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Symptoms and Signs of Decompression Sickness

Doctor's Notes on Scuba Diving: Barotrauma and Decompression Sickness

Barotrauma refers to injuries that arise from the pressure differences between areas of the body and the environment. Scuba divers may suffer from a particular type of barotrauma called decompression sickness, or “the bends.” While diving, water pressure causes body tissues to absorb nitrogen gas faster when a diver descends than when ascending to the surface. If a diver comes up to the surface too quickly, nitrogen gas bubbles form in body tissues rather than being exhaled. These nitrogen bubbles cause severe pain.

Symptoms of barotrauma include pain in the ear canal and blood from your ear, ear fullness, eardrum rupture, disorientation, nausea, vomiting, ringing in the ear, dizziness, hearing loss, sinus pressure or pain, nasal bleeding, "bloodshot" eyes and redness or bruising of the face under the mask, chest pain, cough, bloody cough, shortness of breath, abdominal fullness, colicky pain (severe pain with fluctuating severity), belching, flatulence, hoarseness, neck fullness, painful swallowing, loss of consciousness, paralysis, numbness, blindness, deafness, seizures, confusion, or difficulty speaking. Specific symptoms of decompression sickness include rashes, itching, bubbles under the skin, localized swelling, joint pain that worsens with movement and commonly involves the elbows and shoulders, paralysis, sensory disturbances, bladder problems, chest pain, cough, and shortness of breath.

Medical Author: John P. Cunha, DO, FACOEP
Medically Reviewed on 3/11/2019

Scuba Diving: Barotrauma and Decompression Sickness Symptoms

The doctor will gather information about the dive and perform a standard physical exam, paying particular attention to the areas of pain and nervous system.

Depending on the patient's condition, they may be referred immediately to a recompression (hyperbaric) chamber or may undergo further testing.

  • The patient's vital signs will be taken, measuring blood pressure, pulse, breathing rate, and temperature.
  • Doctors will do a pulse oximetry - an instrument that measures the level of oxygen in the blood - using a sensor on a finger or earlobe.
  • The most common initial treatments may be oxygen (through a face mask or a tube near the nose) and intravenous fluids.

Air embolism and decompression sickness usually will require recompression treatment and repeated physical examinations. After treatment, the doctor may recommend a specialized imaging study (CT scan or MRI) to further evaluate any neurological problems.

Chest pain and shortness of breath associated with pulmonary barotrauma may require an electrocardiogram (ECG) and a chest X-ray.

The doctor will inspect the patient's ear canal and eardrum if they have an ear squeeze, looking for physical signs that can range from no visible problems to a small amount of bleeding to eardrum rupture to heavy bleeding.

Any hearing loss or dizziness will probably require referral to an otolaryngologist (ear, nose, and throat specialist) or audiologist (hearing specialist). They will test the patient's hearing and balance systems to determine if they have suffered any inner ear problems.

You should consider the signs and symptoms of diving injuries with regard to your overall dive plan, including what part of the dive you were performing when the problems occurred.

  • The history of the dive is very important to medical personnel and should always be included when assistance is required.
    • Barotrauma such as squeezes will commonly occur during descent, and the symptoms will frequently prevent a diver from reaching the desired depth.
    • You will notice symptoms of aerogastralgia, pulmonary barotrauma, air embolism, and decompression sickness both during and after ascent.

The following are symptoms for specific pressure problems:

  • External ear squeeze: Pain in your ear canal and blood from your ear
  • Middle ear squeeze: Ear fullness, pain, eardrum rupture, disorientation, nausea, and vomiting
  • Inner ear barotrauma: Feeling that your ear is full, nausea, vomiting, ringing in the ear, dizziness, and hearing loss
  • Sinus squeeze: Sinus pressure, pain, or nasal bleeding
  • Face mask squeeze: "Bloodshot" eyes and redness or bruising of the face under the mask
  • Lung squeeze: Chest pain, cough, bloody cough, and shortness of breath
  • Aerogastralgia (gastric squeeze): Abdominal fullness, colicky pain (severe pain with fluctuating severity), belching, and flatulence (gas expelled through the anus).
  • Pulmonary barotrauma: Hoarseness, neck fullness, and chest pain several hours after diving. Shortness of breath, painful swallowing, and loss of consciousness also may occur.
  • Air embolism: Sudden loss of consciousness within 10 minutes of surfacing. Other symptoms include paralysis, numbness, blindness, deafness, dizziness, seizures, confusion, or difficulty speaking. The paralysis and numbness can involve several different parts of the body at the same time.
  • Decompression sickness: Rashes, itching, or bubbles under your skin
    • Lymphatic obstruction which can cause localized swelling
    • Musculoskeletal symptoms include joint pain that worsens with movement and commonly involves the elbows and shoulders
    • Nervous system after-effects include paralysis, sensory disturbances, and bladder problems, usually the inability to urinate.
    • Pulmonary symptoms include chest pain, cough, and shortness of breath.
    • Symptoms usually appear within 1 hour of surfacing but can be delayed up to 6 hours. In rare instances symptoms may not appear until 48 hours after the dive.
    • Flying in a commercial aircraft after diving may cause "the bends" to develop in the airplane because the cabin pressure is less than sea level pressure.

Sinus squeezes usually require oral and nasal decongestants. Antibiotics are usually recommended for a squeeze involving the frontal sinuses. Pain medication may also be prescribed.

Ear squeezes also require decongestants, both oral and long-acting nasal types. Antibiotics may be given if the patient had a rupture, a previous infection, or the diving occurred in polluted waters. Pain medication also may be prescribed.

Sinus squeezes usually require oral and nasal decongestants. Antibiotics are usually recommended for a squeeze involving the frontal sinuses. Pain medication may also be prescribed.

Ear squeezes also require decongestants, both oral and long-acting nasal types. Antibiotics may be given if the patient had a rupture, a previous infection, or the diving occurred in polluted waters. Pain medication also may be prescribed.

Scuba Diving: Barotrauma and Decompression Sickness Causes

Two different phenomena cause barotrauma:

  • The inability to equalize pressures
  • The effect of pressure on an enclosed volume
  • Decompression sickness is caused by the elevated pressures of the gas mixture inhaled underwater that diffuse into the body tissues, and then the inadequate diffusion of the gas from the tissues if the diver surfaces too quickly.
  • Middle ear squeezes occur because of obstruction of the Eustachian tube.
    • The most common cause is an upper respiratory infection (cold), creating congestion.
    • Other causes of obstruction include congestion caused by allergies or smoking, mucosal polyps, excessively aggressive Valsalva attempts, or previous facial injuries.
  • Factors that trigger sinus squeezes include a cold, sinusitis, or nasal polyps.
  • Contributing factors to aerogastralgia (swallowing air) include performing Valsalva maneuvers with the head down (which allows air swallowing), consuming carbonated beverages or heavy meals prior to diving, or chewing gum while diving.
  • Pulmonary barotrauma occurs from the diver holding their breath during ascent, which allows pressure to rise in the lungs.
    • The pressure increase results in rupture.
    • Air also may penetrate into the tissue around the lungs.
  • The classic description of a dive causing an air embolism is rapidly ascending to the surface because of panic.
  • Failure to make recommended decompression stops during ascent usually causes decompression sickness. Stops are based on diving tables or charts, which factor into account the depth, duration of the dive, and previous dives completed and give you guidelines on the proper rate of ascent.

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REFERENCE:

Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.

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