Case Presentation: We present a case of a 70 year old diet controlled hypertensive female, a New York State trained and licensed scuba diver, who presented to our emergency department with worsening headache after a rapid ascent from freshwater diving to approximately 60 feet.
Patient was reportedly close to surfacing when she panicked and made the remaining ascent swiftly. Upon surfacing she immediately had difficulty breathing, epistaxis, headache and cough. Soon after, the dyspnea and epistaxis resolved but her headache and cough persisted. She was subsequently taken to an outside facility by the emergency medical services.
There, she was found to have elevated cardiac enzymes and an electrocardiogram (EKG) showing ST depression in lateral leads on first line testing. She was given 325 milligrams of Aspirin and transferred to our hospital for higher level of care. Upon arrival, she complained of persistent left periorbital headache and cough but was otherwise asymptomatic. Besides routine labwork, a rapid bedside echocardiogram showed a left ventricular Ejection Fraction (EF) of 20-25% and a plain chest film showed pulmonary edema and bilateral pleural effusions. Because of the diving history, Hyperbaric Medicine was consulted along with cardiology.
The patient did not have any prior cardiac illness and took no medications at home. She also did not have any relevant family history of premature cardiac disease and was a non smoker. Given this low pre test probability for acute coronary syndrome coupled with the non ST elevation in the electrocardiogram, cardiology recommended against emergent coronary angiography. She was thereafter taken to the hyperbaric chamber and received a shortened protocol due to her poor ventricular function and risk of flash pulmonary edema.
After completing her hyperbaric treatment, a repeat echocardiogram the next day showed recovery of the left ventricular function with EF at 55-60% and no wall motion abnormalities. Without any form of dieresis, her repeat chest Roentgenogram showed resolution of the fluid overload and her EKG did not show any of the residual ST depression. Subsequent elective cardiac stress test done a month later was inconclusive for inducible ischemia and a cardiac catheterization was done which did not reveal significant coronary stenosis.
Discussion: Recreational scuba diving is increasing in popularity, and diving-related injuries have increased proportionally. Potential complications include hypothermia, barotrauma, nitrogen narcosis among others. Barotrauma can manifest as lung injury, including pneumothorax, arterial gas embolism, and ear or sinus injuries. Decompression sickness occurs with rapid ascent resulting in tissue gas tension exceeding the ambient pressure, leading to the liberation of free gas from the tissues in the form of bubbles which can alter organ function by blocking blood vessels, rupturing or compressing tissue, or activating clotting and inflammatory cascades. Treatment includes hydration, administration of 100 percent oxygen, and hyperbaric oxygen therapy.
Conclusions: Even though cardiac complications are less likely, it is still possible in injury related to ascent in Scuba as described above. In our patient’s case, Hyperbaric treatment was given priority over cardiac intervention with good outcome. A high index of suspicion and prompt management is thus necessary to manage potential devastating consequences.