Diving With Cirrhosis and Ascites

Cirrhosis and Ascites

Here's a query from a scuba instructor:

57 year old male, history of alcoholism & suffering cirrohsis of the liver. Very large, distended belly ( has the largest "outie" belly button you've ever seen! ), but otherwise not obese. Passed the N.A.U.I. pool test better than most of his classmates. Claims his drinking days are past & has non-diving physician, unrestricted approval to participate. No other medical contraindications noted on the standard N.A.U.I. medical questionaire. He is an educated man ( prof. engineer ) with previous sport diving experience years ago... What is your advice?

Answer:
It is highly likely that your diver has ascites (large quantities of free fluid in his abdomen surrounding his organs). In addition to his umbilical hernia (which can rupture easily under these circumstances) which has occurred in response to the excess pressure of the fluid - it is also highly likely that he has esophageal varices or dilated blood vessels in the lower end of his gullet.

Due to the effects of immersion on the blood supply of the body, during a dive blood is shunted from the periphery into the blood vessels of the gastrointestinal tract, liver and spleen. This would cause dilation and possible rupture of the esophageal varices with massive hemorrhage. Add to this the acid reflux changes that occur about the cardia (lower end of the gullet and upper stomach) due to the action of Boyle's law during ascent and we have a set up for rupture of not only the varices but the stomach.

This not just a theoretical possibility but has been reported.

Massive variceal bleeding caused by scuba diving.
Am J Gastroenterol. 2000 Dec;95(12):3677-8.
Nguyen MH, Ernsting KS, Proctor DD.
http://snipurl.com/3s76

Finally, cirrhosis of the liver to the extent that it causes ascites can have significant mental effects of obtundation of the intellect. Hepatic encephalopathy can cause apathy, confusion, disorientation, drowsiness and slurred speech. This alone would be dangerous enough to disallow diving.

Because of what I consider significant risk, I would not certify this person as fit to dive.

Immersion Hypothermia and Near-drowning

*This material can also be seen on the website, Scubadoc's Diving Medicine

What is hypothermia and near-drowning?

Hypothermia is a lowered body temperature less than 95 degrees F. Cold water near-drowning is considered a submersion accident often leading to unconsciousness or coma in water temperatures of 70 degrees F or less. A long submersion time is considered 4 to 6 minutes or greater. (See further discussion below)

Why is this important to scuba divers?

Decompression sickness or air embolism often lead to immersion hypothermia and cold water near-drowning as the natural consequences of these diving accidents.

How does this occur?

The body loses heat to the environment by:

• Conduction, the transfer of heat by direct contact with the water, air or ground
• Convection, the transfer of heat by air or water that moves away
• Radiation, the transfer of energy by non-particulate means, heat loss from an unprotected head
• Evaporation, conversion of water droplets (sweat) into water vapor, thereby absorbing calories of heat.

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IMMERSION HYPOTHERMIA

Why is hypothermia dangerous?

Hypothermia may be mild, moderate, or severe. The presentation may range from shivering and piloerection ("goosebumps"), to profound confusion, irreversible coma and death. Significant hypothermia begins at temperatures of 95 degrees F and below. The lowering of the body temperature occurs as the body is robbed of heat by the surroundings. Water conducts body heat away up to 26 times faster than air of the same temperature. Normal body functions slow down with decreasing heart rate, decreasing respiratory and metabolic rate. Thinking is impaired and speech becomes confused. Reflexes are slowed and muscles become stiff and unusable. Then dangerous life-threatening heart rhythms develop which are hard to reverse.

What is a 'diving reflex'?

On immersion in very cold water, reflex actions occur right away. There is sudden hyperventilation, an involuntary gasp, and a varying amount of diving response follows. The diving response is more evident in the very young (infants and toddlers); it consists of a slowing of the heart beat, a decrease or cessation of respiration and a dramatic change in the circulation of the blood with circulation only to the most inner core of the body, the heart, lungs and brain. The casual observer sees this victim as cold, blue and not breathing. These victims appear dead. Cold water immersion victims have been fully resuscitated when treated carefully with a variety of rewarming techniques ranging from warm blankets to complete cardiopulmonary bypass techniques in major hospitals.

Differences in cooling rates occur depending on the age of the victim, sex, body weight, protection worn, nutritional status, general health, specific diseases, water temperature, length of exposure, areas of exposed heat loss, rough versus calm seas, circumstances of the immersion and the "will to live".

*Remember: Immersion hypothermia should be considered part of most dive accidents.

The body loses its temperature in a variety of ways: in the water, after removal and during transport. Cold water immersion victims may look dead but may be entirely resuscitatable.

How can hypothermia victims be recognized?

SYMPTOMS AND SIGNS

1. SHIVERING
2. LOWERED BODY TEMPERATURE
3. COLD BLUE SKIN
4. SLOW HEARTBEAT
5. SLOW RESPIRATION
6. SLURRED SPEECH
7. CONFUSION
8. MUSCLE STIFFNESS
9. CARDIOPULMONARY ARREST

What can be done to assist the hypothermic victim?

TREATMENT

The basic goals of early care are to prevent cardiopulmonary arrest, stabilize the core temperature, then carefully transport the victim to definitive medical care.
1. Removethe patient from the cold environment.
2. Check the ABC's of airway adequacy, breathing and circulation. If acceptable, then we add a "D" as in ABCD: DEGREES - what is the body temperature? A low reading thermometer is commercially available (most clinical thermometers read to 94 degrees F only) and this should be part of an emergency kit. As always, if the patient is not breathing and the heart not beating, standard cardiopulmonary resuscitation (CPR) should be started immediately.
3. Prevent further heat loss. This is done by removing wet clothing, gentle drying of the skin, remove or cut off suits, covering the high heat loss areas of the body, e.g., the head and neck (accounts for 50% of the heat loss), the lateral thorax and groin areas.
4. Gentle handling is a must. As the body rewarms it gets colder first for a short time; this is known as afterdrop.

Why is 'afterdrop' so dangerous?

During this period the heart is very vulnerable to developing life threatening rhythm disturbances. Immediately after rescue the victim should be removed horizontally from the water and kept that way. A litter or stretcher should be used to carry the victim since unnecessary exercising, jumping, climbing or exertion may trigger the heart rhythm disturbance.

Victims may deny they are ill and want to decline medical care, or want to climb into ambulances or helicopters on their own. Remember their judgement may be clouded, and yours should prevail.

Afterdrop can be worsened by certain types of "field treatments", such as a cigarette, a hot cup of coffee and a drink of alcohol, all time-honored treatments. These all prolong the afterdrop and may not help the hypothermic victim recover. They should not be given to hypothermic individuals with core temperatures below 95 degrees F.

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COLD WATER NEAR-DROWNING

Are cold water near-drowning victims any different from warm water victims?

Submersion accidents which lead to unconsciousness in waters colder than 70 degrees F occur with regularity. Oxygen needs are much reduced when the body is cold, therefore a permanent brain damage from low oxygen states may not occur. A 60 minute cold water submersion victim has been fully resuscitated. Similar to the hypothermic victims above these nearly drowned individuals appear cold to touch, blue, with no respiration or evident circulation and their pupils are fixed and dilated.

What is the pathophysiology of drowning?

The principal physiologic consequence of immersion injury is prolonged low oxygen level in the blood (hypoxemia). After initial gasping, and possible aspiration, immersion stimulates hyperventilation, followed by voluntary cessation of breathing and a variable degree and duration of laryngospasm. This leads to hypoxemia. Depending upon the degree of hypoxemia and resultant acidosis, the patient may develop cardiac arrest and central nervous system (CNS) lack of blood supply (ischemia). Asphyxia leads to relaxation of the airway, which permits the lungs to fill with water in many individuals ("wet drowning"). Approximately 10-20% of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased. These victims do not aspirate any fluid ("dry drowning").

In young children suddenly immersed in cold water, the mammalian diving reflex may occur and produce apnea,
bradycardia, and vasoconstriction of nonessential vascular beds with shunting of blood to the coronary and cerebral circulation.

The target organ of submersion injury is the lung. Injury to other systems is largely secondary to hypoxia and ischemic acidosis. Fluid aspirated into the lungs produces vagally mediated pulmonary vasoconstriction and hypertension.

Freshwater moves rapidly across the alveolar-capillary membrane into the microcirculation. Surfactant destruction occurs, producing alveolar instability, atelectasis, and decreased compliance with marked ventilation/perfusion (V/Q) mismatching. As much as 75% of blood flow may circulate through hypoventilated lungs.

In salt water near drowning, surfactant washout occurs, and rapid exudation of protein-rich fluid into the alveoli and pulmonary interstitium is observed. Compliance is reduced, direct alveolar-capillary basement membrane damage is seen, and shunting occurs. This results in rapid production of serious hypoxia. Fluid-induced bronchospasm also may contribute to hypoxia.

What are some of the factors relating to surviving cold water near-drowning?

• Age of the patient - the younger the better the prognosis

• Length of submersion - the shorter the better

• Water temperature - the colder the better the survival

• CPR - if appropriately applied the better the survival

• Water Quality - the cleaner the better the survival

• Struggle - the more struggle the worse the results

• Other injuries - burn, blast, fractures reduce the survival

*Remember: Cold water near-drowning is more survivable than previously thought. Submersions as long as an hour can in some circumstances be fully resuscitated. Cold water may be protective to some body systems as oxygen needs are markedly reduced.

How can I recognize cold water near-drowning?

SIGNS and SYMPTOMS

1. COUGH, CLEAR TO FROTHY RED SPUTUM
2. BLUE SKIN COLOR
3. SHORTNESS OF BREATH
4. CONFUSION TO COMA
5. RESPIRATORY ARREST
6. CARDIAC ARREST

What is the early management of the diver with cold water near-drowning?

Quick Response

1. Remove from the water

2. Do not do a Heimlich Maneuver, as it may induce vomiting and aspiration.

3. ABC's of resuscitation, begin CPR if indicated.

4. Oxygenate.

5. Remove wet or constricting clothing, wet suits, etc.

6. Transport to the nearest medical facility, noting that if this is a diving accident a recompression chamber will be necessary. Decompression sickness or air embolism may have led to the cold water near-drowning in the first place and full resuscitation should be done inside the chamber to be successful.

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Thermal Protection and Hypothermia Considerations

Adapted from Martin J. Nemiroff, M.D.

Introduction

Thermal protection is paramount for undersea recreation, effective work, and military warfare needs. Heat loss is accentuated by many factors including the increased thermal conductivity of water as compared to air of the same temperature. The study of immersion hypothermia has increased survivability in downed pilots and aircrew, shipwreck victims, sport scuba enthusiasts, and near-drowned victims.

Where does the body lose heat ?

• Head, neck, axilla, and inguinal region, for the most part
• 50 % lost from the head and neck alone heat flux across the skull, blood vessels close to surface
• Remember children lose heat quicker because of ratio of body mass to skin surface

How does the body lose heat ?

• Conduction-the transfer of heat by direct contact with water, air or ground
• Convection-the transfer of heat by air or water that moves away
• Radiation-the transfer of energy by non-particulate means, heat loss from an unprotected head
• Evaporation conversion of water droplets (sweat) Into water vapor, thereby absorbing calories of heat

How do we protect these heat-loss areas?

• Create a micro-climate around body with insulators
• Waders, gloves, hats, boots, shoes
• Wet suits made of closed cell neoprene
• Dry Suits and under garments
• Clothing In layers, virtues are loose fitting, air trapping, no ligatures, belts, zippers
• Head coverings

What are some of the factors affecting how fast we lose heat?

• Water Temperature
• Outside Air Temperature (OAT)
• Wind, wind-chill
• Wave action, sea state
• Wet clothes versus dry (5 times greater loss)
• Body habitus
• Sexual differences
• Age
• Air versus water (water 25 times greater loss)
• Breathing Gas, air helium
• Activity level, breathing rate
• Fear, panic
• Tachycardia
• Fight or flight

What are some medications and conditions that increase heat loss?

• Beta blockers
• Phenothiazines
• Benzodiazepines
• Barbiturates
• Effect of alcohol
• Cigarettes
• Metabolic states, thyroid function, or other medications
• Sepsis
• Nutritional state
• Adaptation, "Polar Bear Clubs"
• Ability to shiver

Have there been any studies about cold immersion?

Modern studies

• University of Victoria "U-VIC" physical education majors; Determinants of effective working suits,
• U S Coast Guard Cape Disappointment and Cape May, New Jersey Studies; Special considerations for survival suits, flying suits

Prognostic Factors recently published:

• JAMA October 10, 1990 Vol 264, No. 14, Hyperkalemia a Prognostic Factor During Acute Severe Hypothermia
• JAMA ibid above. Editorial Some People Are Dead When They Are Cold And Dead.

*Outlines from Lectures presented at Medical Seminars, May, 1991
*Adapted from M.J. Nemiroff, M.D.

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Links

Antarctica Marine Research
Ice Rescue Training
SARBC - Hypothermial
Survival in Cold Water; Minnesota Sea Grant
Drowning

Diving in Polluted Waters

This material can also be seen on the website, Scubadoc's Diving Medicine

Water Pollution

As our rivers, lakes and shorelines become more heavily populated, our diving population has to become more aware of the potentially hazardous presence of pollution in the water. Collectively, our waterways and the sea have been traditional dumping grounds for pollutants of many types and degrees of danger. In 1991, a Los Angeles Times article indicated that 2000 U.S. beaches were closed due to sewage spills. California, as always, a leader had 745 closures with 588 occurring just in southern California. This was quite probably only a fraction of the closures that would have occurred if consistent and regular monitoring was being done across the board. The lack of any standardized program for monitoring our waterways is clearly a problem.

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Flush Areas?

Areas of special concern are harbors and similar areas which do not "flush" well; rivers, especially those with high levels of industry on the shores; sewage outfalls which go out to sea but are often overloaded and areas which have their deposits of soft, silty materials dropped as the currents reduce their velocities in dispersal areas. Heavy metal contamination, for example, has caused a major problem with the dredging of a large marina entrance due to the fact that hazardous levels of contaminants including heavy metals, have been identified in the silt and the material cannot be pumped or dumped deeper into the sea as is commonly done. It has been estimated that there are on the order of 15,000 chemical spills that enter our water areas each year in the U.S. alone. The contaminated areas are growing and now include many recreational diving areas as well as scientific study sites and search and rescue operations.

The health consequences of the water pollution have not been quantified by careful study but many local health professionals are concerned with infectious and immunosuppressed patients who are ocean swimmers, lifeguards and divers. Until adequate epidemiologic data is available the recourse would appear to be logically focused upon conservative practices in selecting dive sites and conditions.

This increase in areas of pollution is a worldwide problem and has effected many diving operations. Diving in polluted water requires additional precautions and, in many instances, sophisticated equipment and procedures. Avoiding diving in areas with high potential for pollution, particularly after heavy rains is fundamental in urban or industrialized areas.

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Microbial and Chemical Hazards

The problem centers around the fact that microbial and chemical hazards can affect the human body by skin contact, entry through orifices and invasion through the skin. The number of specific hazards and their relative severity is beyond the scope of this presentation. The following list was produced in the NOAA Manual and the details were obtained from the medical literature.

Vibrio - 34 species of this family of bacteria are known and cholera and El Tor vibriones are among those known to be pathogenic to man. Cholera vibriones have recently been found in Santa Monica Bay in California and have raised concerns although it is not known to have produced any disease. Other vibriones may be anaerobic and produce disease states such as purulent otitis, mastoiditis, and pulmonary gangrene. V. Proteus found in human fecal material is a common cause of diarrheal disease. V. Vulnificus is found in sea water.

Enterobacteria
Escherichia - found widely in nature, occasionally pathogenic to man, produces carotenoid pigments and can often be recognized by the orangish pus. E. coli, which has some pathogenic strains is often found in fecal material, and can produce urinary tract infection and epidemic diarrheal disease.

Shigella - produces dysentery
Salmonella - 1000 serotypes, ingestion can produce gastroenteritis including food poisoning, typhoid and paratyphoid.
Klebsiella - can produce pneumonia, rhinitis, respiratory infection.

Legionella - causes Legionnaires disease and Potomac fever. Perhaps inhibited in salt water.

Actinomycetes - causes a "ray fungus" actinomycosis an infectious disease in man which inflames lymph nodes, develops abscesses, can drain into the mouth causing damage to the peritoneum, liver and lungs.

Pseudomonas - pathogenic to man, "blue pus" formed by some pseudomonas infections can lead to a wide variety of infections including wound sepsis, endocarditis, pneumonia, meningitis. It is known to flourish in dark, warm, damp places, i.e. inside hoses, bladder compartments and similar places that are not cleansed after being infiltrated by contaminants.

Cryptosporidiosis is a gastrointestinal disease caused by the parasite Cryptosporidiumparvum, It causes severe diarrhea from getting the parasite in the mouth while drinking or swimming.

Viruses - infectious agents which can result in fevers (frequently severe), mononucleosis, and a wide range of disease states.

There are seven currently recognized hepatic viruses:

Type of virus	Route of Transmission	Comments
A	Fecal-oral	Common, no chronic component
B	Blood-borne	DNA virus, 5-10% chronic
C	Blood-borne	RNA virus, 50-80% chronic
D	Blood-borne	RNA, needs prior Hep B to exist
E	Fecal-oral	Asian, rare USA
F	Fecal-oral	Existence debated
G	Blood-borne	Being evaluated clinically

Parasites - many types with all manner of effects, all bad, can are found in polluted water. Cercaria, shistosomes are examples.

Chemicals - There are over 15,000 chemical spills in the U.S. waterways each year and many of these are releasing chemicals that are incompatible with man and the equipment that is worn.

As detailed information becomes available on this issue the divers will become sensitized to the need for preventive measures before, during and after diving. At present the scientific and public safety diving communities are developing techniques for isolating the diver from the potential problems and decontaminating all exposed elements of the diving equipment. It appears eminent that the recreational community will feel the need to exert greater care in the future.

It is becoming increasingly important to develop an understanding of the variations in the local conditions to which individuals expose themselves. Some areas become particularly hazardous following heavy rains, hot weather and windstorms. Local health authorities can usually be called for advice regarding any tests that have been performed and the results. They should also be able to identify areas of high concentrations of pollutants that should be avoided.

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What Measures can be taken?

When diving in areas where pollution is suspected or expected the following issues are worthy of evaluation.

1. The individual diver should consider the need for appropriate vaccinations and inoculations. Many of the diseases can be avoided if the individual has taken the appropriate "shots". Some that should be considered are:
Hepatitis A, B and C. (There is no vaccine currently available for Hepatitis C).
Cholera,
Polio
Tetanus.
Typhoid, Smallpox and Diphtheria

2. Pollution and filth are often associated. If the water contains obvious trash and garbage it is quite probably an unhealthful diving environment and another location should be selected. If the water looks nasty it probably is nasty!!

3. Many diseases have an incubation period before they exhibit symptoms. Medical advice is as close as the phone and early diagnosis and treatment can sometimes be improved if the Doctor understands that an individual may have been submerged in polluted water.

4. Information on chemical spills can be obtained from the Chemical Transportation Emergency Center (1 800 424 9300 US).

5. "When in doubt- Check about"

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What does NOAA recommend?

A basic procedure if one has to dive in high risk water involves reducing the exposure of the diver. NOAA has pioneered a sophisticated SOS (suit over suit) system that will virtually isolate the diver from any contact with the water. This system is somewhat complex inasmuch as it requires complete system integrity from the times the diver dresses out until the system has been decontaminated following the dive. Strict procedures are followed to ensure that the divers body does not contact the fluid in which it is immersed.

Previously, many public safety divers wore a single dry suit and a full face mask during their dives. However, Stephen Barsky now states that "Full-face masks only provide minimal protection and should only be used in environments where the pollutants are known, and do not pose a threat of death or permanent disability. In environments where the pollutants are not known, or where they lead to death or permanent disability, a helmet should be worn connected to a mating dry suit with mating dry gloves. This is considered the standard today." (See Reference below)

If good seals are involved and the diver is effectively rinsed, scrubbed down and rinsed again prior to breaking any existing seals, the probability of exposure to the pollutants can be minimized. Special care must be taken to clear hoses and fittings that interface with the life support system. A failure to rinse bladders and hoses which may later be linked to the divers mouth or lungs could provide a path to the host days after the dive. The use of snorkels, alternate air sources, oral inflation devices and hose connections should all be given careful attention since the can carry contaminants directly into the mouth. Positive pressure, "self bailing" breathing systems have definite advantages in that they resist flooding.

Recreational divers maybe well advised to place their regulator in their mouth and their mask over their nose before entering suspect water and keeping it there until they have safely exited the water where they can remove the regulator without needing to replace it.

Polluted water is a fact of our lives. The degree of pollution can only be mitigated through education and the "upstream" elimination of the sources of the contaminants. The attitude that careful rinsing of diving gear is a waste of time "cuz its just going to get wet again next time it is used" should probably be replaced with the attitude that one should begin every dive with clean gear.

References:
Glen Egstrom, Ph.D
Medical Seminars, Inc. 1992

Colwell, et.al. Microbial Hazards Of
Diving In Polluted Waters, Maryland Sea Grant
Publication UM-SG-TS-82-01.

Diving in High-Risk Environments, 3rd Edition
by Steven M. Barsky
Amazon.com
Paperback - 197 pages 3rd edition (December 15, 1999)
Hammerhead Press; ISBN: 0967430518