US NAVY DIVE MANUAL CHAPTER 20 DIAGNOSIS AND TREATMENT OF DECOMPRESSION SICKNESS AND ARTERIAL GAS EM
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Diving Supervisor’s Responsibilities
- Is thoroughly familiar with all recompression procedures.
- Knows the location of the nearest, certified recompression facility.
- Knows how to contact a qualified Diving Medical Officer if one is not at the site.
- Has successfully completed Basic Life Support training.
Only DMOs with subspecialty codes 16U0 or 16U1 may modify the treatment protocols as warranted by the patient’s condition with the concurrence of the Commanding Officer or Officer in Charge
Diagnosis of Arterial Gas Embolism
As a basic rule, any diver who has obtained a breath of compressed gas and who loses consciousness, or has any obvious neurological symptoms within 10 minutes of reaching the surface, must be assumed to be suffering from arterial gas embolism
Symptoms of AGE
- The signs and symptoms of AGE may include:
- Paralysis or weakness in the extremities
- Large areas of abnormal sensation
- Vision abnormalities
- Personality changes
- Extreme fatigue
- Difficulty in thinking
- Nausea and/or vomiting n Hearing abnormalities
- Bloody sputumn Loss of control of bodily functions
- Loss of coordination
Treating Arterial Gas Embolism
Arterial gas embolism is treated with initial compression to 60 fsw. If symptoms are improved within the first oxygen breathing period, then treatment is continued using Treatment Table 6. If symptoms are unchanged or worsen, assess the patient upon descent and compress to depth of relief (or significant improvement), not to exceed 165 fsw
Resuscitation of a Pulseless Diver
If a qualified provider with the necessary equipment can administer the potentially lifesaving therapies within 10 minutes, the stricken diver should be kept at the surface until a pulse is obtained.
If defibrillation becomes available within 20 minutes, the pulseless diver shall be brought to the surface at 30 fpm and defibrillated when appropriate on the surface.
Avoid recompressing a pulseless diver who has failed to regain vital signs after defibrillation.
Symptoms of Type I Decompression Sickness
- Joint pain (musculoskeletal or pain-only symptoms)
- Skin (cutaneous symptoms)
- Swelling and pain in lymph nodes
Musculoskeletal Pain-Only Symptoms
- The most common symptom of decompression sickness is joint pain.
- The hallmark of Type I pain is its dull, aching quality and confinement to particular areas.
Cutaneous (Skin) Symptoms.
The most common skin manifestation of decompression sickness is itching.
Marbling of the skin may precede a symptom of serious decompression sickness and shall be treated by recompression as Type II decompression sickness
Lymphatic Symptoms during recompression
Recompression may provide prompt relief from pain. The swelling, however, may take longer to resolve
A full neurological exam is not completed before initial recompression
Minimal Treatment Table 6
When Treatment is Not Necessary
When firmly established to be due to causes other than decompression sickness or arterial gas embolism
If the diving supervisor cannot rule out the need for recompression then commence treatment.
Defibrillation at depth.
Symptoms of musculoskeletal pain
- If absolutely no change after the second oxygen breathing period at 60 and Diving Medical Officer feels that the pain can be related to specific orthopedic trauma or injury, a Treatment Table 5 may be completed.
- If a Diving Medical Officer is not consulted, Treatment Table 6 shall be used.
Symptoms of Type II Decompression Sickness.
- symptoms are divided into three categories:
- Inner ear (staggers)
- Cardiopulmonary (chokes)
Differentiating Between Type II DCS and AGE
Time of onset
20-3.5 Treatment of Type II Decompression Sickness
- Is treated with initial compression to 60 fsw
- If symptoms improved within the first oxygen breathing period, then treatment is continued on a Treatment Table 6.
- If severe symptoms are unchanged or worsen within the first 20 minutes at 60 fsw, compress to depth of relief not to exceed to 165 fsw. Treat on Treatment Table 6A.
- To limit recurrence, severe Type II symptoms warrant full extensions at 60 fsw
Decompression Sickness in the Water, most common symptom and depth
The predominant symptom will usually be joint pain, most likely to appear at the shallow decompression stops just prior to surfacing
Symptomatic Omitted Decompression
- Treatment Table 5 is not an appropriate treatment for symptomatic omitted decompression.
- If the diver surfaced from 50 fsw or shallower, compress to 60 fsw and begin Treatment Table 6.
- If the diver surfaced from a greater depth, compress to 60 fsw or the depth where the symptoms are significantly improved, not to exceed 165 fsw, and begin Treatment Table 6A.
- For uncontrolled ascent deeper than 165 feet, the diving supervisor may elect to use Treatment Table 8 at the depth of relief, not to exceed 225 fsw.
Joint Pain Treatment (Aviator)
If only joint pain was present but resolved before reaching one ata from altitude, then the individual may be treated with two hours of 100 percent oxygen breathing at the surface followed by 24 hours of observation.
Other Symptoms and Persistent Symptoms (Aviator)
For other symptoms or if joint pain symptoms are present after return to one ata, treat on the appropriate treatment table, even if the symptoms resolve while in transport. Individuals should be kept on 100 percent oxygen during transfer to the recompression facility.
The primary objectives of recompression treatment are:
- Compress gas bubbles
- Allow sufficient time for bubble reabsorption
- Increase blood oxygen content
Guidance on Recompression Treatment
- Treat promptly and adequately
- The effectiveness of treatment decreases as the length of time between the onset of symptoms and the treatment
- Do not ignore seemingly minor symptoms.
- Follow the selected treatment table unless changes are recommended by a Diving Medical Officer
- Treat for the most serious condition.
Rules for Recompression Treatment.
Rules for Recompression Treatment.
Recompression Treatment With Oxygen.
- Use Oxygen Treatment Table 5, 6, 6A, 4, or 7.
- The descent rate for all these tables is 20 feet per minute.
- Upon reaching a treatment depth of 60 fsw or shallower place the patient on oxygen.
- For treatment depths deeper than 60 fsw, use treatment gas if available.
20‑4.3.2 Recompression Treatments When Oxygen Is Not Available.
- Use Air Treatment Table 1A if pain is relieved at a depth less than 66 feet.
- If pain is relieved at a depth greater than 66 feet, use Treatment Table 2A.
- For treatment of serious symptoms where oxygen cannot be used. Use Treatment Table 3 if symptoms are relieved within 30 minutes at 165 feet.
- If symptoms are not relieved in less than 30 minutes at 165 feet, use Treatment Table 4.
Transporting the Patient.
- The patient should be kept supine.
- Do not put the patient head-down.
- The patient should be kept warm and monitored continuously
Medical Treatment During Transport
- 100 percent oxygen during transport,
- If symptoms are relieved or improve after breathing 100 percent oxygen, the patient should still be recompressed as if the original symptom(s) were still present.
- Always ensure the patient is adequately hydrated.
Transport by Unpressurized Aircraft.
If the patient is moved by helicopter or other unpressurized aircraft, the aircraft should be flown as low as safely possible, preferably less than 1,000 feet.
To be used only when no recompression facility is on site, symptoms are significant and there is no prospect of reaching a recompression facility within a reasonable time frame (12–24 hours).
Not for divers with severe Type II symptoms, or symptoms of arterial gas embolism
Type I or non severe Type II
- Begin breathing 100 percent oxygen immediately.
- Continue breathing oxygen at the surface for 30 minutes before committing to recompress in the water.
- If symptoms improve 100 percent oxygen, do not attempt in-water recompression, unless symptoms reappear when oxygen is discontinued.
- Continue breathing 100 percent oxygen as long as supplies last, up to a maximum time of 12 hours
In‑Water Recompression Using Air.
- Follow Air Treatment Table 1A as closely as possible.
- Use either a full face mask or, preferably, a surface-supplied helmet UBA.
- Never recompress a diver in the water using a SCUBA with a mouth piece unless it is the only breathing source available.
- Maintain constant communication.
- Keep at least one diver with the patient at all times.
- Plan carefully for shifting UBAs or cylinders.
- Have an ample number of tenders topside.
- If the depth is too shallow for full treatment according to Air Treatment Table 1A:
- -Recompress the patient to the maximum available depth.
- -Remain at maximum depth for 30 minutes.
- -Decompress according to Air Treatment Table 1A. Do not use stops shorter than those of Air Treatment Table 1A.
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