Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC!!

Transcription

1 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Diving Medicine USN Diver/SEAL Submarine Overview Tom Kersch CAPT, MC SEAL Deliver Vehicle Team 1 Pearl City, HI 1 Content Attestation I, Thomas Kersch, MD, hereby declare that the content for this activity, including any presentation of therapeutic options, is well balanced, unbiased, and to the extent possible, evidence-based. 2 Conflict of Interest Disclosure I have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content I am planning, developing, presenting, or evaluating. 3 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

2 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Hyperbaric Medicine Part I DCS, AGE and Treatment Table Considerations Brett B. Hart CAPT MC USN 4 Decompression Illness (DCI) Troubles with Bubbles DCI Physical signs and symptoms caused by inert gas emerging from solution Compressed gas at higher pressures of deeper depths saturates our tissues - Upon ascent bubbles come out of solution with lower pressure 5 (like opening a soda/beer) DCI Theory Troubles with Bubbles Type I DCS (decompression sickness) Joint Pain Skin Symptoms Lymphatic Symptoms Type II DCS Neurologic Symptoms Inner Ear Symptoms Cardiopulmonary Symptoms AGE (Arterial Gas Embolus) Neurologic Symptoms 6 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

3 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC DCI Theory Troubles with Bubbles -No laboratory and radiographic tests are used for the diagnosis of decompression sickness -Clinical diagnosis based on new symptoms, more common after a longer and deeper dive 7 DCI Treatment Considerations Rationale for Hyperbaric Oxygen in DCI Based on Diving Experience Mechanical Compression of Bubbles Improved Gas Diffusion Gradients Acute Ischemia Modulation with high partial pressure of Oxygen 8 DCI Treatment Considerations MK 1 / Mod 0 USN Solution 9 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

4 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Pulmonary Barotrauma POIS (Pulmonary Over- Inflation Syndrome) LT Jim Ripple (UMO/DMO) 10 Barotrauma Boyle s Law At constant Temperature, Volume varies inversely proportional to Pressure PV=k P1V1=P2V2 11 Definition Expansion of gas trapped in lung during decreasing ambient pressure (ascent) with rupture of lung tissue Increasing alveolar pressure 12 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

5 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Causes - ***Diving Related*** Breath-holding during ascent Inhaling while pushing purge button Free ascent training Rapid uncontrolled ascent (blow-up) Unconscious ascent Air trapped in lung Aggressive Valsalva after deep inspiration. Breathing compressed air in heavy seas 13 Air trapped in lung due to: Airway obstruction as in asthma Thick secretions Lung granulomas (sarcoidosis) Cysts and blebs o spontaneous pneumothorax, NPQ for diving 14 Depth considerations Can occur with 3-4 ft excursion in shallow water. May make larger excursions in deeper water It is the percent change in volume that matters not the absolute change in depth 15 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

6 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Pulmonary Overinflation 1 ATA 300 % Surface 2 ATA 150% 33 FSW 3 ATA 100 % 66 FSW 16 Clinical presentation Initial rupture of lung tissue with release of gas Gas may remain in lung tissue - migrate to pulmonary circulation - move to the pleural space - dissect along the bronchial tree into the mediastinum and subcutaneous tissues 17 ***Conditions resulting from POIS*** Arterial gas embolism Pneumothorax Mediastinal emphysema Subcutaneous emphysema Pneumopericardium 18 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

7 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC Arterial Gas Embolism Alveolar rupture with concomitant venous or capillary rupture. Air traverses pulmonary vein to left heart. Overwhelming bubble load that exceeds the filtering capacity of the pulmonary capillary bed. Venous gas emboli that enter systemic circulation via a R->L shunt (ie PFO) Regardless of mechanism, emboli are pumped out to the systemic circulation and distributed to all organs. 19 Arterial Gas Embolism CNS and Heart most susceptible to injury CVA sx most commonly caused by emboli to brain Emboli to coronary arteries may cause myocardial ischemia or infarction 20 Arterial Gas Embolism (AGE) ***Symptoms*** Ischemia of the organ involved Neurological symptoms Usually present within the first ten minutes of a surface interval 21 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

8 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC *AGE - Neurological Signs and Symptoms* Mental deficits including unconsciousness Lack of coordination Cranial nerve deficits Weakness or paralysis Sensory abnormalities 22 Treatment of AGE Emergent Symptoms are severe and involve cardiorespiratory and/or central nervous system Symptoms are progressive or relapsing Patient is obviously sick Signs are easily observed without examination Every attempt must be made to secure immediate treatment. 23 ***Recompression Therapy*** Compress to 60 FSW on O 2 100% If there is an adequate response at 60 FSW, complete TT6 with or without extensions If worsening, can press to depth of relief, up to 165 FSW 24 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii

9 Diving Medicine USN Diver/SEAL Submarine Overview / Tom Kersch, CAPT, MC SEAL Delivery Vehicle Team -1 Pearl City, HI Submarine (SSGN converted TRIDENT missile sub) with Two Dry Deck Shelters that house a SDV (mini sub) and two recompression chambers Divers assist in rigging up a launch and recovery system for SDV missions from the host submarine SEALs conduct mission and manuever SDV Mini ER/ICU set up with ventilator, defibrillator, Istat lab, ACLS drugs for remote operations, one board certified Diving MO and 5 corpsmen 25 Western Occupational Health Conference: September 25 28, 2013 / Sheraton Waikiki, Honolulu, Hawaii