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Diagnosis and management of diving accidents.

Humans experience significant physiological stresses while diving, which can result in disease on occasion. With the increasing popularity of sports diving, it is critical that both physicians and divers be aware of the spectrum of illness associated with diving. An overview of common diving-related disorders is presented. After a brief discussion of relevant physics principles, the clinical presentation of ear and sinus squeeze is covered along with preventive strategies and treatment. This is followed by a discussion of the pathophysiology, clinical settings, and manifestations of pulmonary barotrauma along with a review of the pathophysiology and presentation of decompression illness. Initial emergency measures and referral procedures for decompression related disorders are addressed. A brief discussion of recompression therapy is included.

Accidents↗

Mammary implants, diving, and altitude exposure.

Mammary implants were exposed to various simulated dive profiles followed by altitude exposures to stimulate aircraft travel and then were observed for bubble formation and volume changes. Minimal volume changes occurred after each dive. Numerous bubbles formed, however, reaching their maximum size in 3 hours. By comparison, when implants were exposed to high altitude following a dive exposure, significant volume changes occurred. This in vitro study showed that bubble formation and volume expansion occur after exposing implants to diving and altitude, but the circumstances required to produce these changes in vivo are extremely unlikely to occur normally.

Altitude↗

Paralysis from sport and diving accidents.

OBJECTIVE: To examine the causes of sport-related spinal cord injuries that developed into paraplegia or tetraplegia, and to compare data from different sports with previous studies in the same geographical region. DESIGN: A retrospective epidemiological study and comparison with previous studies. SETTING: The Orthopedic Department, specializing in the treatment and rehabilitation of paralyzed patients, at the University of Heidelberg, Germany. PARTICIPANTS: Between 1985 and 1997, 1,016 cases of traumatic spinal cord injury presented at the Orthopedic Department at the University of Heidelberg: 6.8% were caused by sport and 7.7% by diving accidents. MAIN OUTCOME MEASURES: Sport-related spinal cord injuries with paralysis. RESULTS: A total of 1.016 cases of traumatic spinal cord injury were reviewed. Of these, 14.5% were caused by sport accidents (n = 69) or diving accidents (n = 78). Age of patients ranged from 9 to 52 years. 83% were male. 77% of the patients developed tetraplegia, and 23%, paraplegia. 16 of the sport accidents resulted from downhill skiing, 9 resulted from horseback riding, 7 from modern air sports, 6 from gymnastics, 5 from trampolining, and 26 from other sports. Previous analyses had revealed that paraplegia had mainly occurred from gymnastics, trampolining, or high diving accidents. More recently, however, the number of serious spinal injuries caused by risk-filled sports such as hang gliding and paragliding has significantly increased (p = 0.095), as it has for horseback riding and skiing. Examinations have shown that all patients who were involved in diving accidents developed tetraplegia. An analysis of injury from specific sports is still under way. CONCLUSIONS: Analysis of accidents resulting in damage to the spinal cord in respect to different sports shows that sports that have become popular during the last 10 years show an increasing risk of injury. Modern air sports hold the most injuries. Injury-preventing strategies also are presented.

Accidents↗

Cartilage palisade tympanoplasty and diving.

OBJECTIVE: To determine whether a patient with a serious defect of the tympanic membrane (TM) will be able to dive after surgery. PATIENTS AND METHODS: The authors describe three patients who were divers with serious defects of the TM (more than 75% of TM). In all three cases, cartilage palisade tympanoplasty was used to reconstruct the TM. RESULTS: Six months after surgery, the patients passed clinical examinations, audiograms (hearing restored to normal), tympanometry (increased stiffness of the TM), and pressure tolerance tests in hyperbaric chamber (30-m immersion was simulated for 4 minutes), and they began to dive again. Approximately 2 years after the surgery, all three patients are able to dive without any difficulties. CONCLUSION: The authors conclude that patients can dive after cartilage palisade tympanoplasty.

Acoustic Impedance Tests↗

First records of dive durations for a hibernating sea turtle.

The first published record, from the early 1970s, of hibernation in sea turtles is based on the reports of the indigenous Indians and fishermen from Mexico, who hunted dormant green turtles (Chelonia mydas) in the Gulf of California. However, there were no successful attempts to investigate the biology of this particular behaviour further. Hence, data such as the exact duration and energetic requirements of dormant winter submergences are lacking. We used new satellite relay data loggers to obtain the first records of up to 7h long dives of a loggerhead turtle (Caretta caretta) overwintering in Greek waters. These represent the longest dives ever reported for a diving marine vertebrate. There is strong evidence that the dives were aerobic, because the turtle surfaced only for short intervals and before the calculated oxygen stores were depleted. This evidence suggests that the common belief that sea turtles hibernate underwater, as some freshwater turtles do, is incorrect.

Animal Migration↗

Lunar cycles in diel prey migrations exert a stronger effect on the diving of juveniles than adult Galápagos fur seals.

In our study of the development of diving in Galápagos fur seals, we analysed changes in diving activity and body mass trends over the lunar cycle. Based on previously observed lunar cycles in colony attendance patterns, we hypothesized a greater impact of prey migrations of deep scattering layer organisms on younger fur seals. Using electronic dive recorders, we determined that seals dived less and deeper on moonlit nights than at new moon, and incurred body mass losses. These changes in foraging over the lunar cycle correlate with the suppression of the vertical migration of prey by lunar light. All effects were more pronounced in juveniles than adult females, with greater relative mass loss during full moon, which must (i) negatively affect long-term juvenile growth rates, (ii) lengthen periods of maternal dependence, and (iii) contribute to the lowest reproductive rate reported for seals. This underlines the importance of studying ontogeny in order to understand life histories, and for determining the susceptibility of animal populations to fluctuations in food availability.

Animals↗

The effect of foraging parameters on the probability that a dive is successful.

In this paper, we investigate the foraging decisions of an animal that dives to obtain its food. It might seem reasonable to use the probability that the diver is successful in any dive as an indicator of habitat quality. We use a dynamic model of optimal prey choice to show that this interpretation of diving success is not generally valid. In particular, we show that diving success is not directly proportional to the overall rate of gain that can be achieved in an environment. Furthermore, some environmental factors can have a non-monotonic effect on the probability of success. For example, as the travel time to the foraging area increases, the probability of success may first increase and then decrease. We point out that the same conclusions are likely to apply in the context of mate choice, i.e. the probability of getting a mate may not be an indicator of the quality of the environment in terms of reproductive success.

Animals↗

U.K. deep diving trials.

Using a breathing medium of 40 kPa oxygen, remainder helium, 18 volunteer subjects participated in a series of 15 exposures to pressures equivalent to depths of 180-540 m s.w. The time of exposure at these pressures was mostly 2 days, except for the 540 m s.w. exposure, when 6 days were spent at full pressure. Compression procedures, based upon placing 'stages' at 60 m s.w. intervals, evolved with experience and proved to be a highly successful way of achieving acceptable pressure-time courses. Decompression combined slow linear release of pressure with overnight halts for sleep. On one occasion a depth of 660 m s.w. was reached by breathing 40 kPa oxygen, 10% nitrogen, remainder helium. Throughout all exposures, teams of investigators followed the changes in cardiovascular, respiratory, haematological, neurophysiological and metabolic status, and mental performance of the volunteers. Some major findings were that the neurophysiological and behavioural changes could be assigned to the motor, or vestibular, or cerebral, or autonomic systems, and were mainly first observed during compression. The subjects suffered, apparently from severe nitrogen narcosis, when breathing 10% (by volume) nitrogen in oxygen-helium at 420 m s.w. Lung ventilation was remarkably adaptable to the oxygen requirements of exercise at all depths, but cardiac output was adversely affected at 540 m s.w., particularly for heavier workloads. Ventilatory responses to carbon dioxide were significantly elevated after diving. Thermal balance was seen to be precarious, but nevertheless it was achieved by the normal subjective assessments of comfort. Water loss was affected by diminished evaporation from the skin. Skin temperature sensitivity was changed and took many days after the dives to return to normal. Energy requirements increased for work purposes, but basal metabolic rate was undisturbed. Body chemistry altered at pressures in excess of 300 m s.w., for example thyroid hormone and nitrogen balances were affected. No decompression sickness was encountered until the pressures were low, but marked haematological changes could occur during decompression. Every change that occurred during these dives reverted to normal, mostly before the end of the decompression. It is concluded that diving with oxygen-helium breathing mixtures to depths as great as 540 m s.w. can be effective and safe. An attempt is made to assess the physiological significance of the principal findings.

Adult↗

Evolution of subterranean diving beetles (Coleoptera: Dytiscidae: Hydroporini, Bidessini) in the arid zone of Australia.

Calcrete aquifers in arid inland Australia have recently been found to contain the world's most diverse assemblage of subterranean diving beetles (Coleoptera: Dytiscidae). In this study we test whether the adaptive shift hypothesis (ASH) or the climatic relict hypothesis (CRH) is the most likely mode of evolution for the Australian subterranean diving beetles by using a phylogeny based on two sequenced fragments of mitochondrial genes (CO1 and 16S-tRNA-ND1) and linearized using a relaxed molecular clock method. Most individual calcrete aquifers contain an assemblage of diving beetle species of distantly related lineages and/or a single pair of sister species that significantly differ in size and morphology. Evolutionary transitions from surface to subterranean life took place in a relatively small time frame between nine and four million years ago. Most of the variation in divergence times of the sympatric sister species is explained by the variation in latitude of the localities, which correlates with the onset of aridity from the north to the south and with an aridity maximum in the Early Pliocene (five mya). We conclude that individual calcrete aquifers were colonized by several distantly related diving beetle lineages. Several lines of evidence from molecular clock analyses support the CRH, indicating that all evolutionary transitions took place during the Late Miocene and Early Pliocene as a result of aridification.

Adaptation, Biological↗

The diving reflex in non-eosinophilic non-allergic rhinitis.

The usual nasal response to head submersion in aquatic mammals is an increase in resistance to airflow, the so-called diving reflex. Although less well developed in humans, it is nevertheless present. It is likely to occur due to a relative increase of parasympathetic over sympathetic control of the nasal vasculature. Non-eosinophilic non-allergic rhinitis is thought to be due to a similar imbalance and we have attempted to establish whether the diving reflex is abnormal in this condition. Sixteen normal subjects and 18 subjects with non-eosinophilic non-allergic rhinitis (NENAR) underwent simulated diving using the "cold face test'. Expiratory total nasal airway resistance (ETR) was measured before and after the test by means of active anterior rhinomanometry. There was no significant increase in ETR in the normal group but a significant increase in ETR in the NENAR group (pre-test median ETR-0.464 kPa.s.l(-1). post-test median ETR 0.667 kPa.s.l(-1), (Wilcoxon's signed rank test P < 0.05). The change in median ETR in the NENAR group was also significantly higher than the median change in ETR in the normal group (Mann-Whitney, extract probability P = 0.04). We conclude the nasal airway response to simulated diving in NENAR is abnormal.

Airway Resistance↗

Changes in sleep patterns during He-O2 saturation dives.

During simulated hyperbaric saturation diving experiments of He-O2 mixture at the depths of 150, 180 and 230 m the standard polysomnography of four divers, as well as their subjective feelings of fatigue, were recorded for 268 nights. In all three diving conditions, during the bottom period and the decompression period, wakes after sleep onset and Stage 1 sleep increased while Stage 4 sleep decreased. In deeper diving conditions stage 4 sleep tended to decrease and subjective feelings of fatigue increased. When the results are considered it can be assumed that the deeper the diving depths, the increased sleep disturbances and fatigue. However, it is believed that a fundamental sleep pattern will be maintained.

Adult↗

Colonization of professional divers by toxigenic Vibrio cholerae O1 and V. cholerae non-O1 at dive sites in the United States, Ukraine and Russia.

Vibrio cholerae, recognized as the causative agent of epidemic cholera, was isolated from healthy professional divers and from water samples collected at dive sites in the United States, Ukraine and Russia. Swabs of nose, ear and throat of divers and their tank regulators, i.e. the divers and their diving gear, were taken before and after routine dives. Blood samples were collected before and 30-60 days after each dive to measure IgG and IgA titers against the whole cell antigen of V. cholerae O1. Nine strains of V. cholerae O1 and nine strains of V. cholerae non-O1 were isolated during this study. These isolates were identified by conventional biochemical tests and indirect fluorescent antibody staining methods, using fluorescein isothiocyanate-labeled monoclonal antibody, COLTA, prepared against the 'A' antigenic factor of the lipopolysaccharide of V. cholerae O1, and serotyped by slide agglutination. Seven of the nine strains of V. cholerae O1 isolated and successfully cultured during the studies, were toxigenic by enzyme-linked immunosorbent assay and polymerase chain reaction. Analyses of IgG and IgA antibodies of the divers showed that most of the divers had prior exposure to V. cholerae O1. V. cholerae serotype non-O1 strains isolated during the study were found to be non-toxigenic.

Antibodies, Bacterial↗

The initiation and maintenance of bradycardia in a diving mammal, the muskrat, Ondatra zibethica.

1. The cardiac and respiratory responses shown by muskrats in both unrestrained and restrained dives have been compared with responses elicited by stimulation of a number of cardio-depressant receptor inputs, in an attempt to determine which are most important in initiating and maintaining diving bradycardia. 2. In unrestrained voluntary dives heart rate fell from 310 +/- 3 to 54 +/- 3 beats min-1 in 1 to 2 sec, which was significantly below that seen in dives by restrained unanaesthetized or anaesthetized animals. 3. Pouring water on the external nares during maintained artificial ventilation caused heart rate to decline to 76 +/- 12 beats min-1 after 1 sec. Flowing water through the internal nares caused apnoea, in the expiratory position, and bradycardia within one third of a second. Heart rate fell to 20 +/- 2 beats min-1, 1 sec after the start of water flow. Substituting saline for water reduced both the apnoeic and cardiac responses. Bilateral section of the maxillary branch of V and the inferior laryngeal (X) nerves completely abolished the cardiac and respiratory response to water flow. 4. Artificial ventilation throughout periods of nasal stimulation with water or saline reduced the bradycardia, although even the saline driven response could not be completely abolished. Lung deafferentation eliminated any direct effect of artificial ventilation on heart rate during nasal stimulation. 5. Lung deflation caused bradycardia within 0.97 +/- 0.17 sec, heart rate falling from 268 +/- 7 to 59 +/- 4 beats min-1. Bradycardia also occurred during maintained lung inflation but it was delayed for a period which varied from 6.8 +/- 1.8 sec at an inflation pressure of 0.5 kPa to 35 +/- 7 sec at 1.5 kPa. 6. Bradycardia caused by nasal water flow or lung deflation was unaffected by bilateral section of the sinus nerve. 7. Artificial ventilation of paralysed muskrats with 5% CO2 in N2 caused bradycardia when Pa, O2 reached 8.4 +/- 0.8 kPa and heart rate declined to 76 +/- 7 beats min-1 at 4 kPa. Bilateral section of the sinus nerve delayed bradycardia until Pa, O2 reached 4.5 +/- 0.5 kPa. 8. These results suggest that the cardiac response to submergence could be the expression of input from three groups of receptors, nasal, lung and carotid chemoreceptors, although it is not clear how they interact with one another to generate the cardiac responses displayed by unrestrained animals during submergence.

Animals↗

Pulmonary and circulatory adjustments determining the limits of depths in breathhold diving.

Data on pulmonary gas exchange were collected in breathhold dives to 90 feet in a tank and in open-sea breathhold dives to depths of 217.5 and 225 feet. Thoracic blood volume displacements were measured at depths of 25, 50, 90, and 130 feet, by use of the impedance plethysmograph. The open-sea dives were carried out with an average speed of descent of 3.95 feet per second and an average rate of ascent of 3.50 feet per second. End-dive alveolar oxygen tensions did not fall below 36 millimeters of mercury, while alveolar carbon dioxide tension did not rise above 40 millimeters of mercury except in one case. These findings indicate that for diver Croft, who has unusual lung capacity, neither hypoxia nor hypercapnia determined the depth limits under those conditions. At depths of 90 and 130 feet blood was forced into the thorax, amounting to 1047 and 850 milliliters respectively.

Adaptation, Physiological↗

Seal lungs collapse during free diving: evidence from arterial nitrogen tensions.

Arterial blood nitrogen tensions of free-diving Weddell seals (Leptonychotes weddelli) were measured by attaching a microprocessor-controlled blood pump and drawing samples at depth to determine how these marine mammals dive to great depths and ascend rapidly without developing decompression sickness. Forty-seven samples of arterial blood were obtained from four Weddell seals during free dives lasting up to 23 minutes to depths of 230 meters beneath the sea ice of McMurdo Sound, Antarctica. Peak arterial blood nitrogen tensions of between 2000 and 2500 millimeters of mercury were recorded at depths of 40 to 80 meters during descent, indicating that the seal's lung collapses by 25 to 50 meters. Then arterial blood nitrogen tensions slowly decreased to about 1500 millimeters of mercury at the surface. In a single dive, alveolar collapse and redistribution of blood nitrogen allow the seal to avoid nitrogen narcosis and decompression sickness.

Animals↗

Respiratory effects of a single saturation dive to 300 m.

Lung function and the response to exercise were monitored in seven diver/welders who took part in a test saturation dive to 300 m for an average duration of 12 days; decompression took an average of nine days. Immediately after the dive the forced vital capacity was increased above base line by on average 0.51, the forced expiratory volume by 0.281 and peak expiratory flow rate by 0.71 s-1. There was no change in flow rate at small lung volumes (FEF 75% FVC). Recovery was complete and appeared to have a half time of 28 days. Transfer factor of the lungs for carbon monoxide (TlCO) was reduced by on average 9.6% after the dive but while partial recovery occurred, the values at one year were on average lower than those observed initially. The reason is unclear. One subject developed transient oxygen toxicity with stiff lungs and increased ventilation and cardiac frequency during submaximal exercise; a second subject developed similar changes but without accompanying symptoms. There is need for detailed physiological surveillance of people undertaking deep dives; this should be undertaken in circumstances that permit accurate measurements and full subject cooperation.

Adult↗

Positive reform of tuna farm diving in South Australia in response to government intervention.

OBJECTIVES: Much of the tuna harvested in South Australia since 1990 has involved "farming" techniques requiring the use of divers. From 1993 to 1995, 17 divers from this industry were treated for decompression illness (DCI). In response, the State Government introduced corrective strategies. A decrease in the number of divers presenting for treatment was subsequently recorded. Consequently, the hypothesis was tested that the government intervention resulted in a decrease in the incidence of DCI in the industry and an improved clinical outcome of divers with DCI. METHODS: The incidence of treated DCI in tuna farm divers was estimated from the number of divers with DCI treated and the number of dives undertaken extrapolated from a survey of the industry in 1997-8. General health was measured in the tuna farm diving population by a valid and reliable self assessment questionnaire. The outcome of the divers treated for DCI was analysed with a modified clinical severity scoring system. RESULTS: The apparent incidence of treated DCI has decreased in tuna farm divers since the government intervention. The evidence supports a truly decreased incidence rather than underreporting. The general health of the tuna farm divers was skewed towards the asymptomatic end of the range, although health scores indicative of DCI were reported after 1.7% of the dives that did not result in recognised DCI. The clinical outcome of the divers treated since the intervention has improved, possibly because of earlier recognition of the disease and hence less time spent diving while having DCI. CONCLUSIONS: The government intervention in the tuna industry in South Australia has resulted in a reduced incidence of DCI in the industry.

Adult↗