Download Bove and Davis' Diving Medicine 4th ed - A. Bove (Saunders, 2004) WW PDF

TitleBove and Davis' Diving Medicine 4th ed - A. Bove (Saunders, 2004) WW
File Size16.7 MB
Total Pages615
Table of Contents
Chapter 1 - A Short History of Diving and Diving Medicine.pdf
Chapter 2 - Diving Physics.pdf
Chapter 3 - Diving Equipment.pdf
Chapter 4 - Inert Gas Exchange and Bubbles.pdf
Chapter 5 - Breath-Hold Diving.pdf
Chapter 6 - Mixed-Gas Diving.pdf
Chapter 7 - Mechanisms and Risks of Decompression.pdf
Chapter 8 - Pathophysiology of Decompression Sickness.pdf
Chapter 9 - Pulmonary Barotrauma.pdf
Chapter 10 - Treatment of Decompression Illness.pdf
Chapter 11 - Inert Gas Narcosis and High-Pressure Nervous Syndrome.pdf
Chapter 12 - Toxicity of Oxygen, Carbon Dioxide, and Carbon Monoxide.pdf
Chapter 13 - Hypothermia.pdf
Chapter 14 - Near Drowning.pdf
Chapter 15 - Marine Animal Injuries.pdf
Chapter 16 - Marine Poisoning and Intoxication.pdf
Chapter 17 - Human Performance Underwater.pdf
Chapter 18 - Medical Supervision of Diving Operations.pdf
Chapter 19 - Women in Diving.pdf
Chapter 20 - Diving in the Elderly and the Young.pdf
Chapter 21 - Aseptic Necrosis of Bone.pdf
Chapter 22 - Ear and Sinus Problems in Diving.pdf
Chapter 23 - Neurologic Consequences of Diving.pdf
Chapter 24 - Pulmonary Disorders.pdf
Chapter 25 - Cardiovascular Disorders and Diving.pdf
Chapter 26 - Diabetes and Diving.pdf
Chapter 27 - Medical Evaluation for Sport Diving.pdf
Chapter 28 - Medical Evaluation of Working Divers.pdf
Chapter 29 - U.S. Navy Diving Equipment and Techniques.pdf
Appendix 1 - Pressure Conversion Table.pdf
Appendix 2 - Medical Examination Forms.pdf
Appendix 3 - Diving Medicine Physician's Kit for Remote Locations.pdf
Appendix 4 - Recommended Protocol for Diabetic Management During Recreational Scuba Diving.pdf
Document Text Contents
Page 307

cannot be immersed, as on the head or body,
hot packs may be applied. The total duration
of the hot water immersion depends on the
symptoms. If the injury site is removed and
the pain recurs, it should be reimmersed.
The wound should be thoroughly irrigated
(preferably with isotonic saline) and cleaned
after the immediate treatment is no longer
required. As an alternative, if other methods
are not available and if the therapist is pre-
pared to risk any legal repercussions, a small
incision can be made across the wound and
parallel to the long axis of the limb to encour-
age mild bleeding and to relieve pain. A liga-
ture or tourniquet is contraindicated. Local
vasoconstriction is already a hazard to tissue
vascularity without aggravating it with
further circulatory restriction.

Medical treatment includes first aid as
described. If injected through the puncture
wound, a local anesthetic, e.g., 5 to 10 mL
lidocaine 1% without adrenaline (epineph-
rine), affords considerable relief. It may need
to be repeated frequently, possibly within
the hour. Local or regional anesthetic blocks
may also be of value. Treatment may be
needed for generalized symptoms of cardio-
genic shock or respiratory depression. Sys-
temic analgesics or narcotics are rarely
needed, although they may be of value in
severe cases.

Local cleansing and debridement of the
wound, with removal of any broken spines or
their integuments, is best followed by the
application of a local antibiotic such as
neomycin or bacitracin. Tetanus prophylaxis
may be indicated if there is necrotic tissue or
if the wound has been contaminated. If the
stings are severe, they can mimic the lesions
described under the headings of stonefish or
stingray. The treatment sections of these
injuries should be referred to because the
principles (other than the use of antivenom)
apply generally to all fish stings. Cellulitis,
abscesses, and osteomyelitis were not rare
in the pre-antibiotic era.



Perhaps the most venomous fish known,
stonefish (Fig. 15–7) inhabit the whole tropi-

cal Indo-Pacific region. Many species similar
to Synanceja verrucosa and S. trachynis are
found in other tropical areas. Some of the
Scorpaenidae, such as the spotted scorpion-
fish of the Caribbean, probably have compa-
rable toxicity.7

This fish grows to about 30 cm in length. It
lies dormant in shallow waters, buried in
mud, coral, or rocks, and is practically
indistinguishable from the surroundings. It
can catch a small passing fish by sucking it
into its gaping mouth. The 13 dorsal spines,
capable of piercing wet suit booties, sneak-
ers and skin, become erect when the fish
is disturbed. Apart from the tip of the
spine, the fish is covered by loose skin or
integument. When pressure is applied, two
venom glands discharge along ducts on
each spine into the penetrated wound. Each
spine has 5 to 10 mg of venom that can be
neutralized by 1 mL of antivenom produced
by the Australian Commonwealth Serum
Laboratories. Occasionally, a stonefish spine
is associated with no venom. It is thought
that the venom is regenerated very slowly, if
at all. The fish may live for many hours out of
the water.

The venom is an unstable protein, with a
pH of 6.0 and a molecular weight of 150,000.
It produces an intense vasoconstriction and
therefore tends to localize itself. It is
destroyed by heat (2 min at 50°C), alkalis and
acids (pH > 9 or < 4), potassium perman-
ganate, and Congo red. The toxin is a
myotoxin that acts on skeletal, involuntary,
and cardiac muscles, blocking conduction
in these tissues. It releases acetylcholine,

Chapter 15 Marine Animal Injuries 303

Figure 15–7. Stonefish (Scorpaenea plumieri). This
species is prevalent along the Atlantic coast from
Massachusetts to Brazil. They are very difficult to
locate because of their perfect camouflage. (Photo
courtesy of Paul Cianci, MD.)

Page 308

substance P, and cyclooxygenase. This
results in a muscular paralysis, respiratory
depression, peripheral vasodilation, shock,
and cardiac arrest. The toxin also can
produce cardiac arrhythmias.


Whether local or general symptoms predom-
inate seems to depend on many factors, such
as the geographic locality, number of spines
involved, depth of spine penetration, protec-
tive covering, previous sting, and first aid

Immediate pain is noted. This increases in
severity over the ensuing 10 min or more.
The pain, which is excruciating, may be
sufficient in some cases to cause uncon-
sciousness and thus drowning. Sometimes
the pain comes in waves, a few minutes
apart. Ischemia of the area is followed by
cyanosis, which is probably due to local
circulatory stasis. The area becomes swollen
and edematous, often hot, with numbness in
the center and extreme tenderness around
the periphery. The edema and swelling may
be gross, extending up the limb. Paralysis of
the adjacent muscles is said to immobilize
the limb, as may pain. The pain is likely to
spread proximally to the regional lymph
glands, e.g., in the axilla or groin. Both the
pain and the other signs of inflammation may
last for many days; delayed healing, necrosis,
and ulceration may persist for many months.
Swelling can likewise continue, although to a
gradually lessening degree. These long-term
sequelae are not as common in patients
treated correctly in the first few days with
antitoxin, debridement, cleansing, and local

Signs of mild cardiovascular collapse are not
uncommon. Pallor, gross sweating, hypoten-
sion, and syncope on standing may be
present. Respiratory failure may be due to
pulmonary edema, depression of the respira-
tory center, cardiac failure, paralysis of the
respiratory musculature, or a combination
thereof. Bradycardia, cardiac arrhythmias,
and arrest are also possible. Malaise, exhaus-

tion, fever, and shivering may progress to
delirium, incoordination, generalized paraly-
sis, convulsions, and death. Convalescence
may take many months and may be charac-
terized by periods of malaise and nausea.


See the earlier discussion of fish stings.

Medical treatment depends on the site and
severity of the symptoms. A local anesthetic
agent without adrenaline, infiltrated into and
around the wound, is the treatment of
choice, especially if administered early. It
may also remove the pain in the regional
lymphatic area. A repeat injection will
probably be needed and often reduces
central pains (probably lymphatic in origin).
Systemic analgesics and narcotics are
seldom indicated or useful, although intra-
venous narcotics are sometimes used.

Elevate the affected limb to reduce pain
and swelling and apply local antibiotics to
prevent secondary infection. After the initial
resuscitation and analgesia have been
effected, débridement of necrotic tissue
must be considered if there is any significant
tissue damage or embedding of integument
or spine. Otherwise, both local and general-
ized symptoms can continue for many
months. Even when treatment has been
inadequate or delayed, surgical excision of
the damaged area may be necessary to
reduce symptoms and hasten recovery.
Ultrasound or another imaging technique is
used to localize foreign bodies, although
they are not excluded by a negative result.

Stonefish antivenom may be administered.
One mL neutralizes 10 mg of venom (i.e., the
venom from one spine). Initially, 2 mL of
antivenom is given intramuscularly, although
in severe cases the intravenous route can be
used. Further doses can be given if required,
but antivenom should never be given to
patients with horse serum allergy. Anti-
venom should be stored between 0° and 5°C
but not frozen, protected from light, and
used immediately on opening. Tetanus pro-
phylaxis is sometimes needed, and systemic
antibiotics may be used because secondary
infection is likely.

304 Chapter 15 Marine Animal Injuries

Page 614

alternobaric. See Alternobaric

vertigo (ABV).
associated with diving, 369–374,

after surfacing, 373t
alternobaric, 352, 357, 362t, 372,

caloric, 353, 371–372, 514,

causes of, 370, 513–514, 514t
central versus peripheral,

371–374, 372t
cerebral arterial gas embolism

and, 374
CNS oxygen toxicity and, 374
decompression sickness and,

differential diagnosis of,

371–374, 372t, 373t, 512
during ascent, 357, 362t
during descent, 352, 362t, 517
eye pursuit evaluation, 371, 372t
general balance evaluation, 370
high-pressure liquid

chromatography and, 374
incidence of, 369–370
inert-gas isobaric

counterdiffusion and, 374
inner-ear barotrauma and, 373t

with perilymph fistula, 372–373
without perilymph fistula, 373

nitrogen narcosis and, 374
auditory evaluation, 370–371,

372t, 373t, 513
diagnostic testing for, 513
medical history/medications and,

neurologic evaluation for, 371,

372t, 373t, 513
nystagmus evaluation for, 373t,

positional, 370–371, 372t
spontaneous, 370, 372t

pathophysiology of, 512
physical examination for, 370–371,

symptoms of true, 370, 372t,

Vestibular system

anatomy and physiology of,
509–510, 509f

decompression sickness of,
132–133, 133f–134f, 176, 468

evaluation of for diving, 531–532
historical diving considerations

of, 507–508, 522
unequal stimulation vs. unequal

response of, 514, 521–522
VGE. See Venous gas embolism

Vibrio infections, from coral cuts,

Vinegar irrigation, for jellyfish

stings, 310
Virus(es), in marine poisonings, 324
Viscous adhesion, gas bubble

formation and, 68, 69f
Visibility, in underwater

performance, 332

Vision loss, from oxygen toxicity
irreversible, 244–245
reversible, 245
with hyperbaric oxygenation,

Visual acuity

evaluation of for diving, 523, 534,

underwater performance and,

Visual distortion, underwater, 37, 332
Visual field

oxygen toxicity impact on, 245
restrictions of, with diving masks,

underwater performance and,

Vital capacity (VC)

immersion impact on, 78–79
lung disorders impact on, 478,

with breath-hold diving, 83, 85, 88
with whole-body oxygen toxicity,

Vitamin E therapy, for retrolental

fibroplasia, 244
Volume, in diving physics, 13, 14,

changes as function of depth, 29,

changes as function of pressure,

28–29, 29f

from fish poisons, 166, 166t, 323
in near drowning, 277

Vulnerability, impact on underwater
performance, 337, 338–339

VVAL 18 decompression algorithm,

V-values, in exponential-linear
decompression model, 67, 67f

evaluation of for diving, 527–528,

for cardiovascular disorders, 503

Warm-water diving
by elderly divers, 414
decompression sickness risks

with, 132, 141–142
Navy-wide Interim Guidelines for,

567–568, 567t
Watch test, for hearing loss, 512

as underwater performance
medium, 331–332

aspiration of, during drowning,
276–278, 278t

gas cylinder capacity for, 28
in diving gases, 13, 19b–20b, 20
propagation of sound in, 22
refraction index of, 37
thermal conductivity coefficient

of, 566
transmission of light in, 21–22

Water intake
for decompression illness, 211–212
in heat balance, 261–262, 262f

622 Index

Water temperature. See Cold-water
diving; Warm-water diving.

Water vapor, partial pressure of
gas bubble formation and, 68–69,

in oxygen window, 62–65, 63f–64f,

Weber test, for hearing loss, 375,

375t, 511
Weight, in diving physics, 12–13, 14f,

Weight belts and weighting

adjusting for buoyancy
compensators, 46–47

for breath-hold diving, 77, 78t
for pregnant divers, 402
training on, 336, 338

Weight loss, in women athletes,
381–382, 384

Weight-bearing exercise
by women

bone development and, 384
pregnancy and, 467

osteonecrosis and, 428
Weightlessness, in underwater

performance, 332
Welding chamber, 122
Well-stirred tissue, nitrogen

exchange in, 55, 56f, 65
Wet suits

hypothermia protection with, 268,
269, 566

impact on buoyancy, 16
materials used for, 48

for shark-resistance, 292
selection of, 348, 350
thickness factors of, 48, 48f–49f

Wheezing, with asthma, 478
WHI (Women’s Health Initiative),

405–406, 405t
Whiplash, in women divers, 382
Whistling, for breath-hold diving, 84
White matter

carbon monoxide toxicity impact
on, 251

gas bubble embolism of, 462
autochthonous hypothesis,

171–174, 172f
hemorrhage with, 168–169,

170–171, 173
Whole-body oxygen toxicity, in

mixed-gas diving, 105–106, 106f,

Wolff-Parkinson-White syndrome,
417, 500, 500f

Women divers, 381–406
accidents and injuries in, 394
anatomic and physiologic sex

differences affecting,

breast cancer and, 404
breast implants in, 403–404
breast surgery and, 403–404
contraception and, 396–399, 529

barrier methods, 399
evaluation of for diving, 529
implants, injectables, and

transdermal, 398–399
intrauterine devices, 399
oral agents, 396–398

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