Emergency Medicine

Environmental Emergencies 211

SPORTS-DIVING ACCIDENTS

5 Pulmonary barotrauma
This is the most serious form of barotrauma that causes:
(i) Surgical emphysema, pneumothorax or pneumomediastinum
associated with chest pain and dyspnoea.
(ii) Arterial gas embolus affecting the:
(a) coronary circulation, with cardiac pain, arrhythmia and
cardiac arrest
(b) cerebral circulation, with sudden onset of neurological
symptoms just before or within 5 min of surfacing (without
the delay seen in CNS decompression illness)

• any neurological symptom or sign from confusion to sei-
  zures or coma may occur, and may fluctuate.

6 Gain i.v. access and take blood for FBC, U&Es, LFTs, blood sugar level and
cardiac biomarkers.

7 Perform an ECG in patients with cardiopulmonary symptoms, and request a
CXR to exclude pneumothorax or pneumomediastinum.

MANAGEMENT

1 Middle ear barotrauma
(i) Give an analgesic such as paracetamol 500 mg and codeine
phosphate 8 mg.
(ii) Give amoxicillin 500 mg orally t.d.s. for 5 days if tympanic
membrane rupture is present, and refer the patient to the next
ENT clinic.
(iii) The patient should not dive again until the drum is fully healed.

2 Inner ear barotrauma
Discuss immediately with a hyperbaric medicine unit, as labyrinthine CNS
decompression illness is possible.

3 Sinus and dental barotrauma
Give an analgesic such as paracetamol 500 mg and codeine phosphate 8 mg.

4 Pulmonary barotrauma
(i) Give oxygen and insert an intercostal drain if a significant
pneumothorax is present (see p. 473)
(a) manage a pneumomediastinum and surgical emphysema
conservatively.
(ii) If arterial gas embolus is suspected:
(a) keep the patient horizontal on their left side (not head-down,
as this raises intracranial pressure)
(b) give 100% oxygen by tight-fitting face mask with reservoir
bag
(c) commence normal saline rehydration