I Made Muliarta

Bagian Fisiologi
Fakultas Kedokteran Universitas Udayana

Denpasar, 25 Februari 2012

 Overview
 Fisiologi penyelaman
 Cedera yang terkait dengan penyelaman
 Pencegahan dan Penanganan
 Bali daerah tujuan wisata
 Diving/penyelaman
 7 juta di seluruh dunia dan 500.000 di

antaranya melakukan pelatihan menyelam

setiap tahunnya.
 Penyelaman: aktivitas bawah permukaan air
 Dilakukan sejak lama
 Tujuan:

◦ makanan, eksplorasi, olah raga, rekreasi, salvage,

dll
 Penyelaman:
◦ breath hold diving
◦ diving bell
◦ hard hat diving
◦ SCUBA
◦ Saturasi (Deep diving)
 Diving accidents
 Kejadian meninggal akibat diving 40 kali

lebih tinggi dari pada main sepak bola

maupun sky air (The Australian Lung
Foundation)
 1990s studi diving australasia 9% meninggal

karena asma (Divernet, 2007)

 Pencegahan korban jiwa dan kecelakaan
 Underwater Medicine/ Diving Medicine/
Undersea and Hyperbaric medicine
 Diving Medicine: diagnosis, treatment,

prevention akibat masuk bawah air

◦ Prevention and treatment of diving related
injuries/illnesses
◦ Pre-employment/pre-placement examinations
◦ Fitness for diving evaluations and so on
 Negatively impact their safety and well-being
underwater
◦ Kelainan yang mempengaruhi kesadaran
◦ Kelainan yang mempengaruhi Boyle’s Law
◦ Kelainan yang menyebabkan ketidakmampuan
mempertanggungjawabkan tindakan
 Asma:
◦ 4-7% divers di Amerika
◦ DAN (Divers Allert Network): kecelakaan tidak
meningkat
◦ Bukan kontraindikasi absolut
 Tentukan jenis
 Fungsi paru
 Saat descent: Kesulitan bernafas
 Saat ascent: udara terjebak
 Spirometri
 Peak flow test
 Bronchial agitasion test: debate
 Exercise test
 Post bronchial dilator test
 Dalton's law, Boyle’s Law, and Henry's law
 Dalton’s law
◦ The partial pressure of a gas can be
calculated from its fractional concentration
 Feet M ATM mmHg Lung O2 Insp. Air
vol (ml) (mmHg)
Sea level 1 760 6000 159
33 10 2 1520 3000 318
66 20 3 2280 2000 477
99 30 4 3040 1500 636
133 40 5 3800 1200 795
166 50 6 4560 1000 954
200 60 7 5320 857 1113
300 90 10 7600 600 1590
400 120 13 9880 461 2068
500 150 16 12160 375 2545
600 180 19 14440 316 3022
 Penurunan secara cepat ke kedalaman akan
menimbulkan gaya kompresi yang hebat
 Pada saat kompresi volume paru di bawah 1-

1,5 ltr, akan terjadi squeeze

 Rasio TLC:RLV di permukaan= 4:1
 Squeeze terjadi bila TLC>RLV atau

TLC/RLV<1
 Unequalize bila TLC < RLV
 Prediksi RLV (liter)
◦ Laki-laki berat normal
 RLV = (0,022 x umur) + (0,0198 x tinggi) - (0,015 x BB) -
1,54
◦ Wanita berat normal
 RLV = (0,007 x umur) + (0,0268 x tinggi) - 3,42
◦ Overweight (laki dan wanita)
 (0,0167 x umur)+ (0,0130 x BB) + (0,0185 x tinggi) –
3,34413
 Diving reflex
 Bradikardi
 Penurunan COP
 Vasokonstriksi perifer
 Akumulasi laktat
 Gas dissolve directly proportional partial
pressure
 1 gram Hg mampu membawa 1,34 ml O2
 15 gram Hg dalam 100 ml mampu membawa 20,1
ml O2

 Koefisien kelarutan dalam plasma: 0,0214 ml

O2/100 ml plasma
 21% O2 tekanan 1 Ata 0,0045 ml O2/100 ml
plasma
 100% O2 tekanan 1 Ata 2,14 ml O2/100 ml plasma
 100% O2 tekanan 3 Ata 6,42 ml O2/100 ml plasma
 Hipoksia
 Keracunan CO2
 Keracunan CO
 Keracunan O2
 Tenggelam/nyaris tenggelam
 Barutrauma
 Hipothermia
 Nitrogen Narcosis
 Sengatan dan Gigitan hewan laut
 Decompression illness
 Faktor penyebab:
◦ Individu
◦ Lingkungan perairan
◦ Alat selam
 Fitness
 Training & experience
 Respon terhadap lingkungan
 Diving Refleks
 Gas-gas pernafasan
 Keseimbangan suhu
 Exhaustion
 Bouyancy
 Disorientasi
 Panik
 Kondisi perairan
 Ledakan di bawah air
 Sengatan/gigitan hewan laut
 Hipoksia
◦ Terjadi penurunan asupan oksigen
◦ Sering pada penyelaman tahan nafas
◦ Gejala: penurunan konsentrasi, penurunan
kontrol motorik ekstremitas, kelelahan,
penurunan kesadaran
 Keracunan CO2
◦ Timbul pada penggunaan closed circuit oxygen
karena gagal menyerap O2
◦ Gejala: pusing, lemas, kehilangan kesadaran
 Effects of Different Levels of Oxygen Partial Pressure
PO2 (atm) Application and Effect
<0.08 Coma to ultimate death
<0.08-0.10 Unconsciousness in most people
0.09-0.10 Serious signs/symptoms of hypoxia
0.14-0.16 Initial signs/symptoms of hypoxia
0.21 Normal environmental oxygen (sea level air)
0.35-0.40 Normal saturation dive PO2 level
0.50 Threshold for whole-body effects; maximum saturation dive exposure
1.6 NOAA limit for maximum exposure for a working diver
2.2 Commercial/military “Sur-D” chamber surface decompression, 100% O2 at
40 fsw (12 msw) pressure
2.4 60% N2 / 40% O2 nitrox recompression treatment gas at six ata (165 fsw/50
msw)
2.8 100% O2 recompression treatment gas at 2.8 ata (60 fsw/18 msw)
3.0 50/50 nitrox recompression treatment gas for use in the chamber at six ata

Credit: Permission granted by Best Publishing Company (NOAA Diving Manual 4th Ed.) Flagstaff, AZ
 The Relationship of Physiological Effects of
CO2 Concentration and Exposure Periods:

Credit: Permission granted by Best Publishing Company (NOAA Diving Manual 4th Ed.) Flagstaff, AZ
 Hyperventilation lowers the amount of CO2
in the blood, resulting in the urge to
breathe being postponed
 Breath-hold divers diving too deep for too
long use up oxygen, but do not feel the
urge to breathe,
 Upon ascent, reductions in ambient

pressure reduce the partial pressure of

oxygen in the body – this hypoxic condition
can cause unconsciousness
 Keracunan CO
◦ Karena kebocoran pada gas buang kompresor
udara
◦ Gejala: sakit kepala, lemas, pingsan, meninggal
 Keracunan O2
◦ Penyelaman dengan O2 murni
◦ Menyelam terlalu lama dan kedalaman lebih dari
10 meter (>1,6 ATA)
◦ Gejala: lapang pandang menyempit, tinitus, mual,
twitching, iritabel, pusing, kejang
 Tenggelam/nyaris tenggelam
◦ Tenggelam: tersumbatnya jalan nafas
mengakibatkan kematian dalam 24 jam setelah
terendam
◦ Nyaris tenggelam: kecelakaan yang mengakibatkan
selamatnya korban dalam >24 jam setelah
terendam air
◦ Tenggelam dalam air tawar/air laut
 Barotrauma
◦ Terjadi karena GRAVE: gas filled space, rigid wall,
ambient pressure change, vascular penetration,
enclosed space
◦ Sering mengenai telinga, wajah, sinus, gigi, paru,
lambung
◦ Terjadi squeeze (pengkerutan) sehingga timbul
perdarahan
 Hipothermia
◦ Suhu inti < 35oC
◦ Hilangnya panas badan 30 kali lebih cepat dari
pada di udara
◦ Gejala: kram, amnesia, tremor, kulit dingin,
delirium, hipokinesia, tonus otot meningkat,
sianosis, menggigil, takikardi, takipneu, hilang
kesadaran
 Nitrogen narcosis
◦ In the 1930s this “rapture of the deep” was linked to
nitrogen in the air breathed under higher pressures.
Known as nitrogen narcosis, this condition occurred
because nitrogen has anesthetic properties that
become progressively more severe with increasing air
pressure.
◦ Pemakaian nitrogen 79% di kedalaman >30 meter
◦ Gejala: seperti mabuk alkohol, kurang konsentrasi,
halusinasi, kejang, hilang kesadaran
◦ Gejala berkurang bila naik
 Gigitan hewan laut
 Thalmann and colleagues:Type I symptoms
106 cases of Type I as compared to 37 cases
of Type II DCS
 In the navy, the incidence of DCS is variously

reported between 0.01% and 1.25%

 Symptoms influenced by the depth of the dive

and the bottom time of the dive, the inert gas

breathed, the adequacy of decompression,
and the delay to presentation
 DCS
Tahun Jumlah
Laki Perempuan

2009 20 13 33
2010 25 24 49
2011 15 7 22
Jumlah 60 44 104
 Ascent terlalu cepat
 95% timbul <3 jam setelah penyelaman
 DCS:
 DCS tipe
 DCS tipe II
 AGE
◦ DCS tipe 1:
◦ nyeri tangan, kaki, gatal dan keunguan pada kulit, cutis
marmorata, bengkak pada kelenjar getah bening
◦ DCS tipe II:
◦ Terjadi 1 jam setelah menyelam – 36 jam
◦ gejala neurologis: lemah, mati rasa, kelumpuhan,
sensasi tertusuk jarum, tinitus, vertigo, gangguan
fungsi otak; gejala pulmoner: batuk, takipneu, sakit
dada, nyeri substernal, tersedak, dyspneu
◦ AGE: perubahan kesadaran dalam 10 menit disertai
bingung, gangguan visus, vertigo, hemiplegia
 The role of Nitrogen , which comprises 78% of atmospheric
gas and is biologically inert, is the gas which leads to
pathology as it follows the gas laws in the vessels and organs
of a scuba diving human. As a diver breathing air from a tank
descends, the increased pressure causes more nitrogen to
enter his tissues than was present at the surface. If enough
nitrogen enters into solution and the diver returns to the
surface too quickly, the excess gas will not have a chance to
be eliminated ("blown off") gradually through the lungs. The
nitrogen will then come out of solution and go into a gas
phase--bubbles, which form in the blood and tissues of the
body. These bubbles account for the clinical entity that we
call decompression sickness (DCS).
 ABC
 IV line

 100% oxygen – N - free breathing

2
 HBO therapy
 Pharmacologic therapy

(Wikipedia, 2012)
 Prevention.Important questions for
divers include "how quickly should I
rise?”
◦ Gunakan Tabel dekompresi
◦ Prebreathing NBO dan HBO
Pressure Related Problems
(direct)
Descent (squeezes) Ascent (expansion)
– Ears – Air embolism
– Sinuses
– Pneumothorax
– Mask
– Thoracic – Mediastinal
Emphysema
– Teeth
– Stomach/Intestines – Subcutaneous
– Suit Emphysema
 Potential Lung Injuries
AGE
– Blockage circulation
– Air bubble enter lung
capillary
Mediastinal emphysema
– Air from lung rupture fill
mediastinum
Subcutaneous
emphysema
– Air in the tissues under the
skin
Pneumothorax
Pressure Related Problems
(indirect)
Decompression sickness
– Nitrogen partial pressures
– Solubility
Nitrogen narcosis
Oxygen toxicity
 Nitrogen narcosis

Nitrogen Narcosis
“Rapture of the Deep” - “Martini’s Law”

SURFACE

Thinking and
Judgment
POTENTIALLY
75-100’ Symptoms and Effects on
Individual Diver Vary
Affected With Depth and Exposure.

Communication, 150-175’
Motor and Mental
Tasks IMPAIRED

NOT IN CONTROL 200’+

 Barotrauma
Direct Pressure Indirect Pressure
Related Problems Related Problems
- Descent (Compression) - Decompression Sickness Descend and Ascend
Squeezes (The Bends) (DCS) Slowly to Minimize
Potential Problems
Ear, Sinus, Lung,
Stomach, Intestinal, - Nitrogen Narcosis
Tooth, Equipment
- Oxygen Toxicity
- Ascent (Expansion)

Lung Ruptures -
Subcutaneous and Precautionary
Mediastinal Emphysema
Pneumothorax Decompression Stops
(Safety Stops) Help
Air Embolism NEVER HOLD YOUR Reduce Bubble Formation
BREATH ON SCUBA! and Incidence of DCS