6-19
Objective: Signs
Decompression sickness or arterial gas embolism (see appropriate sections of this chapter) may occur
secondary to a rapidly aborted dive, or because the trauma of the explosion may suddenly move the diver
into more shallow water.
Using Basic Tools: General: Fracture or dislocation of any body part; swollen extremities (possible heart
failure).
HEENT: Subcutaneous emphysema (‘crackling’ with palpation of the skin) over the neck (leak in the respiratory
tract, such as pneumothorax); ruptured tympanic membrane (TM), tender or collapsed sinuses, blood in nose
and ears, nystagmus, dizziness, vertigo, and loss of balance; distended neck veins (heart failure or cardiac
tamponade).
Chest: Hemoptysis, obvious discomfort with deep inspiration, rales and friction rubs upon auscultation, cough,
and respiratory failure; decreased or absent breath sounds (simple, or tension pneumothorax, hemothorax);
subcutaneous emphysema.
GI tract: Blood in stool; rigid abdomen; rebound tenderness (probably due to intestinal rupture/hemorrhage).
CNS: Mental status changes (delirium, confusion, unresponsiveness), and paralysis of any part of the body
(stroke from emboli).
Using Advanced Tools: X-rays: CXR: Pneumothorax; patchy or diffuse infiltrates (pulmonary contusion) a
few hours after the blast injury. Cervical spine: assess for fractures, dislocations and other abnormalities.
Assessment:
Differential Diagnosis - arterial gas embolism (AGE) and decompression sickness (DCS) (see appropriate
sections in this chapter), as well as these possible blast-associated injuries:
Lungs - pulmonary contusions, pneumothorax, tension pneumothorax, hemothorax, alveolar rupture.
Gastrointestinal - intestinal hemorrhage, intestinal perforation, paralytic ileus, acute abdomen
Heart - cardiac contusion, congestive heart failure, tamponade
Brain and nervous system - brain injury/contusion, paralysis, stroke and C-spine injury.
Ears and sinuses - ruptured TMs, conductive hearing loss, ruptured sinuses and inner ear barotraumas
including round window and oval window ruptures.
Body - fractured bones, joint dislocations.
Plan:
Treatment
- Treat as major trauma patient (see Trauma on CD-ROM). Immobilize the head and neck with a cervical
collar until head/neck trauma is ruled out. - Secure the airway. Intubate if there is a doubt that the patient will be able to maintain his own airway. Place
on 100% O 2 initially and then wean down over the next 12 hours (except CNS injury). - Perform needle decompression in 2nd intercostal space in the mid-clavicular line if any type of
pneumothorax develops (see Procedure: Thoracostomy). Follow this later with a chest tube in the
5 th - 6th intercostal space in the mid-axillary line (also for hemothorax). - Keep patient hydrated. Adjust IV infusion rate to ensure a urine output of at least 30 cc/hour. Do not
over-hydrate patient. Do not use any fluids with a dextrose component, since the sugars may cause
increased swelling in the neurological tissues. - Perform serial neurological examinations. Use Glasgow coma scale (See Appendices).
- For CNS injuries, hyperventilate with 100% O 22. Immobilize trunk for any suspected spinal cord injury (SCI).
For SCI with NO BRAIN INJURY, give high-dose methylprednisolone within the first 8 hours of injury
ONLY: one dose of 30 mg/kg IV, followed by 5.4 mg/kg/hour IV for the next 23 hours. - Splint any deformed extremities.
- If TM is ruptured, keep ear canal clean and dry to allow the TM to heal. If the rupture is large, an
ENT surgeon may need to surgically repair the TM. Do not insert any drops or topical antibiotics in
the ear canal. If there is any loss of balance, keep the patient supine with the head up about 30°.
Start broad-spectrum systemic antibiotics: imipenem 500 mg IV q 6 hrs or ciprofloxacin 250-500 mg
po bid.