A 33 yo  man presents to the ED with multiple complaints 2 hours after completing a scuba dive.  Which of the following symptoms indicates a need for recompression therapy?

  • Decreased hearing
  • Ear pain
  • Epistaxis
  • Knee pain
  • Petechial rash

Joint pain that begins after an ascent from diving is concerning for decompression sickness (DCS). The pain is usually in a single joint, most commonly the knee or shoulder. Decompression sickness is believed to be caused by bubbles of nitrogen coming out of solution within the vascular and musculoskeletal systems. Type I DCS is characterized by musculoskeletal pain and a rash typically described as “mottling.” Type II DCS is more serious and can involve the pulmonary, cardiovascular, neurologic, and vestibular systems. Both types of DCS are treated with rapid recompression therapy.

Decreased hearing, ear pain, epistaxis, and petechial rash are most likely caused by dysbarism of descent, when air is trapped in enclosed spaces and causes local trauma due to increased pressure at depth and “squeeze.” The most common location is in the middle ear, which can cause decreased hearing and ear pain. When the sinus ostia are obstructed, and air is trapped, facial pain and epistaxis can also result. Additionally, when there is air between the skin and the diver’s wetsuit, “suit squeeze” can result, causing a streaking, petechial rash from the local trauma.

How can you differentiate joint pain from decompression sickness from other musculosketal pain?The joint pain of decompression sickness is typically unrelieved, but not worsened with any movement.


1.Rosh Review Environmental Disorders Question 922656

2. Snyder B, Neuman T: Dysbarism and Complications of Diving, in Tintinalli, JE, Kelen, GD, Stapczynski, JS (eds): Emergency Medicine, A Comprehensive Study Guide, ed. 7. New York. McGraw-Hill. 2011. (Ch) 208: p.1368-1371.

May 2024