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Decompression sickness and other disorders related to rapid changes in environmental pressure are hazards for fliers and for divers who are involved in recreational diving (eg, scuba diving), deep-water exploration, rescue or salvage operations, or construction At low depths the greatly increased pressure (eg, at 30 meters [100 feet] the pressure is four times greater than at the surface) compresses the respiratory gases into the blood and other tissues During ascent from depths greater than 9 meters (30 feet), gases dissolved in the blood and other tissues escape as the external pressure decreases The appearance of symptoms depends on the depth and duration of submersion; the degree of physical exertion; the age, weight, and physical condition of the diver; and the rate of ascent The size and number of gas bubbles (notably nitrogen) escaping from the tissues depend on the difference between the atmospheric pressure and the partial pressure of the gas dissolved in the tissues The release of gas bubbles and (particularly) the location of their release determine the symptoms Predisposing factors include injury, right to left cardiac shunt, obesity, dehydration, alcoholic excess, hypoxia, some medications (eg, opioids, antihistamines), and cold Decompression sickness also occurs among fliers during rapid ascent from sea level to high altitudes when there is no adequate pressurizing protection Deep-sea and scuba divers may be vulnerable to air embolism if airplane travel is attempted too soon (within a few hours) after diving Asthma, pneumothorax, reduced pulmonary function, lung cysts, or thoracic trauma may be contraindications to diving

The range of clinical manifestations includes gas bubble formation in the joints ( bends ), cerebral or pulmonary decompression sickness, arterial gas embolism (cerebral, pulmonary), ear and sinus barotrauma, and dysbaric osteonecrosis Reported sequelae include hemiparesis, neurologic dysfunction, and bone damage The onset of acute decompression symptoms occurs within 30 minutes in half of cases and almost invariably within 6 hours Symptoms, which are highly variable, include pain (largely in the joints), headache, fatigue, numbness, confusion, pruritic rash, visual disturbances, nausea, vomiting, loss of hearing, weakness, paralysis, dizziness, vertigo, dyspnea, paresthesias, aphasia, and coma Pulmonary decompression sickness ( chokes ) presents with burning, pleuritic substernal pain; cough; and dyspnea

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Victims of near drowning who have had prolonged hypoxemia should remain under close hospital observation for 2 3 days after all supportive measures have been withdrawn and clinical and laboratory findings have been stable Residual complications of near drowning may include intellectual impairment, convulsive disorders, and pulmonary or cardiac disease

Olshaker JS Submersion Emerg Med Clin North Am 2004 May;22(2):357 67 [PMID: 15163572]

FIGURE 10-13

Early recognition and prompt treatment are extremely important Continuous administration of 100% oxygen is indicated as a first aid measure whether or not cyanosis is present Aspirin may be given for pain, but opioids should be used very cautiously, since they may obscure the patient s response to recompression Rapid transportation to a treatment facility for recompression, hyperbaric oxygen, hydration treatment of plasma deficits, and supportive measures is necessary not only to relieve symptoms but also to prevent permanent impairment It has been recommended, however, that decompression symptoms be treated whenever they are seen even up to 2 weeks post injury since it is still possible to reduce morbidity The clinician should be familiar with the nearest compression center The National Divers Alert Network at Duke University (919-684-8111 or wwwdiversalertnetworkorg) provides assistance in the management of underwater diving accidents

Benton PJ et al Diving medicine Travel Med Infect Dis 2006 May Jul;4(3-4):238 54 [PMID: 16887745] Bove AA et al Diving Medicine, 4th ed WB Saunders, 2003 DeGorordo A et al Diving emergencies Resuscitation 2003 Nov;59(2):171 80 [PMID: 14625107] Hamilton-Farrell M et al Barotrauma Injury 2004 Apr;35(4): 359 70 [PMID: 15037370] McMullin AM Scuba diving: What you and your patients need to know Cleve Clin J Med 2006 Aug;73(8):711 16 [PMID: 16913196]

Dacryocystitis is infection of the lacrimal sac due to obstruction of the nasolacrimal system It may be acute or chronic and occurs most often in infants and in persons over 40 years It is usually unilateral The usual infectious organisms are Staphylococcus aureus and -hemolytic streptococci in acute dacryocystitis and Staphylococcus epidermidis, anaerobic streptococci, or Candida albicans in chronic dacryocystitis Acute dacryocystitis is characterized by pain, swelling, tenderness, and redness in the tear sac area; purulent material may be expressed In chronic dacryocystitis, tearing and discharge are the principal signs, and mucus or pus may also be expressed Acute dacryocystitis responds well to systemic antibiotic therapy Surgical relief of the underlying obstruction is usually done electively but may be performed urgently in

Conjunctivitis is the most common eye disease It may be acute or chronic Most cases are due to bacterial (including gonococcal and chlamydial) or viral infection Other causes include keratoconjunctivitis sicca, allergy, chemical irritants, and deliberate self-harm The mode of transmission of infectious conjunctivitis is usually direct contact via fingers, towels, handkerchiefs, etc, to the fellow eye or to other persons It may be through contaminated eye drops Conjunctivitis must be differentiated from acute uveitis, acute glaucoma, and corneal disorders (Table 7 1)

The organisms isolated most commonly in bacterial conjunctivitis are staphylococci, streptococci (particularly S pneumo-

Acute Conjunctivitis Incidence Discharge Vision Pain Conjunctival injection Cornea Pupil size Pupillary light response Intraocular pressure Smear

Acute Uveitis Common None Often blurred Moderate Mainly circumcorneal Usually clear Small Poor Usually normal but may be low or elevated No organisms

Acute Glaucoma1 Uncommon None Markedly blurred Severe Mainly circumcorneal Steamy Moderately dilated and fixed None Markedly elevated No organisms

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