A diver who recently ascended rapidly from about 30 feet reports difficulty breathing, cyanosis around the lips, and pink froth. What is the correct initial management and destination?

• A. Place him in a semi-sitting position, suction his mouth and nose, apply a CPAP device, and transport to the closest ED.
• B. Suction his mouth and nose, keep him supine and elevate his legs to prevent air bubbles from entering the brain, administer high-flow oxygen, and transport to a hyperbaric chamber.
• C. Position him supine with his head elevated 30°, suction mouth and nose, hyperventilate with a bag-valve mask, and contact medical control for further guidance.
• D. Suction his mouth and nose, apply high-flow oxygen, monitor the patient's breath sounds for a pneumothorax, and contact medical control regarding transport to a recompression facility.

Answer: (D)

Rapid ascent can cause decompression illness with circulating nitrogen bubbles that impair gas exchange and can lead to pulmonary barotrauma. The first priority is to maximize oxygen delivery and begin definitive treatment as quickly as possible.

Give high-flow oxygen to improve oxygenation and help dissolve nitrogen bubbles, and suction the airway to keep it clear. Then assess the chest for signs of pneumothorax by listening to breath sounds; a pneumothorax could worsen with certain therapies, and it changes the transport plan. Finally, contact medical control and arrange transport to a recompression (hyperbaric) facility—the treatment that directly reduces and dissolves nitrogen bubbles and is the standard of care for decompression illness.