What is Barotrauma (Trauma in SCUBA Diving)?
Barotrauma refers to physical damage to body tissue caused by extreme pressure differences between a gas or fluid surrounding and an unventilated part of the body, like the sinuses or lungs, or even across different layers of tissue. This damage happens due to forces that compress or stretch the tissues. Frequently, this results in injuries to the sinuses or middle ear. However, it can also lead to injuries of the face or teeth, ruptures in the digestive system, lung collapse, lung bleeding, or pockets of air in the chest and beneath the skin.
In addition, tears in lung tissue can allow gas to enter the bloodstream. This can block blood flow in distant parts of the body or interfere with the normal functioning of organs.
What Causes Barotrauma (Trauma in SCUBA Diving)?
Boyle’s Law of Gases states that if you keep the temperature of a gas the same, the space it takes up and the pressure it exerts are closely related – when one increases, the other decreases. For example, if a balloon goes up into the sky, it will get bigger as the air pressure around it drops. Similarly, a diver who holds his breath will have the air in his lungs expand as he rises to the surface and the pressure from the water reduces.
At sea level, the atmosphere exerts a pressure of 14.7 pounds per square inch (psi), or 760mmHg, this is also referred to as one atmosphere (1 Atm or 1 Barr). When diving, due to the heaviness of water, the pressure increases an extra 1 Atm for every 33 feet of descent in seawater.
Barotrauma, or injury from changes in pressure, can happen while scuba diving, but also during activities like flying, mountain climbing, or skiing. This is often because of going up or coming down too fast. When diving, a diver can experience damage known as ‘squeezes,’ which happens when the body can’t adjust to pressure changes fast enough. This can affect the face mask, sinuses, teeth, or ears.
Damage from pressure changes can also happen on the way up from a dive. It can again affect the ears, sinuses and teeth, but the most serious issue is damage to the lungs. There’s a special case of barotrauma that can happen when someone has air pumped into their lungs mechanically. The most dangerous outcome of barotrauma is a tear in the tiny air sacs in the lungs, which can lead to air bubbles that can block circulation and potentially cause a stroke or heart problem.
People with asthma, sinusitis, dental problems, lung diseases, seizures, ear problems, fainting spells, panic disorders, and balance issues, as well as inexperienced or poorly trained divers, or those with issues with their Eustachian tubes (tubes connecting the middle ear to the upper throat) are at greater risk of barotrauma. People who are on life support with a mechanical ventilator are also at risk, especially if they have acute respiratory distress syndrome (ARDS), a severe lung condition.
Risk Factors and Frequency for Barotrauma (Trauma in SCUBA Diving)
Around five million people in the US are certified SCUBA divers. Each year, there are 500 to 1000 nonfatal diving injuries in the United States and Canada, many of which are due to barotrauma. The likelihood of diving injuries increases with age, alcohol consumption, obesity, specific health conditions like asthma and COPD, and chronic issues like sinusitis and ear infections.
Signs and Symptoms of Barotrauma (Trauma in SCUBA Diving)
When examining a patient with potential diving-related issues, it’s important to understand the conditions and events leading up to the dive. This can include factors like the weather, water conditions, and duration of the dive, as well as when symptoms first started. Symptoms can vary widely and may include everything from chest pain and difficulty breathing, to problems with balance or disorientation. Also, details about a person’s past medical history such as the presence of allergies, ear, sinus, or lung diseases can be relevant. It’s also important to know if the diver took any medications before the dive.
- The conditions during the dive
- When symptoms first appeared
- Presence of chest pain or difficulty breathing
- Problems with balance or disorientation
- Any issues with nasal or ear pressure
- Prior medical history and any medications taken
A thorough physical exam should include checking the sinuses, ears, and dental health, as well as conducting assessments of lung function and neurological status. Symptoms that may be cause for concern include things like rapid breathing, pain around the chest, or changes in voice, among others. Any signs of severe conditions, like a collapsed lung or abnormal heart sounds, require urgent medical attention.
- Check sinuses, ears, and dental health
- Assess lung and neurological function
- Look for signs of severe issues needing urgent care
Finally, any sign of nerve or brain issues (such as numbness, weakness, or confusion) would warrant a comprehensive neurological exam to look for possible arterial gas embolism. This is a serious condition where gas bubbles block blood flow, potentially causing stroke-like symptoms and needs to be ruled out in every diver showing neurological symptoms after a dive.
- Signs of nerve or brain issues
- Conduct a thorough neurological exam
- Check for possible arterial gas embolism
Testing for Barotrauma (Trauma in SCUBA Diving)
In diagnosing the problem, your doctor’s observations and your physical examination are of great importance. Lab tests may not grant much insight. However, an arterial blood gas test might be helpful if there’s a suspicion of an air embolism, as it can reveal any oxygen and carbon dioxide differences in your blood. Levels of creatine phosphokinase (CPK) and troponin-I increasing could point to more tissue damage because tiny gas bubbles are blocking blood flow in the heart.
You may also need an electrocardiogram (EKG) to check your heart. The EKG can track any heart rhythm issues or demonstrate signs of a fluid-filled sac around your heart. The doctor may also decide to perform an urgent chest x-ray if there’s a possibility of a collapsed lung, air-filled space in the chest or around the heart. If there is any concern that there might be air inside the heart, a bedside cardiac echo could be done immediately. If you come in with symptoms of a stroke or a deep unconscious state, then the doctor might order a Head CTA or MRA, which are specialized types of scans.
The TEED scale is used to classify ear injuries caused by changes in pressure. Grade I refers to minor inflammation of the ear drum, Grade II to a partial blood-filled ear drum, Grade III to a completely blood-filled ear drum, Grade IV to a bluish and swollen ear drum bleeding internally, and Grade V to a ruptured ear drum.
Treatment Options for Barotrauma (Trauma in SCUBA Diving)
For mild injuries like sinus squeeze and middle ear squeeze, treatments like NSAIDs, decongestants, or painkillers can be used as needed. Mild middle ear problems can be treated with steroids and decongestants, either topically or systemically. If the eardrum has ruptured, oral antibiotics and ear drops should be prescribed. Infections causing discharge from the ear should be treated with antibiotics and a referral to an ear, nose, and throat specialist should be obtained. Dental injuries should be assessed by a dentist, and dental abscesses may require antibiotics. Ruptures in the stomach or intestines require immediate treatment and likely surgery. Pulmonary barotrauma can be managed with rest and supplemental oxygen, and a collapsed lung may need decompression. Arterial gas emboli require urgent treatment in a hyperbaric chamber. During mechanical ventilation, precautions are taken to reduce the risk of pulmonary barotrauma and other complications.
What else can Barotrauma (Trauma in SCUBA Diving) be?
When a doctor is trying to figure out what’s wrong, several conditions might look similar to one another. For example:
- Heart problems like acute coronary syndrome or a heart attack (myocardial infarction)
- Drug misuse or overdose
- A severe asthma attack
- A stroke
- A blood clot in the lungs (pulmonary embolism)
- A head injury
- Extreme cold exposure (hypothermia)
- Shock, a serious condition causing low blood flow to the body
- Ear infections, either of the middle ear (otitis media) or the outer ear (otitis externa)
- Bacterial sinusitis, an infection of the sinuses
- A collapsed lung (pneumothorax)
- A lung infection (pneumonia)
- Sudden, severe abdominal pain (acute abdomen)
- Problems with the teeth such as cavities (dental caries) or infections
- Bubble in the bloodstream (arterial gas embolism)
- Decompression sickness, also known as ‘the bends’, which can occur after scuba diving
A doctor will need to run tests and ask about symptoms to work out which of these conditions might be causing a patient’s distress.
What to expect with Barotrauma (Trauma in SCUBA Diving)
The future outlook for barotrauma, a physical damage to body tissues due to a pressure difference, is generally positive. Most of these conditions naturally improve over time without needing treatment. Most injuries to the eardrum or external ear canal also tend to heal by themselves.
However, inner ear damage, especially if there is a leak or mixture of inner ear fluids, may result in chronic issues like hearing loss, dizziness, and ringing in the ears. In severe cases, a gas bubble in the artery (acute arterial gas embolism) could lead to a stroke, heart attack, or even death. If the gut ruptures, it can lead to severe infection and inflammation in the abdomen (septic shock and peritonitis).
