dive travel edmond kay md. acknowledgementsacknowledgements dr richard moon, divers alert network ...
TRANSCRIPT
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Dive TravelDive TravelDive TravelDive Travel
Edmond Kay MDEdmond Kay MDEdmond Kay MDEdmond Kay MD
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Acknowledgements Acknowledgements Acknowledgements Acknowledgements
Dr Richard Moon, Dr Richard Moon, Divers Alert NetworkDivers Alert Network
Jack Connick, Jack Connick, Optical OceanOptical Ocean
Dr Richard Moon, Dr Richard Moon, Divers Alert NetworkDivers Alert Network
Jack Connick, Jack Connick, Optical OceanOptical Ocean
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DeclarationsDeclarationsDeclarationsDeclarations
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TopicsTopicsTopicsTopics
Before travelingBefore traveling- fitness issuesfitness issues- medicationmedication
While travelingWhile traveling- DAN dive & travel insuranceDAN dive & travel insurance- region specific precautionsregion specific precautions
Unwanted souvenirsUnwanted souvenirs- nastiesnasties
Bubble troubleBubble trouble- decompression illnessdecompression illness
Before travelingBefore traveling- fitness issuesfitness issues- medicationmedication
While travelingWhile traveling- DAN dive & travel insuranceDAN dive & travel insurance- region specific precautionsregion specific precautions
Unwanted souvenirsUnwanted souvenirs- nastiesnasties
Bubble troubleBubble trouble- decompression illnessdecompression illness
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Gravity & MomentumGravity & MomentumGravity & MomentumGravity & Momentum
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Pressure & ImmersionPressure & ImmersionPressure & ImmersionPressure & Immersion
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Boyles Law Boyles Law Boyles Law Boyles Law
Pressure and Volume - Inversely ProportionalPressure and Volume - Inversely ProportionalPressure and Volume - Inversely ProportionalPressure and Volume - Inversely Proportional
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Henry’s LawHenry’s LawHenry’s LawHenry’s Law
Amount of gas dissolved in a liquidAmount of gas dissolved in a liquiddirectly proportional to the partial pressuredirectly proportional to the partial pressure
of that gasof that gas
Amount of gas dissolved in a liquidAmount of gas dissolved in a liquiddirectly proportional to the partial pressuredirectly proportional to the partial pressure
of that gasof that gas
On surfaceOn surface
On decentOn decent
At pressureAt pressure
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0
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800
1000
1200
1400
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
Accidents
Deaths
Divers Alert Network, 1998Divers Alert Network, 1998
NN
Recreational Diving:Recreational Diving: DCS and Death DCS and Death
Recreational Diving:Recreational Diving: DCS and Death DCS and Death
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What kind of DivingWhat kind of DivingWhat kind of DivingWhat kind of Diving
““Fitness to dive should apply only to the type of Fitness to dive should apply only to the type of diving in which the diver plans to engage”diving in which the diver plans to engage” - David Elliott, MD, OBE - David Elliott, MD, OBE
Moon REMoon RE
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What kind of DiverWhat kind of DiverWhat kind of DiverWhat kind of Diver
Not fit right nowNot fit right now - dehydration, fatigue, URI, pregnancy- dehydration, fatigue, URI, pregnancy
Not fit withoutNot fit withoutspecial trainingspecial training
ADAADA - accommodation - accommodation - supervision - supervision
Adapted from Moon REAdapted from Moon RE
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Fitness to DiveFitness to DiveFitness to DiveFitness to Dive
Able to do the “work”Able to do the “work”: : breathe, swim, exercisebreathe, swim, exercise Not susceptible to barotrauma:Not susceptible to barotrauma: ear, lung, GIear, lung, GI Not susceptible to loss of consciousness (drowning): Not susceptible to loss of consciousness (drowning):
convulsions, insulin dependent diabetes, heart blockconvulsions, insulin dependent diabetes, heart block Not pregnantNot pregnant
No diseases that diving could make worse:No diseases that diving could make worse: sinus or sinus or middle ear disease, previous labyrinthine window middle ear disease, previous labyrinthine window rupture, heart failurerupture, heart failure
Not ‘overly’ susceptible to DCINot ‘overly’ susceptible to DCIAge?Age? Female gender?Female gender?Obesity?Obesity? Menses?Menses?Previous decompression illness?Previous decompression illness? Fatigue, dehydration?Fatigue, dehydration?Orthopedic injuries or surgery?Orthopedic injuries or surgery? Atrial septal defects, PFO?Atrial septal defects, PFO?
Moon REMoon RE
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Psychological & Behavioral Psychological & Behavioral Fitness?Fitness?
Psychological & Behavioral Psychological & Behavioral Fitness?Fitness?
Able to exercise good judgmentAble to exercise good judgment Not susceptible to disabling anxietyNot susceptible to disabling anxiety No sedating drugsNo sedating drugs
- alcohol & tranquilizers - alcohol & tranquilizers ADHDADHD
- oppositional & defiant- oppositional & defiant Psychosis, ManiaPsychosis, Mania
Able to exercise good judgmentAble to exercise good judgment Not susceptible to disabling anxietyNot susceptible to disabling anxiety No sedating drugsNo sedating drugs
- alcohol & tranquilizers - alcohol & tranquilizers ADHDADHD
- oppositional & defiant- oppositional & defiant Psychosis, ManiaPsychosis, Mania
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Class of Drugs Drug Effects Adverse to Diving
Anticoagulants Hemorrhage from Barotrauma or Spinal DCS
Narcotics, Marijuana & Alcohol
Impaired judgment & problem solving. Aggravation of nitrogen narcosis
Tranquillizers Impaired judgment & problem solving. Aggravation of nitrogen narcosis
Anti-depressants Risk of seizures with Bupropion (Wellbutrin)
Decongestants & Antihistamines
Sleepiness & nasal rebound congestion. Risk of ear barotrauma and O2 Toxicity with pseudoephedrine (Sudafed)
Motion sickness drugs
Sedation, impaired judgment and aggravation of nitrogen narcosis.
Beta blockersReduced ability to respond to needs of stress. Aggravate Raynaud's Phenomenon and asthma
Anti - malarialsMefloquine (Lariam) psychological & neurological side effects are similar to symptoms of DCS. Doxycycline causes disabling photosensitivity.
Sympathomimetics
Amphetamines, methylphenidate and to a lesser extent pseudoephedrine (CNS stimulants) increase risk of CNS oxygen toxicity. Amphetamines can distort or amplify self-confidence (grandiosity) or increase risk of panic during frightening narcosis
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How to Determine Fitness to DiveHow to Determine Fitness to DiveHow to Determine Fitness to DiveHow to Determine Fitness to Dive
What incremental risk is acceptable?What incremental risk is acceptable? Where should the threshold for qualification Where should the threshold for qualification
be set?be set?
What incremental risk is acceptable?What incremental risk is acceptable? Where should the threshold for qualification Where should the threshold for qualification
be set?be set?
““If you don’t have gills, the term ‘fitness to dive’ is a misnomer”If you don’t have gills, the term ‘fitness to dive’ is a misnomer” - Andy Veale MD- Andy Veale MD
"It's probably more important to ask if someone has ever run "It's probably more important to ask if someone has ever run out of gas on the freeway than to ask about most medical out of gas on the freeway than to ask about most medical conditions” - Tom Neuman MDconditions” - Tom Neuman MD
Adapted from Moon REAdapted from Moon RE
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BarotraumaBarotraumaBarotraumaBarotrauma
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SqueezeSqueezeSqueezeSqueeze
MIDDLE EAR SQUEEZE
MIDDLE EAR OVERPRESSURE (REVERSE BLOCK)
EXTERNAL EAR SQUEEZE
SINUS SQUEEZE
SINUS OVER PRESSURE (REVERSE BLOCK)
TOOTH SQUEEZE (BARODONTALGIA)
BODY (SUIT) / FACE (MASK) SQUEEZE
STOMACH / INTESTINE
INNER EAR BAROTRAUMAS
PULMONARY OVER INFLATION SYNDROMES
MIDDLE EAR SQUEEZE
MIDDLE EAR OVERPRESSURE (REVERSE BLOCK)
EXTERNAL EAR SQUEEZE
SINUS SQUEEZE
SINUS OVER PRESSURE (REVERSE BLOCK)
TOOTH SQUEEZE (BARODONTALGIA)
BODY (SUIT) / FACE (MASK) SQUEEZE
STOMACH / INTESTINE
INNER EAR BAROTRAUMAS
PULMONARY OVER INFLATION SYNDROMES
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Sinus BarotraumaSinus BarotraumaSinus BarotraumaSinus Barotrauma
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PreventablePreventablePreventablePreventable
Ear Barotrauma Ear Barotrauma Ear Barotrauma Ear Barotrauma
Most frequent Most frequent diving injurydiving injury Common in novice diversCommon in novice divers Poor understanding ofPoor understanding of
equalization techniques equalization techniques Middle Ear Barotrauma is…Middle Ear Barotrauma is…
Most frequent Most frequent diving injurydiving injury Common in novice diversCommon in novice divers Poor understanding ofPoor understanding of
equalization techniques equalization techniques Middle Ear Barotrauma is…Middle Ear Barotrauma is…
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What is “Ear Fear”?What is “Ear Fear”?What is “Ear Fear”?What is “Ear Fear”?
Pressure perceived as Pressure perceived as “uncomfortable”“uncomfortable” Childhood pain Childhood pain adult fear adult fear Retrograde tear duct inflationRetrograde tear duct inflation Confusion over instructionsConfusion over instructions
Pressure perceived as Pressure perceived as “uncomfortable”“uncomfortable” Childhood pain Childhood pain adult fear adult fear Retrograde tear duct inflationRetrograde tear duct inflation Confusion over instructionsConfusion over instructions
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Assessing Valsalva EffectivenessAssessing Valsalva EffectivenessAssessing Valsalva EffectivenessAssessing Valsalva Effectiveness
Watch The Nose Inflate!Watch The Nose Inflate! Fingers low on noseFingers low on nose Palpate firmness of inflationPalpate firmness of inflation
and compare it to your own and compare it to your own pressurization effortpressurization effort
Watch the Watch the pars flaccida pars flaccida of the of the Tympanic Membrane balloon out,Tympanic Membrane balloon out,““like a sail catching the wind”like a sail catching the wind”
Watch The Nose Inflate!Watch The Nose Inflate! Fingers low on noseFingers low on nose Palpate firmness of inflationPalpate firmness of inflation
and compare it to your own and compare it to your own pressurization effortpressurization effort
Watch the Watch the pars flaccida pars flaccida of the of the Tympanic Membrane balloon out,Tympanic Membrane balloon out,““like a sail catching the wind”like a sail catching the wind”
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Normal EarNormal EarNormal EarNormal Ear
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HemotympanumHemotympanumHemotympanumHemotympanum
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Video OtoscopyVideo OtoscopyVideo OtoscopyVideo Otoscopy
divingdoc.comdivingdoc.comdivingdoc.comdivingdoc.com
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Ear Clearing TechniquesEar Clearing TechniquesEar Clearing TechniquesEar Clearing Techniques
Valsalva Maneuver (1704)Valsalva Maneuver (1704) Frenzel Maneuver (1932)Frenzel Maneuver (1932)
throat pistonthroat piston BTV (Voluntary Tubal Opening)BTV (Voluntary Tubal Opening)
distilled yawndistilled yawn Lowry Technique (combinations)Lowry Technique (combinations)
pressurize and swallowpressurize and swallow pressurize and yawnpressurize and yawn
Valsalva Maneuver (1704)Valsalva Maneuver (1704) Frenzel Maneuver (1932)Frenzel Maneuver (1932)
throat pistonthroat piston BTV (Voluntary Tubal Opening)BTV (Voluntary Tubal Opening)
distilled yawndistilled yawn Lowry Technique (combinations)Lowry Technique (combinations)
pressurize and swallowpressurize and swallow pressurize and yawnpressurize and yawn
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Pulmonary IssuesPulmonary IssuesPulmonary IssuesPulmonary Issues
Air FlowAir Flow Air TrappingAir Trapping
Air FlowAir Flow Air TrappingAir Trapping
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Maximum Voluntary VentilationMaximum Voluntary Ventilationvs.vs.
Gas DensityGas Density
Maximum Voluntary VentilationMaximum Voluntary Ventilationvs.vs.
Gas DensityGas Density
00
2525
5050
7575
100100
00 5050 100100 150150 200200
Depth (fsw)Depth (fsw)
MVV MVV (fraction of 1 ATA)(fraction of 1 ATA)
Adapted from Moon REAdapted from Moon RE
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CXR - 1 view or 2?CXR - 1 view or 2?CXR - 1 view or 2?CXR - 1 view or 2?
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Bleb visible – Lat onlyBleb visible – Lat onlyBleb visible – Lat onlyBleb visible – Lat only
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CT viewCT viewCT viewCT view
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Chest CT after PBT in DiversChest CT after PBT in DiversChest CT after PBT in DiversChest CT after PBT in Divers
Reuter et al. Reuter et al. Br J RadiolBr J Radiol 70:440, 1997 70:440, 1997
0
5
10
N
Bulla/cystScarringInfiltrate/atelectasisNormal
AGEAGE PneumomediastinumPneumomediastinum
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Unrestricted Clearance ?Unrestricted Clearance ?Unrestricted Clearance ?Unrestricted Clearance ?
Normal exercise toleranceNormal exercise tolerance Normal PFTNormal PFT
Forced vital capacity (FVC)Forced vital capacity (FVC) Forced expiratory volume in 1 second (FEV)Forced expiratory volume in 1 second (FEV)11
No significant reversible obstructionNo significant reversible obstruction Improvement < 12% (BD)Improvement < 12% (BD) Change not greater than 200 cc (BD)Change not greater than 200 cc (BD)
Normal exercise toleranceNormal exercise tolerance Normal PFTNormal PFT
Forced vital capacity (FVC)Forced vital capacity (FVC) Forced expiratory volume in 1 second (FEV)Forced expiratory volume in 1 second (FEV)11
No significant reversible obstructionNo significant reversible obstruction Improvement < 12% (BD)Improvement < 12% (BD) Change not greater than 200 cc (BD)Change not greater than 200 cc (BD)
Moon REMoon RE
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Diving and AsthmaDiving and AsthmaDiving and AsthmaDiving and Asthma
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No symptoms attributable to asthmaNo symptoms attributable to asthma
Normal physical examNormal physical exam
Normal spirometry before and after exercise Normal spirometry before and after exercise provocative test with or without medicationprovocative test with or without medication
Recommendations for Diving with AsthmaRecommendations for Diving with AsthmaRecommendations for Diving with AsthmaRecommendations for Diving with Asthma
Elliott (Ed). Are Asthmatics Fit to Dive? UHMS, 1996Elliott (Ed). Are Asthmatics Fit to Dive? UHMS, 1996
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Seizure RiskSeizure RiskSeizure RiskSeizure Risk
Seizures underwater are likely to be fatalSeizures underwater are likely to be fatal
It is possible that the physiological It is possible that the physiological conditions during diving (hyperoxia, conditions during diving (hyperoxia, hypercapnia, immersion) could lower the hypercapnia, immersion) could lower the seizure thresholdseizure threshold
People with recurrent seizures should People with recurrent seizures should not divenot dive
Moon REMoon RE
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SeizureSeizureSeizureSeizure
50% of adults with new onset seizures, 50% of adults with new onset seizures, normal neurological exam and brain normal neurological exam and brain imaging will have another seizureimaging will have another seizure
Risk increased with family history, Risk increased with family history, abnormal EEG, previous head injuryabnormal EEG, previous head injury
14 years after a first seizure the risk of a 14 years after a first seizure the risk of a second one is several fold greater than in second one is several fold greater than in the general populationthe general population
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Coronary Artery DiseaseCoronary Artery DiseaseCoronary Artery DiseaseCoronary Artery Disease
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Recreational Diving Fatalities USARecreational Diving Fatalities USARecreational Diving Fatalities USARecreational Diving Fatalities USA
0
5
10
15
20
25
30
35
40
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Age (years)
An
nu
al F
ata
lity
Ra
te p
er
10
0,0
00
Male
Female
Moon REMoon RE
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Cause of DeathCause of DeathCause of DeathCause of Death
33%
62%
88%
93% 96%98% 100%
0
50
100
150
200
Drowning AGE Cardiac Trauma DCS LOC InappropriateGas
Fre
qu
en
cy
of
CO
D
0%
20%
40%
60%
80%
100%
Cu
mu
lati
ve
CO
D
33%
62%
88%
93% 96%98% 100%
0
50
100
150
200
Drowning AGE Cardiac Trauma DCS LOC InappropriateGas
Fre
qu
en
cy
of
CO
D
0%
20%
40%
60%
80%
100%
Cu
mu
lati
ve
CO
D
Denoble PJ, Caruso J, Dear G de L, Pieper CF, Vann RD, 2007Denoble PJ, Caruso J, Dear G de L, Pieper CF, Vann RD, 2007
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Redistribution of Blood During ImmersionRedistribution of Blood During ImmersionRedistribution of Blood During ImmersionRedistribution of Blood During Immersion
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Heart FailureHeart FailureHeart FailureHeart Failure
Immersion causes a displacement of 500-Immersion causes a displacement of 500-800 ml of blood from the legs into the thorax. 800 ml of blood from the legs into the thorax. This is even greater during cold water This is even greater during cold water immersionimmersion
If the patient’s ventricle is unlikely to tolerate If the patient’s ventricle is unlikely to tolerate a sudden 500 – 800 ml transfusion, diving a sudden 500 – 800 ml transfusion, diving (swimming?) should be restricted(swimming?) should be restricted
Moon REMoon RE
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Coronary Artery DiseaseCoronary Artery DiseaseCoronary Artery DiseaseCoronary Artery Disease Patients with coronary artery disease are at Patients with coronary artery disease are at
risk of myocardial infarction and sudden risk of myocardial infarction and sudden death (60%)death (60%)
Cardiac work is related to contractility, heart Cardiac work is related to contractility, heart rate, afterload and preload. Preload is rate, afterload and preload. Preload is higher during immersion than in the dryhigher during immersion than in the dry
No diving if CAD. If patient has risk factors No diving if CAD. If patient has risk factors for CAD, rule out with exercise test (13 for CAD, rule out with exercise test (13 METS)METS)
Moon REMoon RE
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Effect of Head and Torso Water Temperature Effect of Head and Torso Water Temperature on Hemodynamicson Hemodynamics
Effect of Head and Torso Water Temperature Effect of Head and Torso Water Temperature on Hemodynamicson Hemodynamics
Wester TE, et al. Wester TE, et al. J Appl PhysiolJ Appl Physiol 106: 691, 2009 106: 691, 2009
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Fitness to Dive: ObesityFitness to Dive: Obesity- 2004 Diving Report- 2004 Diving Report
Fitness to Dive: ObesityFitness to Dive: Obesity- 2004 Diving Report- 2004 Diving Report
NIH Definitions Based on BMINIH Definitions Based on BMI
0
10
20
30
40
50
60
Underweight Normal Overweight Obese
% o
f Pop
ulat
ion
FatalityInjuryPDE
Moon REMoon RE
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Stings & PuncturesStings & PuncturesStings & PuncturesStings & Punctures
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OUCH!OUCH!OUCH!OUCH!
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Jellyfish Jellyfish PrecautionsPrecautions
Jellyfish Jellyfish PrecautionsPrecautions
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Irukandji SyndromeIrukandji SyndromeIrukandji SyndromeIrukandji Syndrome
One of the most venomous jellyfishOne of the most venomous jellyfish Severe headache, backache, muscle pains, Severe headache, backache, muscle pains,
chest and abdominal pain, nausea and chest and abdominal pain, nausea and vomiting, sweating, hypertensionvomiting, sweating, hypertension
EXTREMELY painfulEXTREMELY painful"rip your skin off""rip your skin off"
One of the most venomous jellyfishOne of the most venomous jellyfish Severe headache, backache, muscle pains, Severe headache, backache, muscle pains,
chest and abdominal pain, nausea and chest and abdominal pain, nausea and vomiting, sweating, hypertensionvomiting, sweating, hypertension
EXTREMELY painfulEXTREMELY painful"rip your skin off""rip your skin off"
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Bubble TroubleBubble TroubleBubble TroubleBubble Trouble
Decompression SicknessDecompression Sickness
Arterial Gas EmbolismArterial Gas Embolism
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The BendsThe BendsThe BendsThe Bends
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DCSDCSDCSDCS
The condition caused by inert nitrogen gas The condition caused by inert nitrogen gas coming out of solution within the bodycoming out of solution within the body
In spite of more than a century of In spite of more than a century of investigation, the mechanisms underlying the investigation, the mechanisms underlying the various forms of DCS are far from clear various forms of DCS are far from clear
The condition caused by inert nitrogen gas The condition caused by inert nitrogen gas coming out of solution within the bodycoming out of solution within the body
In spite of more than a century of In spite of more than a century of investigation, the mechanisms underlying the investigation, the mechanisms underlying the various forms of DCS are far from clear various forms of DCS are far from clear
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VENOUS BUBBLEVENOUS BUBBLEHypothesisHypothesiscirca 1980’scirca 1980’s
VENOUS BUBBLEVENOUS BUBBLEHypothesisHypothesiscirca 1980’scirca 1980’s
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Mechanisms of DCSMechanisms of DCSMechanisms of DCSMechanisms of DCS
Bubble vascular occasionBubble vascular occasion - mechanical disruption- mechanical disruption
Endothelial injuryEndothelial injury - leukocyte adhesion, plasma loss- leukocyte adhesion, plasma loss
Tissue anoxiaTissue anoxia Reperfusion injuryReperfusion injury
- excitatory neurotransmitters- excitatory neurotransmitters - oxygen free radical damage- oxygen free radical damage
ApoptosisApoptosis - programmed cell death- programmed cell death
Bubble vascular occasionBubble vascular occasion - mechanical disruption- mechanical disruption
Endothelial injuryEndothelial injury - leukocyte adhesion, plasma loss- leukocyte adhesion, plasma loss
Tissue anoxiaTissue anoxia Reperfusion injuryReperfusion injury
- excitatory neurotransmitters- excitatory neurotransmitters - oxygen free radical damage- oxygen free radical damage
ApoptosisApoptosis - programmed cell death- programmed cell death
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Dive PlanDive Plan(mathematical precision?)(mathematical precision?)
Dive PlanDive Plan(mathematical precision?)(mathematical precision?)
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DCS symptom onsetDCS symptom onsetDCS symptom onsetDCS symptom onset
Time after dive Manifestations of DCS
1 hr 42%
3 hrs 60%
8 hrs 83%
24 hrs 98%
36 hrs 100%
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DCS NomenclatureDCS NomenclatureDCS NomenclatureDCS Nomenclature
Compressed Air Work 1960’sCompressed Air Work 1960’s Diving and Aerospace 1970’sDiving and Aerospace 1970’s
Type 1 (simple DCS)Type 1 (simple DCS) Type 2 (serious DCS)Type 2 (serious DCS)
DCI DCI manifestationsmanifestations 1980’s 1980’s
mild, moderate or severemild, moderate or severe
Compressed Air Work 1960’sCompressed Air Work 1960’s Diving and Aerospace 1970’sDiving and Aerospace 1970’s
Type 1 (simple DCS)Type 1 (simple DCS) Type 2 (serious DCS)Type 2 (serious DCS)
DCI DCI manifestationsmanifestations 1980’s 1980’s
mild, moderate or severemild, moderate or severe
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Symptom Cluster AnalysisSymptom Cluster Analysis1929 CASES OF DCS1929 CASES OF DCS
Symptom Cluster AnalysisSymptom Cluster Analysis1929 CASES OF DCS1929 CASES OF DCS
Ozyigit T, Egi S, Denoble P, Balestra C, AydinS, Vann R, Marroni A. Galatasaray University, Istanbul. Divers Alert Network. Haute EcolePaul Henri Spaak, Brussels, Istanbul University, Hyperbaric Center, Duke University, Durham NC
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0
5
10
15
20
25
30
35
Live-Aboard Shore/Day-Boat Cozumel DiveProfessionals
Scapa Flow Cold-Water Wreck
DC
S C
ases
per
10,
000
Div
es
19,909 dives
5,090 dives
16,356 dives
5,139 divesMean =
4 DCS/103
dives
Absolute DCS RiskAbsolute DCS Risk - 1995-2002 PDE Data - 1995-2002 PDE Data
Absolute DCS RiskAbsolute DCS Risk - 1995-2002 PDE Data - 1995-2002 PDE Data
Vann RDVann RD
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