BackgroundThis is a 27-year-old who was recently certified in scuba diving approximately 3 weeks ago. He has had a couple open water dives since that time and was diving to 75 feet when his regulator started to free-flow. His buddy was an older diver, who is a certified dive master. The buddy provided him with an alternate air source. They both then began a normal ascent to approximately 30 feet where they got entangled in fishing line. At two feet of depth they could not ascend any further due to the line that had ensnared their fins. With the waves and the line, they basically became tied up in it.
It took the dive master a minute or two to cut the line and get untangled and then he realized that his buddy was hanging upside down, tangled in the line. He immediately cut him loose, got him back to the boat and started resuscitation as the victim was blue and not breathing.
The Coast Guard was called immediately while CPR was continued. Within several minutes, possibly 4-5, breathing resumed spontaneously. Patient also had spontaneous pulse.
The patient was air lifted from the dive boat to the nearby pier, at which point he was transported by ambulance to an emergency room. En route, he was breathing on his own and had stable vital signs.
At admission, he is now complaining of chest pain. He has no other complaints other than some nausea and the chest pain, which is fairly severe at approximately 8/10.
He did have some narcotics en route as well as oxygen. His arterial oxygen saturation was maintained in the 90s throughout his time in the emergency department and in transport.
Patient has a medical history of asthma treated with Albuterol inhaler prn.
He does have a history of smoking.
Physical ExaminationHe is currently alert and talkative. He is complaining of chest pain when he takes a deep breath. He has no numbness or tingling. He moves all four extremities and appears to have normal strength. His Cranial nerves II-XII appear to be intact. He has a few petechiae around his eyes and a purplish discoloration to the tip of his tongue consistent with a possible minor trauma or biting his tongue.
His dive profile to 75 feet for a total of 17 minutes is well within the approximately 36 minute no decompression limit. There ascent was controlled and this appears to be a submersion injury or near-drowning episode.
Observation for pulmonary dysfunction and deterioration and respiratory status over at least 12 hours is recommended. Continue anti-inflammatories and/or pain medications for his musculoskeletal chest pain, which is very obvious when this is palpated.
Diagnostic StudiesChest x-ray is reviewed revealing no evidence of pulmonary or air gas barotrauma. No gross evidence of fractured ribs.
EKG: Normal sinus rhythm.
LaboratoryElectrolytes are within normal limits with mild metabolic compensation for respiratory acidosis, which is resolving. His blood gas revealed a pH of 7.27, pCO2 47, pO2 169, base excess -5.6. White count 16.8 and hemoglobin 15.2. Troponin T less than 0.011. He did have a CK elevation of 525, likely due to his chest compressions. BUN and creatinine are within normal limits as are electrolytes.
I do not see at this time any indication for hyperbaric oxygen therapy. We will be available if there are further questions.
DiagnosisSubmersion injury. Post resuscitation.
Trauma service evaluation and observation recommended.