6-18
- Treat severe pain with morphine 5mg IV. Add 1-2 mg doses IV. Do not exceed 10 mg of morphine
in 24 hours. - Evacuate to medical treatment facility as soon as possible if trauma is severe.
- Send any severed limbs with the patient in saline-moistened gauze on ice.
- Cleanse and debride wounds in a clean environment. Explore wounds thoroughly (shark teeth may not
appear on x-ray). - Splint any extremities that look deformed or that have possible fractures. X-ray when possible.
- Monitor pulses and urine function for possible compartment syndrome and/or myoglobinurea from crush
injuries. - Administer tetanus prophylaxis: Tetanus toxoid 0.5 ml IM.
- Culture wounds for aerobes and anaerobes before starting broad-spectrum antibiotics.
- If patient has unexplained neurological symptoms, consider decompression sickness and arterial gas
embolism.
Patient Education
General: Reassure patient
Activity: Rest until all injuries are identified and treated.
Diet: Keep patient NPO since he will possibly undergo surgery very shortly
Medications: Watch for respiratory suppression with morphine.
Prevention and Hygiene: Do not swim with or challenge dangerous marine life. Avoid crocodiles on land.
Do not wear shiny objects while diving. Do not panic in the water. Only as a last resort if bitten, hit snout,
gills or eyes to drive attacker away.
Wound Care: Keep wounds clean, dry and covered.
Follow-up Actions
Return evaluation: Patients should not be allowed back into the water until cleared by a Diving Medical
Officer (DMO).
Evacuation/Consultation Criteria: Evacuate those with severe wounds, which require surgery. Consult a
general surgeon in these cases. Consult a DMO for other diving injuries (e.g., decompression sickness).
Dive Medicine: Underwater Blast/Explosion/Sound Injury
CPT Jeffrey Morgan, MC, USAIntroduction: Underwater explosions create shock waves that move out in all directions at the speed of
sound. Water is non-compressible, therefore it transmits the shock wave a greater distance and with more
intensity than an explosion in air (this is the concept used by depth charges against submarines). Unlike air
explosions, shrapnel and debris injuries are minimal because water quickly dampens any particles propelled
away from the explosion. The shock wave generated by the explosions can bounce off of the surface, ocean
floor, boat hulls or sea walls and strike divers in the water with a compounding impact. Factors affecting the
intensity of an underwater explosion: size of the charge, distance from the blast, protective clothing, depth of
the diver (deeper is worse), depth of ocean floor (shallow depths reflect blast more intensely) and firmness
of reflective surfaces near explosion (firmer surfaces reflect blast waves better, therefore are worse for the
diver). Shock waves cause implosions of gas-filled cavities in the body, tearing of tissues at gas-liquid
interfaces, and emboli.
Subjective: Symptoms
May be unable to talk; complaints may include chest pain, cough, pain with breathing, spitting blood, severe
abdominal pain, confusion, headache, seeing “floaters” or “stars,” ear pain, loss of hearing, and ringing of
ears.