to urinate.

o Pulmonary symptoms include chest pain, cough, and shortness of breath.

 Symptoms usually appear within 1 hour of surfacing but can be delayed up to 6

hours. In rare instances symptoms may not appear until 48 hours after the dive.

 Flying in a commercial aircraft after diving may cause "the bends" to develop in the
airplane because the cabin pressure is less than sea level pressure.

When to Seek Medical Care

Most problems that arise from barotrauma will require medical diagnosis or treatment. The
most important thing the patient can do if they experience barotrauma is to seek medical
attention and avoid future dives until cleared by a doctor.

Some injuries from barotrauma require immediate medical attention, while others can wait
for treatment. In all cases, stop further diving until the patient has been seen by a doctor.

Air embolism is life threatening and requires immediate attention. Planning ahead is
important.

 Know the location of the nearest emergency facility and recompression (hyperbaric)
chamber before you dive.

 Bring emergency phone numbers with you on the dive. A phone can be the best
immediate life saving tool.

 The Divers Alert Network (DAN) at Duke University maintains a list of recompression
facilities and can be reached around the clock at (call local EMS first, then DAN):

o (919) 684-8111 (collect)

 6

o 800-446-2671 (toll free)

o 1-919-684-9111 (Latin America Hotline)

 If a diver collapses within 10 minutes of diving, suspect air embolism and seek help
immediately. Most U.S. communities have an emergency access number (911). Find
out in advance if such a number is available and how to activate emergency medical
services when diving in a foreign country. A diver who has collapsed requires oxygen
and emergency life support. Lay the person flat and keep the diver warm until help
arrives.

Decompression sickness also requires immediate attention, but its symptoms may not
appear as quickly as those of air embolism.

 Information on recompression chambers is important and generally can be obtained

through the emergency medical system (911 in the U.S.).

 Divers with complaints consistent with decompression sickness should seek

attention through their doctor or a hospital's emergency department.

Pulmonary barotrauma and lung squeeze will require attention in an emergency

department in most instances because the studies required to evaluate the symptoms and
determine the possible treatment must be performed in the hospital environment.

A doctor can evaluate and treat ear squeezes and sinus squeezes initially and refer the
patient to a specialist if required.

 Evaluation may require a dive history.

 Ear squeezes require an examination to ensure the eardrum has not ruptured.

The diver needs immediate medical attention if they lose consciousness, show paralysis, or
exhibit stroke symptoms within 10 minutes of surfacing.

 You or your diving buddy should contact an ambulance through 911 or the local
emergency phone numbers.

 Symptoms of chest pain and shortness of breath may occur minutes to hours after a
dive. These require emergency department evaluation.

o If the symptoms are severe enough, contact an ambulance. Otherwise, have

someone drive the patient to the hospital, but do not drive yourself.

o These symptoms can be dive-related or could be caused by another

condition, such as a heart attack. This will be sorted out in the hospital.
 7

 Decompression sickness, or "the bends,” may require an emergency department to

control pain and arrange for recompression services using specialized equipment
that is available only at regional centers that specialize in barotrauma.

 Dizziness or pain from a squeeze may require emergency attention as well. When in
doubt, contact a doctor or a local emergency department for advice.

Exams and Tests

The doctor will gather information about the dive and perform a standard physical exam,
paying particular attention to the areas of pain and nervous system.

Depending on the patient's condition, they may be referred immediately to a recompression

(hyperbaric) chamber or may undergo further testing.

 The patient's vital signs will be taken, measuring blood pressure, pulse, breathing
rate, and temperature.

 Doctors probably will do a pulse oximetry - an instrument that measures the level of
oxygen in the blood - using a sensor on a finger or earlobe.

 The most common initial treatments may be oxygen (through a face mask or a tube
near the nose) and intravenous fluids.

Air embolism and decompression sickness usually will require recompression treatment and
repeated physical examinations. After treatment, the doctor may recommend a specialized
imaging study (CT scan or MRI) to further evaluate any neurological problems.

Chest pain and shortness of breath associated with pulmonary barotrauma may require an
electrocardiogram (ECG) and a chest x-ray.

The doctor will inspect the patient's ear canal and eardrum if they have an ear squeeze,
looking for physical signs that can range from no visible problems to a small amount of
bleeding to eardrum rupture to heavy bleeding.

Any hearing loss or dizziness will probably require referral to an otolaryngologist (ear, nose,
and throat specialist) or audiologist (hearing specialist). They will test the patient's hearing
and balance systems to determine if they have suffered any inner ear problems.

Barotrauma/Decompression Sickness Treatment

The most serious diving complications - air embolism and decompression sickness - will
require recompression therapy in a hyperbaric chamber. These hyperbaric chambers may be
freestanding or associated with a local hospital. The chamber itself is typically made of thick
metal plates with windows for observation. On the outside there are many pipes and valves.
 8

The chamber is usually large enough to accommodate more than one person. Medical
personnel may come into the chamber with the patient or stay outside, watch through the
window, and communicate by intercom, depending on the severity of the illness. While
inside the chamber, one may experience loud noises or cold as the pressures change. Similar
to diving, one will need to do Valsalva maneuvers to clear the ears while being pressurized.
The patient will be closely monitored and be given specific instructions while they are in the
chamber.

Other injuries can be managed at the hospital or doctor's office. All conditions will require
avoidance of diving until improved.

 The patient may need to be transported to another location for hyperbaric

treatments. This may include low-level flights in an aircraft to minimize further
pressure changes.

 "Treatment tables" will determine the length of treatment and treatment steps.
These tables take into account the depth, time of dive, decompression stops, and
previous dives performed. The hyperbaric specialist will recommend which table to
use.

 The hyperbaric chamber will increase the air pressure to make any gas bubbles
inside the tissues smaller and to allow them to go away properly to avoid injury.

Pulmonary barotrauma may result in a collapsed lung (pneumothorax). If this occurs, the
doctor must first determine how much of the lung has collapsed. If the collapse is relatively
small the patient can be treated with supplemental oxygen and observation. Larger ones
require that air be withdrawn from the body.

 Depending on the amount of air in the cavity, the doctor could use a needle or a
hollow tube to withdraw air from the cavity.

 The needle will withdraw small amounts of air, and then the patient will be observed
for at least 6 hours.

 Larger collapses require a catheter, or chest tube, to be placed in the chest wall and
remain for a few days until the lung that has been damaged can heal.

 Doctors must insert this tube through the skin into the chest cavity by doing a small
surgical procedure. Local anesthetics reduce and generally eliminate any pain
associated with this procedure.

 The tube is attached to a flutter valve or suction to promote air escape from the
inappropriate space.
 9

Self-Care at Home

There is no special treatment for face mask and suit squeezes. They usually go away in a few
days.

Aerogastralgia symptoms usually clear up on their own and do not require attention unless
the abdominal discomfort continues to worsen and does not go away in a few hours.

Pain from ear or sinus squeezes can be treated with over-the-counter pain relievers, such as
acetaminophen (Tylenol), ibuprofen (Motrin, Advil), or naproxen (Aleve). The patient should
visit a doctor to exclude possible serious ear injuries.

Medications

Sinus squeezes usually require oral and nasal decongestants. Antibiotics are usually
recommended for a squeeze involving the frontal sinuses. Pain medication may also be
prescribed.

Ear squeezes also require decongestants, both oral and long-acting nasal types. Antibiotics
may be given if the patient had a rupture, a previous infection, or the diving occurred in
polluted waters. Pain medication also may be prescribed.

Next Steps

Follow-up

Doctors will recommend follow-up based on the diagnosis.

Make sure everything has healed and the patient has received clearance before diving
again.

Prevention

The best prevention against barotrauma is to plan and prepare for your dive properly.

 Make sure you are in good health with no upper respiratory or sinus problems.

 Obtain the proper training and always use the buddy system (never dive alone).

 Check that your equipment is in good working order.

 Know the local emergency phone numbers in advance and have a means of
contacting help, for instance, with a cellular phone. (The location of the nearest
recompression facility could be very important in a problem such as air embolism.)

 Newer "dive computers" designed to maximize safety can be used and may allow
longer diving times and fewer or shorter decompression stops. They provide
 10

information similar to the original diving tables but are more precise. Be certain you
are familiar with their use before depending on them.

 Avoid flying in a plane within 24 hours of diving to reduce the risk of "the bends"
occurring unexpectedly in the lower air pressure of an airplane cabin.

Outlook

Most people recover from their diving accidents and are able to participate in future dives.

 Air embolism can be the most devastating complication from a diving accident. The
initial problems that occur can be very dramatic. Appropriate measures, including
recompression, must be taken quickly to minimize disabilities. Recovery rates for
people reaching a recompression chamber have been 66%-90%.

 Decompression sickness can also generally be treated effectively and result in very
good recovery rates when recompression is performed, even several days after the
initial onset.

 Pulmonary barotrauma associated with a collapsed lung (pneumothorax) may

require several days in the hospital if a chest tube is placed. There is always a risk of
recurrence once a diver has a collapsed lung. Complete recovery will usually take
several weeks to months.

 Mild ear squeezes usually take about 1-2 weeks to recover. More significant ones,
typically associated with eardrum rupture, may take longer. Depending on the
severity and amount of damage, surgery may be recommended.
 11

Middle Ear Squeeze

Barotrauma

Joseph Kaplan, MD, MS, FACEP, Attending Physician, Department of Emergency Medicine,
Martin Army Community Hospital, Fort Benning, Georgia
Marshall E Eidenberg, DO, Staff Emergency Physician, Via Christi Regional Medical Center

Updated: Sep 29, 2009

Introduction

Background
 12

Diving as a profession can be traced back more than 5000 years, yet diving-related disease
was not described until Paul Bert wrote about caisson disease in 1878. Symptoms of caisson
disease were noted among bridge workers after finishing their shifts underwater and
coming back to the surface. These symptoms included dizzy spells, difficulty breathing, and
sharp pain in the joints or abdomen. The caisson workers often noted that they felt better
while working. This was usually attributed to their being rested at the beginning of the shift
as opposed to being tired when the workday was through. The workers would often have
severe back pain that left them bent over, which is how caisson disease earned the
nickname "the bends."

Diving barotrauma can present with a variety of manifestations, from ear or mouth pain and
headaches to major joint pain, paralysis, coma, and death. As a result of the wide variety of
presentations, these disorders must be considered in any patient who has recently been
exposed to a significant change in barometric pressure. The 3 major manifestations of
barotrauma include the following: (1) sinus or middle ear effects, (2) decompression
sickness (DCS), and (3) arterial gas emboli.

Barotrauma has also reportedly been caused by an airbag rupturing during deployment,
forcing high-pressure gas into a person's lungs. It has also reportedly been associated with
rapid ascent in military aircraft and with pressure changes associated with space
exploration.

The most current research in barotrauma has been dealing with ventilator-associated
barotrauma and barotrauma prevention.

Recently, there has been a significant rise in articles dealing with combat-associated
barotrauma. These articles deal mainly with blast injury patterns and ballistics. This is an
extensive subject and is not covered in this article.

Pathophysiology

Injuries caused by pressure changes are generally governed by the Boyle and Henry laws of
physics.

The Boyle law states, "For any gas at a constant temperature, the volume of the gas will vary
inversely with the pressure," or P1 X V1 = P2 X V2. Pressure rises by 1 atmosphere for every
33 ft (10 m) of seawater depth. This means that a balloon (or lungs) containing a volume of
1 cubic foot of gas at 33 ft of seawater depth will have a volume of gas of 2 cubic feet at the
surface. If this air is trapped, as occurs when a person holds his or her breath during rapid
ascent, it expands with great force against the walls of that space (reverse squeeze). During
rapid ascent, incidents of pneumothorax and pneumomediastinum as well as sinus squeeze
and inner ear injuries can occur. Sinus squeeze occurs with eustachian tube dysfunction,
which may result in inner ear hemorrhage, tearing of the labyrinthine membrane, or
perilymphatic fistula.

The Henry law states that the solubility of a gas in a liquid is directly proportional to the
pressure exerted upon the gas and liquid. Thus, when the cap is removed from a bottle of
 13

soda pop, the soda begins to bubble as gas is released from the liquid. In addition, when
nitrogen in a diver's air tank dissolves in the diver's fatty tissues or synovial fluids at depth,
nitrogen will be released from those tissues as the diver ascends to a lower pressure
environment. This occurs slowly and gradually if the diver ascends slowly and gradually, and
the nitrogen enters the bloodstream to the lungs and is exhaled. However, should the diver
ascend rapidly, nitrogen exits tissues rapidly and forms gas bubbles.

Once bubbles are formed, they can affect tissues in many ways. They can simply obstruct
blood vessels leading to ischemic injury. This can be devastating when occurring in critical
areas in the brain. The bubbles can also form a surface to which proteins in the bloodstream
can cling, unravel, and begin a clotting/inflammatory cascade. This cascade can lead to
endothelial breakdown and permanent tissue damage.

Decompression sickness

Decompression sickness (DCS) usually results from the formation of gas bubbles, which can
travel to any part of the body, accounting for many disorders. A gas bubble forming in the
back or joints can cause localized pain (the bends). In the spinal cord or peripheral nerve
tissues, a bubble may cause paresthesias, neurapraxia, or paralysis. A bubble forming in the
circulatory system can lead to pulmonary or cerebral gas emboli.

Some gases are more soluble in fats. Nitrogen, for example, is 5 times more soluble in fat
than in water. Approximately 40-50% of serious DCS injuries involve the central nervous
system (CNS). Women may be at an increased risk of DCS because they have more fat in
their bodies. DCS also may occur at high altitudes. Those who dive in mountain lakes or
combine diving with subsequent flying are at increased risk as well.

DCS is classified into 2 types. Type I is milder, is not life threatening, and is characterized by
pain in the joints and muscles and swelling in the lymph nodes. The most common symptom
of DCS is joint pain, which begins mildly and worsens over time and with movement. DCS
type II is serious and life threatening. Manifestations may include respiratory, circulatory,
and, most commonly, peripheral nerve and/or CNS compromise.

Arterial gas embolism (AGE) is the most dangerous manifestation of DCS type II. AGE occurs
after a rapid ascent, when a gas bubble forms in the arterial blood supply and travels to the
brain, heart, or lungs. This is immediately life threatening and can occur even after ascent
from relatively shallow depths. However, AGE can also occur from iatrogenic causes.

Patients with a patent foramen ovale (up to 30% of the population) are at higher risk of gas
passing from a right-to-left shunt and causing CNS injuries.

Frequency

United States

The average risk of severe (type II) DCS is 2.28 cases per 10,000 dives. The number of minor
(type I) injures is not known because many divers do not seek treatment. Risk of DCS is
increased in divers with asthma or pulmonary blebs. Risk of DCS type II is increased 2.5
 14

times in patients with a patent foramen ovale. Deaths due to DCS in military aircraft have
been reported to occur at a rate of 0.024 per million hours of flight time. Rates of
decompression incidents for civilian aviation average about 35 per year, and less than half
are significant.

International

No information is available on the incidence of diving barotrauma worldwide. The Australian

defense force has averaged 82 incidents per million hours of flying time.

Race

No significant differences in the incidence of dive-related injuries have been associated with
race.

Sex

Because of a generally greater percentage of body fat, females have a theoretically higher
incidence of barotrauma injuries than males. However, no data support this hypothesis.

Age

Although no direct correlation exists with age and frequency of barotrauma, the most
common group affected ranges between 21 and 40 years. However, direct correlation does
exist between age and residual effects of barotrauma, which significantly rises after age 50
years.

Clinical

History

Patients with DCS present with a history of diving, generally within 24 hours of the onset of
symptoms. Patients may also have a recent history of occupational pressurization or
depressurization. For example, this occurs with aircraft mechanics who must test aircraft
windows by working in pressurized aircraft. Air emboli have also occurred in mechanics who
maintain training altitude chambers. Recently, military operations involving troops traveling
from ground level to high-altitude environments in a relatively short time and operations
involving soldiers doing strenuous activities at higher altitudes have resulted in many cases
of DCS. Recent studies have indicated that aerobic exercise either prior to a dive or during
decompression stops may decrease the post dive gas bubble formation.[1,2 ]

 Sinus squeeze
o Patients usually present with complaints of facial or oral pain, nausea,
vertigo, or headache.
o Other important information to gather includes any history of recent upper
respiratory infections, allergic rhinitis, sinus polyps, and sinus surgeries and
whether the pain worsened during descent or ascent.
 Middle ear squeeze
 15

o Patients often have a history of sudden vertigo, nausea, tinnitus, ear pain,
deafness, or headache.
o They may have a history of previous diving ear injury or a history of previous
or current ear infection.
 Decompression sickness type I
o Patients often have a history of recent diving followed by a flight home. They
may complain of slowly progressing pain or numbness in their limbs or back.
o Patients present with joint, muscle, or back pain that worsens over time. The
pain worsens with motion but is always present. The pain may range from
mild (tickles) to severe (the bends).
o Patients may have a history of previous decompression illness and multiple
dives in the same day and frequently have not followed the dive tables
closely. New dive computers that offer more "bottom time" do so by
modifying the US Navy dive tables and possibly place divers at an increased
risk for DCS injuries. Divers should be questioned as to the method of
computing bottom and ascent times with safety stops. This information
should be recorded as part of the medical record.
 Decompression sickness type II
o DCS type II usually presents sooner than DCS type I.
o Patients may present with shortness of breath (the chokes), chest pain,
severe headache, altered mental status, and shock. They also may complain
of dizziness or weakness. Patients may rapidly deteriorate without emergent
intervention.
o Essential history to ascertain includes time since dive ended, the dive profile,
when the symptoms began, and prior medical history. The dive profile
consists of prior dives that day, depth of dive, bottom time, decompression
stop depth, and length of stop.
o Diver should be asked about his or her prior dive category.
o Inquiry should be made specifically about previous decompression injuries,
pulmonary blebs, Marfan syndrome, asthma, congenital pulmonary illnesses,
HIV status, chronic obstructive pulmonary disease (COPD), lung tumors,
histiocytosis X, cystic fibrosis, pregnancy, and any prior pulmonary injuries or
surgeries.
 Arterial gas embolism
o AGE usually occurs shortly after ascending very rapidly, often from fairly
shallow depths. People may be described to scream suddenly and lose
consciousness. Onset of AGE often occurs within a few minutes of surfacing.
Patients who experience AGE often die before reaching a medical facility. Air
emboli have also recently been noted to occur iatrogenically in association
with central venous monitoring during surgical procedures. Case reports have
shown AGE occurring secondary to occupational rapid decompression in both
aircraft maintenance and altitude-chamber maintenance personnel.[3 ]
o Obtaining a history from these patients can be difficult because they often
present with altered mental status or are in shock.
o Witnesses often report that divers experience a sudden or immediate loss of
consciousness or collapse, usually within minutes of surfacing.
o Ask the patient or dive partner about a history of patent foramen ovale.
 16

 Abdominal compartment syndrome:[4 ]Divers can develop large amounts of

intraperitoneal extraluminal gas, which can compress the intraperitoneal organs.
This can lead to venous compression of these organs and secondary compartment
syndrome.

Physical

The physical examination should be tailored to the patient's history.

 Perform a general physical examination on all patients, with initial emphasis on ears,
sinuses, and neck as well as on the pulmonary, cardiovascular, and neurologic
systems. AGE often presents with signs and symptoms of acute stroke.
 Inspect and palpate the extremities, and test range of motion in all joints.
 Sinus squeeze
o Inspect nasal mucosa for polyps, hemorrhage, or lesions.
o Palpate and transilluminate sinuses to inspect for hemorrhage.
o Percuss upper teeth with a tongue blade to inspect for severe sinus
tenderness.
 Ear squeeze
o Carefully inspect the tympanic membrane (TM), looking in particular for the
following signs:
 Amount of congestion around the umbo
 Percent of TM involvement
 Amount of hemorrhage noted behind eardrum
 Evidence of TM rupture
o Palpate the eustachian tube for tenderness.
o Test the patient's balance and hearing.
o Evaluate the TM on the Teed scale:
 Teed 0 - No visible damage, normal ear
 Teed 1 - Congestion around the umbo, occurs with a pressure
differential of 2 pounds per square inch (PSI)
 Teed 2 - Congestion of entire TM, occurs with a pressure differential
of 2-3 PSI
 Teed 3 - Hemorrhage into the middle ear
 Teed 4 - Extensive middle ear hemorrhage with blood bubbles visible
behind TM; TM may rupture
 Teed 5 - Entire middle ear filled with dark (deoxygenated) blood
 Decompression sickness type I
o Inspect for swelling or effusion in the affected joint.
o Test for range of motion both actively and passively.
o Palpate the affected area for crepitus and compartment tightness.
o Evaluate neurovascular status by performing a complete neurologic
examination. The examination should include testing motor and sensory
functions, cerebellar function, and mental status. The findings from this
examination must be recorded and used as a baseline to determine
improvement in postdive chamber treatment.
 Decompression sickness type II
 17

o Evaluate cardiovascular and pulmonary systems.

o Note neck vein distention or petechiae on the head or neck.
o Palpate the skin for crepitus.
o Auscultate the lungs and heart for decreased breath sounds, muffled heart
tones, or heart murmurs.
o Evaluate neurologic status, including gross motor, sensory, and cerebellar
examinations. Tandem walking (heel to toe, with eyes closed) is an excellent
method of evaluation.
o Document Glasgow Coma Scale and Mini Mental State Examination.
 Arterial gas embolism: Use the same examination used for decompression sickness
type II.

Causes

The causes of DCS are related to predisposing medical or genetic factors, as listed above,
and to diver error. Diver error includes the following practices:

 Multiple daily dives

 Poor adherence to the dive tables
 Breath holding (most common scenario for pulmonary barotrauma)
 Rapid ascent - This can occur from relatively shallow depths. For example, pilots
undergoing rapid ascent while performing underwater escape training after flight
may experience DCS.
 Flying or traveling to high altitudes within 24 hours after diving
 Occupational causes - These causes include rapid depressurization by maintenance
workers and mechanics after working in pressurized aircraft cabins. Reports of
altitude chamber mechanics who have depressurized too quickly while working on
the altitude chambers have also been documented. Pilots and crewmembers
performing high-altitude air drops on military missions and special-operations
soldiers involved in such missions have also reported instances of DCS.