You are taking medical command when you receive a call from an ALS unit. They are picking up a 33 y/o male with unknown medical history from the beach for a witnessed seizure and confusion. The patient's friend states they were diving at a nearby shipwreck when they encountered a shark, causing the pair to swim to the surface as quickly as possible. While on the boat, the friend noted the patient was acting strangely with slurred speech. He drove the boat to the docks where the patient then had a generalized tonic clonic seizure which resolved with ALS intervention. What are your recommendations for transport? (scroll down for answer)

a) Transport to nearest hospital; likely lowering of seizure threshold from diving at depth

b) Transport to nearest hospital; likely electrolyte abnormality from salt water ingestion

c) Transport to nearest stroke center; likely acute stroke requiring evaluation for clot lysis 

d) Transport to nearest hyperbaric center; likely arterial gas embolism

e) Transport to nearest trauma center

Answer and Explanation: 

The correct answer is d) Transport to nearest hyperbarics center; likely arterial gas embolism

• A cerebral arterial gas embolism (CAGE) is a serious consequence of a rapid, uncontrolled ascent from scuba diving.  
• Symptoms can include altered mental status, loss of consciousness, seizures or stroke signs.
• After the ABCs and stabilization of any other complications (such as a pneumothorax from pulmonary barotrauma), immediate recompression via hyperbarics is indicated. 
• In case you missed it, take a look back at EM Daily’s quick overview of dysbarism from earlier this month! Click here.