Aşkın YILDIRIM

THE DANGERS OF DIVING AND THE MEANS TO AVOID THEM

Many people all over the world enjoy diving safely. Regulations and strict attention to protocols developed by Divers Alert Network and professional Association of Diving Instructors have made diving much safer and accessible to most people. Diving is however not without risk, and accidents or complications do occur. Listed below are the potential major perils associated with diving. We discuss each one briefly and instruct you on how to avoid or provide stabilizing treatments for these highly preventable problems. Importantly we need to warn you not to assume that an injury or symptom incurred while diving is diving-related. All injuries or problems need to be evaluated at a medical facility first and then if recompression treatment is necessary, arrangements will be made. A layperson may see a heart attack as an air embolism or a skin rash as the skin bends, etc.


Acute Decompression Illness ("The Bends")

Decompression illness occurs as a result of excessive gas bubble formation in tissues. These bubbles may form when ascent to the surface is done rapidly. As an illustration, it is like putting a wet Alka Seltzer tablet in the middle of your muscle tissue and allowing it to dissolve. As the gas bubbles formed they could cause pain and/or damage.

During a dive nitrogen or other common gases present in breathable air accumulate in body tissues, because the pressure under the sea is much greater than at the surface. The increased pressure at depth effectively “pushes” nitrogen or other inert gases into tissues. When you ascend to the surface slowly, gases are able to escape your tissues slowly and not form painful or damaging bubbles. The deeper and longer you dive, the more gas forms in your tissues. If you ascend rapidly nitrogen and other gases accumulate in your tissues in high concentrations and often form bubbles. If this happens tissue damage or pain may occur. The symptoms that occur from the bubbles lead to what is called acute decompression illness (DCI). If ascent is very rapid the bubbles often damage the lungs, leading to shortness of breath, coughing up blood, or chest pain. DCI from rapid ascent can lead to widespread bubble formation in the brain and spinal chord. Stupor, coma, and death may ensue. If ascent is slower and staged, yet still fast enough to result in bubble formation, a multitude of other symptoms may predominate (see below). Divers with DCI are placed in decompression chambers with high oxygen content for treatment. Chambers reapply gaseous pressure to your entire body. This keeps the gases in your tissues from escaping rapidly. The pressure is then slowly released, allowing the gas to escape your body in a controlled manner until it is safe to breathe air at normal surface pressures.


Factors that increase your risk of developing DCI

Missed or incomplete decompression: Most dives require staged ascents guided by established decompression tables. If the tables are not followed, bubbles may form.

Flying or altitude after diving: High altitudes (low atmospheric pressures) may result in existing bubble expansion or the formation of new bubbles. If you must fly shortly after a dive the cabin must be pressurized. We recommend that you wait at least a day. After deep or multiday dives wait 36 hours before you fly. For the same reasons, don’t hike a mountain after diving without a standard wait period. If you notice minor precursor signs of the bends, such as the feeling of pins and needles in an extremity or generalized fatigue or malaise, wait until you are feeling normal before you take on a high altitude.

Dehydration: Water loss leads to a lower blood volume. Thus, when you are dehydrated less blood is filtered through the lungs. This decreases the transport of gases to your lungs and hence your ability to exhale the gases from your body. This leads to more gases that are stuck in your tissues.

Alcohol: Causes dehydration.

Rapid ascents: Causes bubble formation in the tissues and blood. The recommended rate of safe ascent is 33 ft/min (A. Kayle, Safe Diving, 1994).

Exposure to heat: Promotes bubble formation (like boiling water). Avoid hot showers, Jacuzzis, or saunas after a dive.

Limb injury: Injury to an extremity produces swelling and circulatory compromise. This may impede gas release from injured tissues and lead to decompression illness in the injured limb (“limb decompression illness”).

Exercise: Increases body heat and thus bubble formation if done five hours before or six hours after a dive. Interestingly, vigorous exercise done 24 hours before a dive markedly decreases your risk of developing bubbles and DCI. The cause for this phenomenon is under investigation.

Obesity: Gases are stored more efficiently in fat, making obese persons capable of storing more nitrogen, etc. This may lead to excessive bubble formation.

Poor physical fitness: Divers should be in excellent physical shape. Oxygen and nitrogen carrying capacity is relatively compromised by poor physical fitness.

Caffeine: Causes dehydration.

How to recognize acute decompression illness

The symptoms of acute decompression illness depend on the body parts that are affected by trapped gas bubbles. If bubbles form in your knee you will have knee pain. If they form in a blood vessel to your heart you may have the symptoms of a heart attack, e.g., chest pain or shortness of breath. If they form in the brain slurred speech, altered mental status, visual disturbances, or limb weakness may occur. The process is also a dynamic one so it may be hard to pinpoint. Bubbles may form in one part of the body and later move somewhere else causing symptoms that may change in severity and location. If you feel or notice any physical abnormality that cannot be easily explained we recommend that you inform your dive master or captain and seek an evaluation from a dive physician before serious damage has occurred.

Acute decompression illness typically occurs on ascent or within 30 minutes of resurfacing. Within six hours 90 percent of cases have occurred. Within 12 hours 99 percent. Most cases affect the skin and joints (60 percent) and of the more serious cases, many manifest with central nervous system dysfunction.

According to statistics compiled at the Institute of Underwater and Hyperbaric Medicine (IUHM) from November 1996 and December 2002 the graph represents the symptoms of DCI and their incidence within a population of 150 divers treated for DCI.

Illnesses or problems that might mimic decompression illnesses include hyperventilation, a panic attack, a drug side effect or a stroke. An injury that occurred during diving, e.g., shoulder sprain from lifting a heavy tank, may be difficult to differentiate from DCI. Headache may be from an undiagnosed brain tumor. Never assume that a symptom is diving-related. Have a medical doctor evaluate all physical complaints or conditions.

Basic principles of decompression illness treatment

The most important principle of treatment is prevention. Follow your dive tables and do not ascend rapidly. Follow the advice listed above and avoid factors that increase bubble formation. Drink plenty of non-alcoholic, decaffeinated fluids.

If you do suspect that a diver is suffering from acute decompression illness follow these guidelines:
*Inform a dive physician
*Keep the diver calm, quiet, and lying flat at all times. Prop the diver’s head up 15°. If unconscious turn the diver on his or her left side.
*Administer 100 percent oxygen (if available).
*Encourage oral fluid intake if the diver is sufficiently conscious.
*Administer CPR if necessary.
*Administer an IV and start fluid resuscitation (if available).
*Transport to the decompression chamber or dive medicine facility.

Barotrauma (Ear and Lung) (Baro= pressure) (Trauma= damage)

Barotrauma is damage to tissues or organs caused by pressure. It occurs in diving when a rigid air-filled compartment within the body is subject to changes in pressure and the compartment cannot conform or contort itself to accommodate the change in pressure. Common rigid compartments in the body that may be injured are the sinus cavities of the face or the middle ear. Damage may be done to other air-filled compartments that are not as rigid if the compartment is subject to a rapid or large internal increase in pressure. The lungs are an example of an organ that may be damaged in this way.

Consider an air-filled beach ball or an empty, sealed tin can. The walls of the beach ball are easily stretched or compressed without causing damage. The walls of the tin can are much more rigid and do not stretch or compress. Atmospheric pressure (the pressure that surrounds you) below the water’s surface is higher than it is at sea level due to the dense weight of water. The deeper you go, the greater the atmospheric pressure. If you were to transport the ball and tin can from sea level to the ocean floor, the further you descended the higher the pressure would be on the walls of either object. In order to counteract the increase in external pressure, pressure within the object would also have to increase. One way to increase internal pressure is to decrease volume by compressing the walls of the object. The beach ball can collapse and not become damaged because its walls are flexible. At a depth of 100 meters, the ball would be much smaller (lower volume with a higher internal pressure) than at the surface. The rigid tin can would have a more difficult time responding to the increase in external pressure. As the tin can descended the external pressure on its rigid walls would increase, and eventually the walls would collapse or the can would “implode” on itself. If a small hole was made in the tin can, water would rush in, pressures would be equalized, and the walls of the can would not collapse. The middle ear is an air-filled, bone-walled cavity much like the tin can. On descent, without pressure equalization, the walls of the middle ear may collapse, the eardrum may break inwards, or blood vessels within the ear may burst to fill the middle ear with blood. Each of these events would result in equal pressure on the inside and outside of the compartment. To avoid such damage during descent you must facilitate air movement into the middle ear via pressure equalization techniques though the eustachian tube.

As you ascend to the surface, atmospheric pressure drops and the eardrum bulges out. To equalize pressure inside the middle ear compartment air must move out of the middle ear through the eustachian tube.

Air-filled cavities that may be injured by barotrauma during a dive are:
*The middle ear
*The lungs
*The sinus cavities of the face
*A segment of intestine
*A tooth with a cavity in the center
*Ear barotrauma

Trauma to the middle ear can occur on ascent or descent. The middle ear would be an entirely closed space were it not for a very thin tube that connects the middle ear to the back of the nasal passages (and thus the outside atmosphere). This channel, called the eustachian tube, must be kept open for there to be adequate drainage of air and fluids into and from the middle ear. Many children get frequent ear infections because the tube may not be very well developed until the age of about two or three. Fluids stagnate in the middle ear of these kids and infection may ensue. Divers must have an open eustachian tube for air to freely pass into the middle ear on descent or out of the middle ear on ascent. If the tube is clogged damage will occur to the walls of the middle ear or to the eardrum. Divers are taught equalizing techniques to move air into the middle ear on descent. These involve swallowing, the valsalva maneuver (holding your nose and closing the glottis while blowing), moving your jaws back and forth, or the Toynbee maneuver. Please refer to your dive instructor for further instruction. On ascent, techniques are used to move air out of the middle ear. If the diver does not attempt equalization techniques then barotrauma will occur.

Factors that interfere with a diver’s ability to move air into or out of the middle ear (eustachian tube dysfunction or blockage) include:
*Allergies
*Upper respiratory tract infections (e.g., a cold)
*Nasal polyps or tumors of the nasal passages
*Smoking
*Use of oral isotretinoin (Accutane™) an acne medication
*Signs and symptoms of middle ear barotraumas:
*Bleeding from the nasal passages (blood vessels have burst on descent)
*Ear pain
*Decreased hearing
*Temporary vertigo (dizziness) and/or nausea (if the eardrum has burst)
*Other damage to the ear

Pain may be experienced in the external ear canal or the eardrum may rupture if wax or earplugs obstruct the external canal. When closed to the outside world the external ear canal has become the closed space subject to the pressure changes of ascent and descent.

The inner ear may be damaged if excessive force is used to equalize middle ear pressures using standard techniques. This is a rare occurrence and typically happens only when there is obstruction of the eustachian tube that predisposes an individual to attempt excessively forceful equalization maneuvers.

Lung barotrauma
Barotrauma of the lungs is not as common as other pressure-related traumas that may affect any of the body’s other air-filled cavities. The lungs are very effective at pressure equalization during normal breathing without special maneuvers. With a few exceptions, lung barotrauma during descent, called chest squeeze, may be experienced by divers holding their breath, by divers on very deep dives or by divers who descend too rapidly. If barotrauma does occur on descent it is characterized by bleeding into the lungs and subsequent difficulty breathing and/or shortness of breath. If severe, it can lead to hypoxia (low oxygen), confusion, stupor, and death.

Lung burst describes the trauma that may affect the lungs during ascent. On ascent, atmospheric pressure decreases and volume within the lung increases. As long as air is released via normal breathing, pressures are equalized and the lungs are not damaged. Under certain conditions, air may be trapped within the small breathing units (alveoli) of the lung despite normal respiration. If an alveoli traps air that cannot be released during normal breathing the alveoli may burst on ascent. If an alveolus bursts, air can escape into the space that surrounds the lung (the pleural cavity). If multiple alveoli burst, then a larger volume of air escapes. Breathing continues and the hole(s) in the lung now act as vents for air escaping into the pleural cavity. Pressure in the pleural cavity then rises with each breath. Soon the air may make its way into the surrounding tissues causing subcutaneous emphysema (visible air bubbles trapped under the skin) or mediastinal emphysema (air trapped along tissues within the chest). Worse yet, the air may make its way into the circulatory system via arteries that have ruptured when the alveoli burst. If this occurs dangerous gas bubbles may travel throughout the circulatory system and become lodged and block the blood supply to any end organ, e.g., kidneys, brain, heart, intestine, etc. Widespread damage and catastrophic events may ensue. Another dangerous sequel to lung burst may occur if the volume and pressure of escaped air into the pleural space becomes so great that the heart cannot pump blood to the body and the lungs can no longer fill with air. The extent of damaged alveoli directly correlates with the severity of emphysema or heart and lung compromise.

Lung burst may occur if a diver:
*ascends too rapidly not following standard dive tables
*panics and ascends very rapidly
*dives with lung disorders that predispose to air trapping such as acute upper respiratory infections (i.e., colds, pneumonia, or bronchitis), chronic bronchitis, bronchiectasis, or asthma (this is mainly due to the formation of mucous that may block the aveoli)
*smokes or has a long, lean and tall body habitus (weakness of the alveolar wall are common to both)
*inhales water, chokes, and panics
*breath-holds in an attempt to conserve air
*experiences equipment failure or difficulty that leads to breath resistance or holding

If lung burst is suspected by chest pain, shortness of breath, or signs of organ damage (namely the brain-altered mental status, confusion, etc.) then immediate medical attention must be sought. The following guidelines should also be followed:
*Inform a dive physician.
*Keep the diver calm, immobile, and lying flat. Some authorities recommend that you put the diver on his or her hands and knees with the left shoulder lower than the right for the first 10 minutes after resurfacing and then lay the diver flat. This may drive bubbles away from the brain.
*If the diver is unconscious, place the diver left side down with the head elevated to 15°.
*Administer 100 percent oxygen (if available).
*Start IV fluid (if available).
*Get to a dive center or emergency room as soon as possible.

Nitrogen Narcosis
Nitrogen narcosis is a condition that describes a state of mental and physical impairment that may affect a diver at depth. It is caused by excessive nitrogen that may build up in the brain on descent (usually rapid). It is more common with deeper dives to greater than 50 Meters salt water. If you may recall, some doctors or dentists have used inhaled nitrogen, commonly referred to as “laughing gas,” as a general anesthetic. The mental and behavioral changes of excessive nitrogen exposure may include overconfidence and risk taking, poor attention or concentration, memory impairment, hallucinations, and sleepiness. Vision is commonly affected, with some describing tunnel vision or blurred vision. Physical movements may be uncoordinated and clumsy. In essence, the diver with nitrogen narcosis has become “drunk” under water. The essential risk is due to underwater accidents that may occur due to the diver’s poor judgment and/or physical impairment. Fortunately, narcosis resolves rapidly with controlled ascent.

Oxygen Toxicity
Oxygen toxicity is rarely seen in sports diving. It refers to the mental and physical impairment that a diver may experience when exposed to elevated levels of respired oxygen for a prolonged period of time. One might experience toxicity under water or in a decompression chamber (highly concentrated oxygen is often used to treat acute decompression illness in a chamber). Symptoms may include abnormal sensations, impaired muscular function of the arms and legs, pallor (a whitening of the skin), twitching of the facial muscles, nausea, dizziness, and/or convulsions (seizure activity). Remember, a blue unconscious diver is oxygen starved and a white (pallor) unconscious diver may have been over-exposed to oxygen. Pallor may also be associated with states of poor blood flow (shock) or hypothermia.

If the lungs are over-exposed to pressurized oxygen for a prolonged period of time they too may suffer from the ill effects of oxygen toxicity. Oxygen toxicity of the lungs may cause the collapse of breathing units and flooding of the lungs with fluid. Symptoms may include a scratchy sensation of the throat, shortness of breath, chest congestion, unremitting cough, and/or chest pain. Symptoms typically abate when the partial pressure of oxygen (the concentration) is reduced.

Factors that increase the risk of oxygen toxicity include:
*Using high percentage oxygen supplies such as Nitrox.
*Prolonged exposure to oxygen on deep dives.
*Using pure oxygen rebreathers.
*Using pure oxygen in decompression chambers.
*Because oxygen toxicity is rarely seen in sport diving we felt that a lengthy discussion of recognition and treatment would be unnecessary for the scope of this guide.

Hypoxia
Hypoxia describes a condition where the body does not have enough oxygen. Any condition that interferes with the transport of air from the tank, to the lungs, into the blood stream, and eventually to the organs can result in hypoxia. Symptoms include shortness of breath, confusion, slurred speech, visual changes, extreme fatigue, and headache. If hypoxia is severe, stupor, coma, or death may ensue. If a diver is severely oxygen-deprived the respiratory rate increases and the lips, tongue, and later the face, all turn blue.

If you suspect hypoxia in a fellow diver consider the multitude of problems that may interfere with oxygen effectively reaching the organs (most notably the brain). Problems may be mechanical such as tank or regulator malfunction. The oxygen mix may be insufficient, the flow rate may be abnormal, or the oxygen supply may be exhausted. There may be a mechanical obstruction of the airway and/or lungs, i.e., a foreign body. The lungs may be damaged from an air embolism, a pneumothorax, or gas bubbles as seen with DCI. Conditions that result in the insufficient transport of blood to the tissues may result in hypoxia. This would include conditions where the heart is no longer pumping well (heart attack, congestive heart failure) or the blood vessels have collapsed (shock), or there has been excessive bleeding.

If hypoxia is suspected evaluate the airway and remove any obstruction. If the diver is not breathing initiate mouth-to-mouth resuscitation or deliver breaths with a hand-held ambu-bag. If there is insufficient circulation initiate chest compressions. Administer oxygen as soon as possible. Seek medical assistance immediately.

Drowning or Near Drowning
If drowning or near drowning is suspected and the diver has lost consciousness and is not spontaneously breathing, initiate cardiopulmonary resuscitation (CPR) as soon as possible (see below). The problem is that sufficient water has flooded the lungs to make it impossible for oxygen and carbon dioxide exchange. Without enough oxygen the brain begins to die and the organs fail. Brain death or damage begins after five minutes of anoxia (no oxygen). Hypothermia provides some protection and extends the permissible term of anoxia. If necessary, initiate CPR in the water with mouth-to-mouth or snorkel-to-mouth breathing and continue CPR for as long as possible until the diver begins to breathe on his or her own or until death is declared.

Drowning is seen under various circumstances. Underwater panic attack, entrapment in a reef or other entanglement, equipment failure that could have been avoided, uncontrolled rapid ascent, failure to inflate a buoyancy compensator, running out of air, failure to turn on the tank valve, failure to release weight belts when an emergency ascent is necessary are the common causes of drowning. In short, the vast majority of drownings are preventable with proper training and with the exercise of diligence in checking equipment, facilitating proper emergency management, and watching your air supply.

Disorientation and Vertigo
Under certain conditions, a diver may develop underwater vertigo. This condition is not to be confused with dizziness or lightheadedness. It is an actual severe disorientation that is experienced as a sensation that either the diver or the sea is spinning around without reference. The condition may become immediately life threatening if not recognized and dealt with appropriately. Conditions that may lead to vertigo include visual sensory deprivation, disorders of the ear, or inhaled gas problems such as hypoxia (low oxygen) or hypocapnia (low carbon dioxide).

The body uses three sensory input systems to establish orientation in space. If any two are rendered ineffective then severe disorientation/vertigo may ensue. The three components are the nervous system, the inner ear, and the eyes. The inner ear contains a network of air and fluid levels that provide gravity-related clues to spatial orientation. The peripheral nerves and brain work together to use touch, weight, and solid ground to determine orientation. The eyes provide visual input. Underwater the sensation of “touching” your environment is all around you so the nervous system remains relatively clueless to spatial orientation. As aforementioned, the inner ear primarily uses gravity for its sensory input. The inner ear is therefore the only system that determines orientation in space without clues from the environment.

Visual sensory deprivation may occur at night or when diving in very murky water. It will typically occur with inexperienced divers who are not skilled at using alternative underwater visual or sensory clues. A diver may use a floating gauge or camera or floating bubbles to determine which way is up. A weight belt will pull in a downward direction giving the nervous system orientation input. A chest filled with air will float upward with heavy legs below. Nevertheless, if a diver is unable to use alternative visual or sensory clues to determine orientation, disorientation may ensue. Hyperventilation, anxiety, and eventually panic often follow. Severe vertigo is often the result. If such severe disorientation is experienced it may accelerate into a life-threatening situation.

Disorders of the ear may cause disorientation. As previously mentioned, two of the three balancing systems of the body must be working to maintain normal spatial orientation. Disorders that affect the balancing mechanisms of the inner ear may therefore lead to vertigo. Barotrauma of the middle, external, or inner ear may lead to vertigo The vestibular nerve, which sends sensory information to the brain from the middle ear, is also sensitive to hot/cold differences between the ears. Diving horizontally into relatively cold water with one external ear canal plugged and the other open may lead to disorientation and vertigo. This “caloric” vertigo resolves when the diver resumes a vertical position in the water.

Abnormalities to the gas supply underwater may lead to severe disorientation. These would include nitrogen narcosis, hypoxia, oxygen toxicity, or carbon dioxide toxicity.

Underwater vertigo must be followed by immediate ascent. Often a diving buddy is the only support capable of providing direction to which way is up. Because the victim may be in panic mode with severe nausea, possible vomiting or water swallowing, the buddy diver may have a very difficult time. Firmness is essential. Staged decompression stops are not followed on ascent and therefore possible decompression illness must be evaluated at the surface.

Underwater Currents
Dangerous up-swelling or down-swelling currents can drive divers into rapid, dangerous ascents or descents that may precipitate DCI, CAGE, or barotrauma. Divers can also be swept away and drown. Follow your divemaster’s advice and stay clear of waters with turbulent surface signs of strong undercurrents. If you do get caught in an undercurrent do not panic. Try to avoid directly swimming against the current and try to swim out at an angle. If you get caught in a down current drop your weight belt and inflate your buoyancy compensator. If you get out from the current and start rising too fast spread out your arms and legs to slow your ascent. The Mexican Caribbean currents are known to be dangerous, especially in the late summer months of hurricane season. The Punta Tunich dive site, out of Cozumel, is known for its sporadic strong currents.

Stings, Bites, and Poisoning from Dangerous Marine Animals

Jellyfish
Many of Mexico’s most beautiful beaches harbor the treacherous jellyfish. Twenty or more species are common in the waters around Mexico; most cause painful stings. Some are harmless but even a few rare species can be fatal. Jellyfish tentacles are armed with thousands of tiny needle-like filaments that can deliver small doses of venom just below the surface of a victim’s skin. Stings can be very painful, especially if an extensive area of the body is involved. Children, asthmatics, or people with a history of significant allergies may be badly affected, and some cases of respiratory distress and shock have been reported. Seek medical attention if there is shortness of breath, nausea, vomiting, severe dizziness, or a severe rash after a sting.

If you do find yourself among a school of jellyish try not to panic. Slowly tread water until you are sure you are clear of the school. If you are stung, rubbing your wounds may aggravate the pain. Do not immediately remove any stray tentacles from your body. If you are able, apply shaving cream, baking soda, or flour first and then after a few minutes scrape off the tentacle(s) with a knife or credit card after it has dried out a bit. This process prevents the further discharge of venom. Do not apply alcohol or vinegar despite what you may have heard. Vinegar may be helpful for preventing further venom discharge in some species but harmful in others. Therefore, do not use vinegar unless one of the locals has seen what jellyfish has stung you and recommends that you use it. Cold compresses or topical anesthetic sprays may be useful in relieving pain. Also, ammonia products, such as Windex®, or certain over-the-counter saves may help soothe the pain. Believe it or not, the primary component of urine is ammonia and if applied to a fresh sting, it may help ease your suffering. Meat tenderizer with papain, applied as a wet paste, destroys venom. Soaking the extremity in very warm (not scalding) water for up to 90 minutes may help deactivate the venom.

There is a new lotion on the market that prevents jellyfish stings and the stings of a number of other marine animals such as sea lice, sea nettle, coral, or sea anemone. The product, called SafeSea™, has the same protective chemical found in clown fish that prevents them from being stung. It is mixed with various strengths of SPF protection and it seems to work on most but not all subjects tested. It has not yet been tested on the Portuguese man-of-war jellyfish which is common to the waters surrounding Mexico, but it makes sense that it would work on all jellyfish. SafeSea™ may be purchased at Nidaria.

Stingrays
Stingrays may be found just under the sandy surface of the ocean floor, typically in shallower waters. The stinger, used by the animal for protection from predators, is located at the end of the ray’s tail. Swimmers and divers are stung when they unknowingly step on the stingray and the long tail reflexively lashes out at the offending leg or ankle. Although the barb of a stingray is poisonous, most of the damage is caused by the actual wound itself or subsequent infection. If enough venom enters the blood stream systemic effects such as dizziness, nausea, vomiting, or fainting may occur. If you or someone you know is stung by a stingray treat it like you would any contaminated puncture wound. Immediately irrigate the wound with clean or sterile saline solution or water. The more you are able to irrigate the wound the better your chance of avoiding a deep wound infection or abscess. Soak the limb in warm soapy water as often as you can. If you do develop any signs of wound infection, seek medical attention immediately. Make sure your tetanus immunization is up-to-date. If cleaning of the wound has been delayed for more than three or four hours consideration should be given to preventative antibiotics. Appropriate antibiotics would include Augmentin or Biaxin.


Echinoderms: Starfish and Sea Urchin
Sea Urchins are small, spiny bottom dwellers that if stepped on can inject a venom that may cause nausea, vomiting, muscle cramps, shortness of breath, or localized swelling, redness, and numbness. Local affects are most common. The spines are difficult to remove and may cause infection, especially if they have broken off and lodged under the skin. If you are wounded by a sea urchin make sure your tetanus immunization is up-to-date, remove easy-to-access spines, and seek medical attention if there are deeper spines that you cannot remove. Follow basic wound care treatment guidelines. Soaking an affected extremity in very warm soapy water may be effective at neutralizing toxins and cleaning out any wounds. If eaten and improperly prepared, sea urchins may cause significant intestinal disturbances. Mexican starfish are not poisonous. They may cause cuts or abrasions if they are stepped on or mishandled. Follow routine wound care guidelines as applicable.

Poisonous Fish
Poisonous fish common to the waters surrounding Mexico include the scorpion (Scorpaena) and zebra or lion (Pterois) fish. These fish have long venomous spines growing out of their skin. Stings from these fish are known to be extremely painful and cause severe swelling at the site of injury. The venom may be destroyed with heat, so soaking the extremity in very warm water (100°-115° F or about 50° C) for up to 90 minutes will help reduce the duration of pain. Topical anesthetics may be helpful. If the pain is severe, seek medical attention and request an anesthetic injection. Follow standard wound care precautions for puncture wounds.

__________________
OZAN YILDIRIMIN ABİSİ-1970