Diving Casualty Assessment - The Diver Clinic

The 4 R’s of Managing a DCI Injury

Recognise

Recognise symptoms

Respond

Respond with oxygen

Relay

Get expert advice

Recompress

Recompress early

The Diving Doctor diving casualty assessment process starts from the initial point of contact where a dive history and medical history is taken to allow the hyperbaric Doctor to make an initial judgement on the best course of action for the patient. In some cases patients are referred to other healthcare professionals or organisations, others will have transfer to the hyperbaric facility arranged for a direct physical examination.

Initial Assessment

Initial rapid assessment to identify and treat any immediate threat to life
The diver will be given high-flow oxygen where indicated
Intravenous access will be obtained where indicated
Catheterisation will be performed where indicated
Any additional tests required will be arranged, e.g. chest x ray, blood or urine tests
Patient monitoring commenced as required, e.g. pulse oximetry, ecg, blood pressure etc

History

The examining hyperbaric Doctor will then take a history – both of the dives carried out preceding the onset of any symptoms and your more general medical history.

By having the full dive history the Doctor can assess the level of gas loading and the level of risk associated with the dive(s). To obtain this the diver will be asked about:

Location and environmental conditions of the dives
Level of dive experience, any previous decompression illness
Depth, times, breathing gases, decompression carried out, ascent rates of the relevant dives
Gas consumption, how hard you were working – any other factors particular to the dive
Dive computers can be interrogated to check dive profiles where required
When did symptoms start – what were they
What treatment (if any) has the diver had prior to arrival

Physical Examination

Finally a physical assessment will be carried out looking at several specific areas for clinical signs of decompression illness.

DCI Type	Signs & Symptoms
Musculoskeletal Bubble Location: Mostly large joints: elbows, shoulders, hip, wrists, knees, ankles	Localised deep pain, ranging from mild to excruciating. Sometimes a dull ache, but rarely a sharp pain. Active and passive motion of the joint aggravates the pain. The pain may be reduced by bending the joint to find a more comfortable position. If caused by altitude, pain can occur immediately or up to many hours later.
Cutaneous Bubble Location: Skin	Itching, usually around the ears, face, neck, arms, and upper torso Sensation of tiny insects crawling over the skin (formication) Mottled or marbled skin usually around the shoulders, upper chest and abdomen. Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting oedema)
Neurologic Bubble Location: Brain	Altered sensation, tingling or numbness paraesthesia, increased sensitivity hyperaesthesia Confusion or memory loss amnesia Visual abnormalities Unexplained mood or behaviour changes Seizures, unconsciousness
Neurologic Bubble Location: Spinal cord	Ascending weakness or paralysis in the legs Urinary incontinence and fecal incontinence Girdling (also referred to as girdle, banding, or tightening feeling) around the abdominal region and/or chest
Constitutional Bubble Location: Whole body	Headache Unexplained fatigue Generalised malaise, poorly localised aches
Audiovestibular Bubble Location: Inner ear	Loss of balance Dizziness, vertigo, nausea, vomiting Hearing loss
Pulmonary Bubble Location: Lungs	Dry persistent cough Burning chest pain under the sternum, aggravated by breathing Shortness of breath

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