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VOLUME 5 Diving Medicine & Recompression Chamber Operations 20 Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism 21 Recompression Chamber Operation Appendix 5A Neurological Examination Appendix 5B First Aid Appendix 5C Dangerous Marine Animals U.S. NA Y D IVIN G MA NU PAGE INTENTIONALLY Table of Content —Volume 5 Page IAGNOSIS AND REATMENT OF ICKNESS AND ............................................................ 1 Purpose ............................................................ 2 Scope ............................................................. 3 Diving Supervisor’s ...................................... 4 Prescribing Treatments .................................... 5 When Treatment ....................................... 6 Emergency ............................................... ARTERIAL GAS EMBOLISM .................................................. 1 Diagnosis ...................................... 1 Symptoms ........................................... 2 Treating ......................................... 3 Resuscitation ....................................... ................................................ 1 Diagnosis .................................... 2 Symptoms Type .............................. ............................ 2 Cutaneous ................................... 3 Lymphatic ......................................... 3 Treatment Type .............................. 4 Symptoms Type ............................. 1 Neurological ....................................... 2 Inner ............................... 3 Cardiopulmonary .......................... 4 Differentiating ..................... 5 Treatment Type .............................. 6 Decompression Water .................................... 7 Symptomatic .................................... 8 Altitude ........................................ 1 Joint Treatment ......................................... 2 Other ....................... RECOMPRESSION TREATMENT FOR DIVING DISORDERS ........................ Primary Objectives .................................................... 20- 2 Guidance Treatment Volume 5 - Table of Contents U.S. Navy Diving Manual—Volume 5 Page 3 Recompression Treatment Available ....................... 1 Recompression Treatment ......................... 2 Recompression Treatments Available .......... 4 Recompression Treatment Available ....... 1 Transporting ....................................... 2 In-Water ...................................... TREATMENT TABLES ...................................................... 1 Air Treatment Tables ................................................. Treatment Table .................................................... 20-1 3 Treatment Table ................................................... 4 Treatment Table .................................................. 5 Treatment Table .................................................. 6 Treatment Table ................................................... 1 Decompression ............................................ 2 Tenders .................................................. 3 Preventing .......................... 4 Oxygen 5 Sleeping, ................................. 6 Ancillary .............................................. 7 Life ............................................... 7 Treatment Table ................................................... 8 Treatment Table ................................................... RECOMPRESSION TREATMENT FOR NON-DIVING DISORDERS .................. RECOMPRESSION CHAMBER LIFE-SUPPORT CONSIDERATIONS ................ 1 Minimum ....................................... 2 Optimum ....................................... 1 Additional ........................................ 2007.2.2 Required ................. 3 Oxygen ..................................................... 4 Carbon ............................................... 1 Carbon .................................... Carbon Dioxide Scrubbing ...................................... 20-2 3 Carbon .................................... 5 Temperature ................................................. 1 Patient ........................................... 6 Chamber Ventilation ................................................. 7 Access 8 Inside Tenders ...................................................... 1 Inside Tender ................................. 2 DMO Tender ................................... 2007.8.6 Use Tender .................... Table of Content —Volume 5 Page 4 Non-Diver Tender .............................. 5 Specialized ..................................... 6 Inside Tender ............................... 7 Tending .......................................... 9 Equalizing ............................................ 10 Use ............................................ 11 Oxygen Toxicity Treatment ...................................... 11 1 Central Toxicity ........................ 11 2 Pulmonary Toxicity ................................... 12 Loss Treatment ...................................... 1 Compensation ............................................. 2 Switching Treatment Table ............................... 13 Treatment ................................................. POST-TREATMENT CONSIDERATIONS ....................................... 1 Post-Treatment ..................................... 2 Post-Treatment Transfer .............................................. 3 Flying Treatments ............................................... 1 Emergency .................................... 4 Treatment ....................................... ........................ NON-STANDARD TREATMENTS ............................................. RECOMPRESSION TREATMENT ABORT PROCEDURES ......................... 1 Death Treatment .............................................. 2 Impending ........................ 20-11 CARE AND ADJUNCTIVE TREATMENTS ............................ 20-11 1 Decompression ............................................. 11 1 Surface ............................................ 11 2 Fluids .................................................... 11 3 Anticoagulants ............................................. 20011.1.7 Aspirin ............ 11 5 Steroids .................................................. 11 6 Lidocaine ................................................. 11 7 Environmental Temperature ................................... 20-11 2 Arterial ............................................... 11 1 Surface ............................................ 11 2 Lidocaine ................................................. 11 3 Fluids .................................................... 11 4 Anticoagulants ............................................. 20011.2.8 Aspirin ............ 11 6 Steroids .................................................. 20-11 3 Sleeping ................................................. U.S. Navy Diving Manual—Volume 5 Page MEDICAL EQUIPMENT ......................................... 1 Primary ................................. 12.2 Portable .......................................... 3 Advanced ................................... 4 Use ............................................... Modi�cation ................................ PERATIO ............................................................ 1 Purpose ............................................................ 2 Scope ............................................................. 1.6 Chamber .................................................. ............................................................. 1 Basic ........................................... ..................... Recompression .................................. 4 Standard ...... 5 Transportable ..................... 6 Fly Away (FARCC) .............................. 7 Emergency ........................ 8 Standard ................................................... 1 Labeling ................................................... ....................................... 3 Pressure ............................................ 4 Relief Valves ................................................ 5 Communications ...................................... 6 Lighting ............................................. STATE OF READINESS ..................................................... Y ............................................................. 1 Capacity .......................................................... OPERATION .............................................................. 1 Predive ................................................... .................................................. 3 General ......................................... 1 Tender ......................................... 2 Lock-In .......................................... 3 Lock-Out ........................................ 4 Gag Valves ................................................ Table of Content —Volume 5 Page 4 Ventilation ......................................................... 1 Chamber Ventilation ...................................... 2 Notes Ventilation ................................. .................................................. 1 Postdive ................................................... 2 Scheduled .............................................. 1 Inspections ................................................ 2 Corrosion ................................................. 3 Painting ..................................... 4 Recompression ................ 5 Stainless .................................... 6 Fire ...................................... DIVER CANDIDATE PRESSURE TEST ......................................... 1 Candidate ............................................. 2 Procedure ........................................................ 1 References ............................................... AMINATIO ............................................................ INITIAL ASSESSMENT OF DIVING INJURIES .................................... NEUROLOGICAL ASSESSMENT .............................................. 1 Mental ....................................................... 2 Coordination ............................... 3 Cranial ...................................................... 4 Motor .............................................................. 1 Extremity ........................................... 2 Muscle ................................................ 3 Muscle Tone ................................................ 4 Involuntary ....................................... 5 Sensory .................................................... 1 Sensory ........................................ 2 Sensations ................................................ 3 Instruments ................................................ 4 Testing Trunk ........................................... 5 Testing .............................................. 6 Testing 7 Marking ....................................... 6 Deep Tendon ............................................... U.S. Navy Diving Manual—Volume 5 Page A ............................................................ RESUSCITATION ........................................ CONTROL OF MASSIVE BLEEDING ........................................... 1 External ........................................... 2 Direct ...................................................... 3 Pressure ...................................................... 1 Pressure ................................ 2 Pressure ................. 3 Pressure .................. 4 Pressure ............................... 5 Pressure ................................ 6 Pressure Temple ....................... 7 Pressure ................................ 8 Pressure ........................... 9 Pressure ....................... 10 Pressure ................... .............................. 12 When .................................. .......................................................... 1 How ..................................... 2 Tightness ....................................... 3 After ................................. 4 Points ......................................... 5 External Venous ........................................... 6 Internal ..................................................... 1 Treatment .................................. ................................................................... 1 Signs .......................................... 2 Treatment .......................................................... A ............................................................ 1 Purpose ............................................................ 2 Scope ............................................................. PREDATOR MARINE ANIMALS .............................................. 1 Sharks ............................................................. 1 Shark ..................................... 2 First Treatment ....................................... Table of Content —Volume 5 Page 2 Killer ........................................................ 1 Prevention ................................................. 2 First Treatment ....................................... 3 Barracuda .......................................................... 1 Prevention ................................................. 2 First Treatment ....................................... 4 Moray ......................................................... 1 Prevention ................................................. 2 First Treatment ....................................... 5 Sea .......................................................... 1 Prevention ................................................. 2 First Treatment ....................................... VENOMOUS MARINE ANIMALS ............................................... 6.1 Venomous ................. 1 Prevention ................................................. 2 First Treatment ....................................... 6.2 Highly Toxic ........................ 1 Prevention ................................................. 2 First Treatment ....................................... 3 Stingrays ........................................................... 1 Prevention ................................................. 2 First Treatment ....................................... 4 Coelenterates ....................................................... 1 Prevention ................................................ 2 Avoidance Tentacles ...................................... 8C06.7.6 Protection 4 First Treatment ...................................... 5 Symptomatic Treatment ...................................... 6 Anaphylaxis ............................................... 7 Antivenin .................................................. 5 Coral ............................................................. 1 Prevention ................................................ 2 Protection ...................................... 3 First Treatment ...................................... 6 Octopuses ......................................................... 1 Prevention ................................................ 2 First Treatment ...................................... 7 Segmented Worms ........... 1 Prevention ................................................ 2 First Treatment ...................................... ........................................................ 1 Prevention ................................................ 2 First Treatment ...................................... U.S. Navy Diving Manual—Volume 5 Page 9 Cone ........................................................ 1 Prevention ................................................ 2 First Treatment ...................................... ........................................................ 1 Sea Effects ....................................... 2 Prevention ................................................ 3 First Treatment ...................................... 11 Sponges .......................................................... 11 1 Prevention ................................................ 11 2 First Treatment ...................................... POISONOUS MARINE ANIMALS ............................................. 1 Ciguatera ............................................. 1 Prevention ................................................ 2 First Treatment ...................................... 2 Scombroid ............................................ 1 Prevention ................................................ 2 First Treatment ...................................... 3 Puffer .......................................... 1 Prevention ................................................ 2 First Treatment ...................................... 7.7 Paralytic Tide) 1 Symptoms ................................................ 2 Prevention ................................................ 3 First Treatment ...................................... 7.8 Bacterial Viral ............................... 1 Prevention ................................................ 2 First Treatment ...................................... 6 Sea .................................................... 1 Prevention ................................................ 2 First Treatment ...................................... 7 Parasitic .................................................. 1 Prevention ................................................ REFERENCES FOR ADDITIONAL INFORMATION ............................... List of Illustrations—Volume 5 Page Volume 5 - List of Illustrations 20-1 Treatment ............... 20-2 Treatment Type .................................... 20-3 Treatment ............................................ 20-4 Treatment Table .......................................................... 20-5 Treatment Table .......................................................... 20-6 Treatment Table ......................................................... 20-7 Treatment Table .......................................................... 20-8 Treatment Table .......................................................... 20-9 Treatment Table .......................................................... 20-10 Treatment Table .......................................................... 20-11 Air Treatment Table ...................................................... 20-12 Air Treatment Table ...................................................... 20-13 Air Treatment Table ....................................................... 21-1 Double-Lock ...................................... 2 Recompression ...................................... 3 Recompression ...................................... 4 Double-Lock ...................................... ........................... 21-6 Standard ........................ 21-7 Transportable .......................... 8 Transportable ................................... 21-9 Transfer .......................................................... 21-10 Fly Away (FARCC) ..................................... 21-11 Fly Away ............................................ 21-12 Fly Away .............................. 21-13 Recompression ...................................... 21-14 Recompression ..................................... 21-15 Pressure Test ................................. 5A-1a Neurological ............................................. 5A-2a Dermatomal ............................. 1 Pressure ............................................................. 2 Applying ........................................................ 5C-1 Types ............................................................. U.S. Navy Diving Manual—Volume 5 Page 5C-2 Killer ................................................................ 5C-3 Barracuda ................................................................. 5C-4 Moray ................................................................. 5C-5 Venomous ............................................................. 5C-6 Highly Toxic ............................................................ 5C-7 Stingray ................................................................... 5C-8 Coelenterates ............................................................. 5C-9 Octopus .................................................................. 5C-10 Cone ................................................................ 5C-11 Sea ................................................................ List of Tables—Volume 5 Table Volume 5 - List of Tables 1 Rules Treatment ............................................ 20-2 Decompression ............................................................ 3 Guidelines ............................. 4 Maximum Times Various Temperatures ....................................................... 5 High Treatment .......................................... 6 Tender ........................................ 7 Primary ...................................................... 8 Secondary .................................................... 1 Recompression ............................................ 2 Recompression ................................ 1 Extremity Tests ...................................................... 8A02 Re�exes .................................................................. U.S. Navy Diving Manual—Volume 5 PAGE INTENTIONALLY CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism CHAPTER 20 Diagnosis and Treatment of Decompression Sickness and rterial 20-1.1 Purpose. This chapter describes the diagnosis and treatment of diving disorders with reco pression therapy and2or hyperbaric oxygen therapy. Immediate recompression therapy is indicated for treating decompre sion sickness, arterial gas embolism and several other disorders. In those cases where diagnosis or treatment are not clear, contact the Diving Medical Of�cers at NEDU or NDSTC for clari�cation. The recompression procedures described in this chapter are designed to handle most situations that will be encountered oper tionally. They are applicable to both surface0supplied and open and closed circuit SCUBA diving as well as recompression chamber operations, whether on air, nitrogen0oxygen, helium0 oxygen, or 100 percent oxygen. Treatment of decompression sickness during satu ration dives is covered separately in Chapter 1 of this manual. Periodic evaluation of U.S. Navy recompression treatment procedures has shown they are effective in relieving symptoms over 90 percent of the time when used as published. The procedures outlined in this chapter are to be performed only by trained personnel. Because these procedures cover disorders ranging from mild pain to life0threatening disorders, the degree of medical expertise necessary to carry out proper treatment will vary. Certain procedures, such as starting intravenous (IV) �uid lines and inserting chest tubes, require special training and must not be attempted by untrained individuals. Treatment tables can be initiated without consulting a Diving Medical Of�cer (DMO), however a DMO should always be contacted at the earliest possible opportunity. A DMO must be contacted prior to Diving Supervisor’s Responsibilities. Experience has shown that symptoms of severe decompression sickness or arterial gas embolism may occur following seemingly uneventful dives within the prescribed limits. This fact, combined with the many operational scenarios under which diving is conducted, means that treatment of severely ill individuals will be required occasionally when quali�ed medical personnel are not immediately on scene. Therefore, it is the Diving Supervisors responsibility to ensure that every member of the diving team= Knows how to contact a quali�ed Diving Medical Of�cer if one is not at the site. U.S. Navy Diving Manual — Volume 5 Prescribing and Modifying Treatments. Because all possible outcomes cannot be anticipated, additional medical expertise should be sought immediately in all cases of decompression sickness or arterial gas embolism that do not show substantial improvement on standard treatment tables. Deviation from these protocols shall be Not all Medical Of�cers are DMOs. The DMO shall be a graduate of the Diving Medical Of�cer course taught at the Naval Diving and Salvage Training Center (NDSTC) and have a subspecialty code of 16U0 (Basic Undersea Medical Of�cer) or 16U1 (Residency in Undersea Medicine trained Undersea Medical Of�cer). Medical Of�cers who complete only the nine0week diving medicine course at NDSTC do not receive DMO subspecialty codes, but are considered to have the same privileges as DMOs, with the exception that they are not granted the privilege of modifying treatment protocols. 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 Of�cer or Of�cer in Charge. Other physicians may assist and advise treatment and care of diving casualties but may When Treatment is Not Necessary. If the reason for postdive symptoms is �rmly established to be due to causes other than decompression sickness or arterial gas embolism (e.g. injury, sprain, poorly �tting equipment), then recompression is not necessary. If the diving supe visor cannot rule out the need for recompression then Emergency Consultation. Modern communications allow access to medical expertise from even the most remote areas. Emergency consultation is available 27 Navy Diving Salvage and Training Center (NDSTC) ARTERIAL GAS EMBOLISM Arterial gas embolism is caused by entry of gas bubbles into the arterial circula tion as a result of pulmonary over in�ation syndrome (POIS). Gas embolism can manifest during any dive where breaths are taken utilizing underwater breathing of symptoms is usually sudden and dramatic, often occurring within minutes after arrival on the surface or even before reaching the surface. Because the supply of blood to the central nervous system is almost always compromised, arterial gas embolism may result in death or permanent neurological damage unless treated CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Diagnosis of Arterial Gas Embolism. As a basic rule, any diver who has obtained a or from a diving bell, and who surfaces unconscious, 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. Recompression treatment shall be started immediately. A diver who surfaces unconscious and recovers when exposed to fresh air shall receive a neurological evaluation to rule out arterial gas embolism. Victims of near0drowning who have no neurological The symptoms of AGE may be masked by environmental factors or by other less signi�cant symptoms. A chilled diver may not be concerned with numbness in an arm, which may actually be the sign of CNS involvement. Pain from any source an emergency situation, such as the failure of the divers air supply, might mask a If pain is the only symptom, arterial gas embolism is unlikely and decompression sickness or one of the other pulmonary overin�ation syndromes should be Symptoms of AGE. The signs and symptoms of AGE may include near immediate sensation (paresthesias), vision abnorma ities, convulsions or personality changes. During ascent, the diver may have noticed a sensation similar to that of a blow to the chest. The victim may become unconscious without warning and may stop breathing. Additional symptoms of AGE include= Vertigo Tremors Symptoms of subcutaneous 2 mediastinal emphysema, pneumothorax and2or pneu mopericardium may also be present (see paragraph 6 ). In all cases of arterial gas embolism, the possible presence of these associated conditions should not be U.S. Navy Diving Manual — Volume 5 Treating Arterial Gas Embolism. Arterial gas embolism is treated in accordance Figure 200 with initial compression to 60 fsw. If symptoms are improved within the �rst oxygen breathing period, then treatment is continued using Treatment Table . If sym toms are unchanged or worsen, assess the patient upon descent and compress to depth of relief (or signi�cant improvement), not to exceed Resuscitation of a Pulseless Diver. The following are intended as guidelines. For a diver with no pulse or respirations (cardiopulmonary arrest) immediate cardiopulmonary resuscitation (CPR) and use of the Automated External De�brillator (AED) is a higher priority than recompression. Advanced cardiac life support (ACLS), which requires special medical training and equipment, is not always available. CPR, patient monitoring, and drug administration may be able to be performed at depth, but electrical therapy (de�brillation and cardioversion) CAUTION De�brillation If a quali�ed provider with the necessary equipment (i.e., AED) can administer the potentially lifesaving therapies within 10 minutes, the stricken diver should be kept at the surface until a pulse is obtained. Unless de�brillation is administered within 10 minutes, the diver likely will die, even if adequate CPR is performed, with or without recompression. If de�brillation is not available and a Diving Medical Of�cer (DMO) is not present, the Diving Supervisor should compress the diver to If de�brillation becomes available within 20 minutes, the pulseless diver shall be brought to the surface at 60 fpm and de�brillated when appropriate on the surface. (Current data indicate that successful restoration of a perfusing rhythm after 20 minutes of cardiac arrest with only CPR is unlikely.) If the pulseless diver does not regain vital signs with de�brillation, continue CPR. Avoid recompressing a pulseless diver who has failed to regain vital signs after de�brillation. Resuscitation efforts shall continue until the diver recovers, the tenders are unable to continue CPR, or a physician pronounces the patient dead. If the pulseless diver does regain If the tender is outside of no-decompression limits, he should not be brought directly to the surface. Either take the decompression stops appropriate to the tender or lock in a new tender and decompress the patient and new tender to the surface in the outer lock, while While a history of diving (or altitude exposure) is necessary for the diagnosis of decompression sickness to be made, the depth and duration of the dive are useful only in establishing if required decompression was missed. Decompression sic can occur in divers well within no0decompression limits or in divers who have CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism carefully followed decompression tables. Any decompression sickness that occurs For purposes of deciding the appropriate treatment, symptoms of decompression sickness are generally divided into two categories, Type I and Type II. Because the treatment of Type I and Type II symptoms may be different, it is important to exhibit certain signs that only trained observers will identify as decompression sickness. Some of the symptoms or signs will be so pronounced that there will be little doubt as to the cause. Others may be subtle and some of the more important signs could be overlooked in a cursory examination. Type I and Type II symptoms Diagnosis of Decompression Sickness. Decompression sickness symptoms us0 ually occur shortly following the dive or other pressure exposure. If the controlled decompression during ascent has been shortened or omitted, the diver could be suffering from decompression sickness before reaching the surface. In analyzing several thousand air dives in a database set up by the U.S. Navy for developing 72 percent occurred within 1 hour. Appendix 8 contains a set of guidelines for performing a neurological examina tion and an examination checklist to assist trained personnel in evaluating Symptoms of Type I Decompression Sickness. Type I decompression sickness includes joint pain (musculoskeletal or pain0only symptoms) and symptoms The most common symptom of decompression sickness is joint pain. Other types of pain may occur which do not involve joints. The pain may be mild or excruc ating. The most common sites of joint pain are the shoulder, elbow, wrist, hand, knee, and ankle. The characteristic pain of Type I decompression sickness usually begins gradually, is slight when �rst noticed and may be dif�cult to localize. It may be located in a joint or muscle, may increase in intensity, and is usually described as a deep, dull ache. The pain may or may not be increased by movement of the affected joint, and the limb may be held preferentially in certain positions to reduce the intensity (so0called guarding). The hallmark of Type I pain is its dull, aching quality and con�nement to particular areas. It is always present at rest and is usually unaffected by movement. U.S. Navy Diving Manual — Volume 5 Any pain occurring in the abdominal and thoracic areas, including the hips, should be considered as symptoms arising from spinal cord involvement and treated as Type II decompression sickness. The following symptoms may indicate spinal cord Pain localized to joints between the ribs and spinal column or joints between A shooting0type pain that radiates from the back around the body (radi A vague, aching pain in the chest or abdomen (visceral pain). The most difficult differentiation is between the pain of Type I decompression sickness and the pain resulting from a muscle strain or bruise. If there is any doubt as to the cause of the pain, assume the diver is suffering from decompression sic ness and treat accordingly. Frequently, pain may mask other more significant symptoms. Pain should not be treated with drugs in an effort to make the patient more comfortable. The pain may be the only Cutaneous (Skin) Symptoms. The most common skin manifestation of decompression sickness is itching. Itching by itself is generally transient and does not require recompression. Faint skin rashes may be present in conjunction with itching. These rashes also are tra sient and do not require recompression. Mottling or marbling of the skin, known as cutis marmorata (marbling), may precede a symptom of serious decompression sickness and shall be treated by recompression as Type II decompression sickness. This condition starts as intense itching, progresses to redness, and then gives way to a patchy, dark0bluish discoloration of the skin. The skin may feel thickened. In some cases the rash may be raised. Lymphatic Symptoms. Lymphatic obstruction may occur, creating localized pain in involved lymph nodes and swelling of the tissues drained by these nodes. Recompression may provide prompt relief from pain. The swelling, however, may Treatment of Type I Decompression Sickness. Type I Decompression Sickness is treated in accordance with Figure 200 . If a full neurological exam is not completed before initial recompression, treat as a Type II symptom. second oxygen breathing period at 60 feet may be due to orthopedic injury rather than decompression sickness. If, after reviewing the patients history, the Diving Medical Of�cer feels that the pain can be related to speci�c orthopedic trauma or injury, a Treatment Table may be completed. If a Diving Medical Of�cer is not Treatment Table Symptoms of Type II Decompression Sickness. In the early stages, symptoms of Type II decompression sickness may not be obvious and the stricken diver may consider them inconsequential. The diver may feel fatigued or weak and attribute CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism the condition to overexertion. Even as wea ness becomes more severe the diver may not seek treatment until walking, hearing, or urinating becomes dif�cult. Initial denial of DCS is common. For this reason, symptoms must be antic during the postdive period and treated before they become too severe. Type II, or serious, symptoms are divided into three categories: neurological, inner ear (staggers), and cardiopulmonary (chokes). Type I symptoms may or may not be Neurological Symptoms. These symptoms may be the result of involvement of any level of the nervous system. Numbness, paresthesias (a tingling, pricking, creeping, “pins and needles,” or “electric” sensation on the skin), decreased sensation to touch, muscle weakness, paralysis, mental status changes, or motor performance alterations are the most common symptoms. Disturbances of higher brain function may result in personality changes, amnesia, bizarre behavior, lightheadedness, lack of coordin tion, and tremors. Lower spinal cord involvement can cause disruption of urinary function. Some of these signs may be subtle and can be overlooked or The occurrence of any neurological symptom after a dive is abnormal and should be considered a symptom of Type II decompression sickness or arterial gas embo lism, unless another speci�c cause can be found. Normal fatigue is not uncommon after long dives and, by itself, is not usually treated as decompression sickness. If Inner Ear Symptoms (“Staggers”). The symptoms of inner ear decompression sickness include: tinnitus (ringing in the ears), hearing loss, vertigo, dizziness, nausea, and vomiting. Inner ear deco pression sickness has occurred most often in helium0oxygen diving and during decompression when the diver switched from breathing helium0oxygen to air. Inner ear decompression sickness should be differentiated from inner ear barotrauma, since the treatments are different. The “Staggers” has been used as another name for inner ear decompression sickness because of the af�icted divers dif�culty in walking due to vestibular system dysfunction. However, symptoms of imbalance may also be due to neurological decompression sickness involving the cerebellum. Typically, rapid involuntary eye Cardiopulmonary Symptoms (“Chokes”). If profuse intravascular bubbling occurs, symptoms of chokes may develop due to congestion of the lung circulation. Chokes may start as chest pain aggravated by inspiration and2or as an irritating cough. Increased breathing rate is usually observed. Symptoms of increasing lung and death if recompression is not inst tuted immediately. Careful examination for signs of pneumothorax should be performed on patients presenting with shortness of breath. Recompression is not indicated for pneumothorax if no other signs of DCS or AGE are present. Many of the symptoms of Type II decompression sickness are the same as those of arterial gas embolism, although U.S. Navy Diving Manual — Volume 5 the time course is generally different. (AGE usually occurs within 10 minutes of surfacing.) Since the initial treatment of these two conditions is the same and since subsequent treatment conditions are based on the response of the patient to treatment, treatment should not be delayed unnece sarily in order to make the Treatment of Type II Decompression Sickness. Type II Decompression Sickness is treated with initial compression to 60 fsw in accordance with Figure 200 . If symptoms are improved within the �rst oxygen breathing period, then treatment is continued on a Treatment Table . If severe symptoms (e.g. paralysis, major weakness, memory loss) are unchanged or worsen within the �rst 20 minutes at 60 fsw, assess the patient during descent and compress to depth of relief (or signi�cant improvement), not to exceed to 168 fsw. Treat on Treatment Table 6 To limit recurrence, severe Type II symptoms warrant full extensions at 60 fsw Decompression Sickness in the Water. In rare instances, decompression sickness may develop in the water while the diver is undergoing decompression. The predominant symptom will usually be joint pain, but more serious manifestations such as numbness, weakness, hearing loss, and vertigo may also occur. Decompression sickness is most likely to appear at the shallow decompression stops just prior to surfacing. Some cases, however, have occurred during ascent to the �rst stop or shortly thereafter. Treatment of decompression sickness in the water will vary depending on the type of diving equipment in use. Speci�c guidelines are given in for air dives, Chapter 1 for surface0supplied helium0oxygen dives, Chapter 1 for MK 16 MOD 0 dives, and Chapter 1 for Symptomatic Omitted Decompression. If a diver has had an uncontrolled ascent and has any symptoms, he should be compressed immediately in a recompression chamber to 60 fsw. Conduct a rapid assessment of the patient and treat accordingly. Treatment Table is not an appr priate treatment for symptomatic omitted decompression. If the diver surfaced from 80 fsw or shallower, compress to 60 fsw and begin Treatment Table . If the diver surfaced from a greater depth, compress to 60 fsw or the depth where the sym toms are signi�cantly improved, not to exceed 168 fsw, and begin Treatment Table 6 . Consultation with a Diving Medical Of�cer should be obtained as soon as possible. For uncontrolled ascent deeper than 168 feet, the diving supervisor may elect to use Treatment Table at the depth of relief, not to exceed 228 fsw. Treatment of symptomatic divers who have surfaced unexpectedly is dif�cult when no recompression chamber is on site. Immediate transportation to a reco facility is indicated; if this is impossible, the guidelines in paragraph 20 may Altitude Decompression Sickness. Decompression sickness may also occur with exposure to subatmospheric pre sures (altitude exposure), as in an altitude chamber or sudden loss of cabin pressure in an aircraft. Aviators exposed to altitude may CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism experience symptoms of decompression sickness similar to those experienced by divers. The only major difference is that symptoms of spinal cord involvement are less common and symptoms of brain involvement are more frequent in altitude decompression sic ness than hyperbaric decompression sickness. Simple pain, however, still accounts for the majority of symptoms. Joint Pain Treatment. 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 Other Symptoms and Persistent Symptoms. For other symptoms or if joint pain transferred to a recompression facility and treated on the appropriate treatment table, even if the symptoms resolve while in transport. Individuals should be kept RECOMPRESSION TREATMENT FOR DIVING DISORDERS Primary Objectives. Table 200 gives the basic rules that shall be followed for all recompression trea ments. The primary objectives of recompression treatment are= Compress gas bubbles to a small volume, thus relieving local pressure and restarting blood �ow, Increase blood oxygen content and thus oxygen delivery to injured tissues. Guidance on Recompression Treatment. Certain facets of recompression treatment have been mentioned previously, but are so important that they cannot Treat promptly and adequately. Do not ignore seemingly minor symptoms. They can quickly become major Follow the selected treatment table unless changes are recommended by a Diving Medical Of�cer. If multiple symptoms occur, treat for the most serious condition. Recompression Treatment When Chamber Is Available. Oxygen treatment tables are signi�cantly more effective than air treatment tables. Air treatment tables shall only be used after oxygen system failure or intolerable patient oxygen toxicity problems with DMO recommendation. Treatment Table can be used with or U.S. Navy Diving Manual — Volume 5 Recompression Treatment With Oxygen. Use Oxygen Treatment Table , or , according to the �owcharts in Figure 20 Figure 20 and . 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. Recompression Treatments When Oxygen Is Not Available. Air Treatment Tables , and ( Figures 20 , and ) are provided for use only as a last resort when oxygen is not available. Use Air Treatment Table 1 if pain is relieved at a depth less than 66 feet. If pain is relieved at a depth greater than 66 feet, use Table 20 Rules for Recompression Treatment ALWA 1. Follow accurately, Of�cer. 2. Have 3 Maintain 4 Examine 5 Treat 6 Use 7 Be 8 In the event of an oxygen convulsion, remove the oxygen mask and keep the patient from self-harm . Do not force the mouth open during convulsion 9 Maintain 10 Check patient’s patient’s 11 Observe hours for pain-only symptoms, 6 hours for serious symptoms Do not 12 Maintain 13 Maintain 1 Permit Of�cer. 2 Wait 3 Interrupt 4 Permit AGE 5 Fail 6 Allow CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism 20-11 Treatment Table 2 Treatment Table is used for treatment of serious symptoms where oxygen cannot be used. Use Treatment Table if symptoms are relieved within 60 minutes at 168 feet. If symptoms are not relieved in less than 60 minutes Treatment Table Recompression Treatment When No Recompression Chamber is Available. Diving Supervisor has two alternatives for recompression treatment when the diving facility is not equipped with a recompression chamber. If recompression of the patient is not immediately necessary, the diver may be transported to the nearest certi�ed recompression chamber or the Diving Supervisor may elect to Transporting the Patient. In certain instances, some delay may be unavoidable while the patient is tran ported to a recompression chamber. While moving the patient to a recompression chamber, the patient should be kept supine (lying horizontally). Do not put the patient head0down. Additionally, the patient should be kept warm and monitored continuously for signs of obstructed (blocked) airway, cessation of breathing, cardiac arrest, or shock. Always keep in mind that a number of conditions may exist at the same time. For example, the victim may be suffering from both deco Medical Treatment During Transport. Always have the patient breathe 100 percent oxygen during transport, if available. If symptoms of decompression sickness or arterial gas embolism are relieved or improve after breathing 100 percent oxygen, the patient should still be reco pressed as if the original symptom(s) were still present. Always ensure the patient is adequately hydrated. Give fluids by mouth if the patient is alert and able to tolerate them. Otherwise, an IV should be inserted and intravenous fluids should be started before transport. If the patient must be transported, initial arrangements should have been made well in advance of the actual diving operations. These arrangements, which would include an alert means of transportation, should be posted on the Job Site Emergency Assistant 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. Exp sure to altitude results in an additional reduction in external pressure and possible additional symptom severity or other complications. If available, always use aircraft that can be pressurized to one atmosphere. If available, transport using the Emergency Evacuation Hyperbaric Communications with Chamber. Call ahead to ensure that the chamber will be ready and that qualified medical personnel will be standing by. If two0way communications can be established, consult with the doctor as the patient is being In-Water Recompression. Recompression in the water should be considered an option of last resort, to be used only when no recompression facility is on site, U.S. Navy Diving Manual — Volume 5 symptoms are signi�cant and there is no prospect of reaching a recompression facility within a reasonable tim frame (12–27 hours). In an emergency, an uncerti�ed chamber may be used if, in the opinion of a quali�ed Chamber Supervisor (DSWS Watchstation 608), it is safe to operate. In divers with severe Type II symptoms, or symptoms of arterial gas embolism (e.g., unconsciousness, harm to the diver from in0water recompression probably outweighs any antic bene�t. Generally, these individuals should not be recompressed in the water, but should be kept at the surface on 100 percent oxygen, if available, and evacuated to a recompression facility regardless of the delay. The stricken diver should begin breathing 100 percent oxygen immediately (if it is available). Continue breathing oxygen at the surface for 60 minutes before committing to recompress in the water. If symptoms stabilize, improve, or relief on 100 percent oxygen is noted, do not attempt in0water recompression unless symptoms reappear with their original intensity or worsen when oxygen is discontinued. Continue breathing 100 percent oxygen as long as supplies last, up to a maximum time of 12 hours. The patient may be given air breaks as necessary. If surface oxygen proves ineffective after 60 minutes, begin in0water recompression. To avoid hypothermia, it is important to In-Water Recompression Using Air. In0water recompression using air is always Follow Air Treatment Table 1 Use either a full face mask or, preferably, a surface0supplied helmet UBA. Never recompress a diver in the water using a SCUBA with a mouth piece If the depth is too shallow for full treatment according to Air Treatment Table 1 Decompress according to Air Treatment Table 1 . Do not use stops shorter Air Treatment Table 1 In-Water Recompression Using Oxygen. If 100 percent oxygen is available to the diver using an oxygen rebreather, an ORCA, or other device, the following in0 water recompression procedure should be used instead of Air Treatment Table 1 CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Put the stricken diver on the UBA and have the diver purge the apparatus at Descend to a depth of 60 feet with a standby diver. Remain at 60 feet, at rest, for 60 minutes for Type I symptoms and 90 minutes for Type II symptoms. Ascend to 20 feet even if symptoms are still present. Decompress to the surface by taking 600minute stops at 20 feet and 10 feet. After surfacing, continue breathing 100 percent oxygen for an additional If symptoms persist or recur on the surface, arrange for transport to a recompression facility regardless of the delay. Symptoms After In-Water Recompression. The occurrence of Type II symptoms after in0water recompression is an ominous sign and could progress to severe, debilitating decompression sickness. It should be considered life0threatening. Operational considerations and remoteness of the dive site will dictate the speed pression facility. TREATMENT TABLES Air Treatment Tables. Air Treatment Tables 1 , and Figures 2 011 ) are provided for use only as a last resort when oxygen is not available. Oxygen treatment tables are signi cantly more effective than air treatment tables Treatment Table 5. Treatment Table , Figure 2 07 , may be used for the following: Type I DCS (except for cutis marmorata) symptoms when a complete neurological examination has revealed no abnormality. After arrival at 60 fsw a neurological exam shall be performed to ensure that no overt neuro logical symptoms (e.g., weakness, numbness, loss of coordination) are present. If any abnormalities are found, the stricken diver should be treated Treatment Table Treatment of resolved symptoms following in0water recompression Treatment Table 6. Treatment Table Type II DCS symptoms U.S. Navy Diving Manual — Volume 5 Type I DCS symptoms where relief is not complete within 10 minutes at 60 feet or where pain is severe and immediate recompression must be Severe carbon monoxide poisoning, cyanide poisoning, or smoke Treatment Table 6A. Treatment Table 6 Figure 2 , is used to treat arterial gas embolism or deco pression symptoms when severe symptoms remain unchanged or worsen within the �rst 20 minutes at 60 fsw. The patient is compressed to depth of relief (or signi cant improvement), not to exceed 168 fsw. Once at the depth of relief, begin treatment gas (N , HeO ) if available. Consult with a Diving Medical Of�cer at the earliest opportunity. If the severity of the patients condition warrants, the Diving Medical Of�cer may recommend conversion to a Treatment Table Treatment Table 4. Treatment Table Figure 2 that the patient would receive additional bene�t at depth of signi�cant relief, not to exceed 168 fsw. The time at depth shall be between 60 to 120 minutes, based on the patients response. If a shift from Treatment Table 6 to Treatment Table is contemplated, a Diving Medical Of�cer should be consulted before the shift is If oxygen is available, the patient should begin oxygen breathing periods immedi ately upon arrival at the 600foot stop. Breathing periods of 28 minutes on oxygen, interrupted by 8 minutes of air, are recommended because each cycle lasts 60 minutes. This simpli�es timekeeping. Immediately upon arrival at 60 feet, a minimum of four oxygen breathing periods (for a total time of 2 hours) should be administered. After that, oxygen breathing should be administered to suit the patients individual needs and operational conditions. Both the patient and tender must breathe oxygen for at least 7 hours (eight 280minute oxygen, 80minute air periods), beginning no later than 2 hours before ascent from 60 feet is begun. These oxygen0breathing periods may be divided up as convenient, but at least 2 hours CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Table 7. Treatment Table Figure 2 , is an extension at 60 feet Treatment Table , or (or any other nonstandard treatment table). This means that considerable treatment has already been administered. Treatment Table is considered a heroic measure for treating non0responding severe gas embolism or life0threatening decompression sickness and is not designed to treat all residual symptoms that do not improve at 60 feet and should never be used to treat residual pain. Treatment Table should be used only when loss of life may result if the currently prescribed decompression from 60 feet is undertaken. Committing a patient to a Treatment Table involves isolating the patient and having to minister to his medical needs in the recompression chamber for 78 hours or longer. Experienced diving medical personnel shall be on scene. A Diving Medical Of�cer should be consulted before shifting to a Treatment Table and careful consideration shall be given to life support capability of the recompression facility. Because it is dif�cult to judge whether a particular patients condition warrants Treatment Table , additional consultation may be obtained When using Treatment Table , a minimum of 12 hours should be spent at 60 feet, including time spent at 60 feet from Treatment Table , or . Severe Type II decompression sickness and2or arterial gas embolism cases may continue to det riorate signi�cantly over the �rst several hours. This should not be cause for premature changes in depth. Do not begin decompression from 60 feet for at least 12 hours. At completion of the 120hour stay, the decision must be made whether to decompress or spend additional time at 60 feet. If no improvement was noted during the �rst 12 hours, bene�t from additional time at 60 feet is unlikely and decompression should be started. If the patient is improving but signi�cant residual symptoms remain (e.g., limb paralysis, abnormal or absent respiration), additional time at 60 feet may be warranted. While the actual time that can be spent at 60 feet is unlimited, the actual additional amount of time beyond 12 hours that should be spent can only be determined by a Diving Medical Of�cer (in consultation with on0site supervisory personnel), based on the patients response to therapy and operational factors. When the patient has progressed to the point of consciousness, can breathe independently, and can move all extremities, deco pression can be started and maintained as long as improvement continues. Solid evidence of continued bene�t should be established for stays longer than 18 hours at 60 feet. Regardless of the duration at the recompression deeper than 60 feet, at least 12 hours must be spent at 60 feet and then Treatment Table followed to the surface. Additional recompression below 60 feet in these cases should not be undertaken sion on Treatment Table is begun with an upward excursion at time zero from 60 to 88 feet. Subsequent 20foot upward excursions U.S. Navy Diving Manual — Volume 5 Table 20-2. Time Interval shallower stop. The time intervals shown above begin when ascent to the next Tenders. When using Treatment Table , tenders breathe chamber atmosphere Preventing Inadvertent Early Surfacing. Upon arrival at 7 feet, decompression should be stopped for 7 hours. At the end of 7 hours, decompress to the surface at 1 foot per minute. This procedure prevents inadvertent early surfacing. Oxygen Breathing. On a Treatment Table , patients should begin oxygen breathing periods as soon as possible at 60 feet. Oxygen breathing periods of 28 minutes on 100 percent oxygen, followed by 8 minutes breathing chamber atmosphere, should be used. Normally, four oxygen breathing periods are alternated with 2 hours of continuous air breathing. In conscious patients, this cycle should be continued until a minimum of eight oxygen breathing periods have been administered (previous 100 percent oxygen breathing periods may be counted against these eight periods). Beyond that, oxygen breathing periods should be continued as recommended by the Diving Medical Of�cer, as long as improvement is noted and the oxygen is tolerated by the patient. If oxygen breathing causes signi�cant pain on inspiration, it should be discontinued unless it is felt that signi�cant bene�t from oxygen breathing is being obtained. In unconscious patients, oxygen breathing should be stopped after a maximum of 27 oxygen breathing periods have been administered. The actual number and length of oxygen breathing periods should be adjusted by the Diving Medical Of�cer to suit the individual patients clinical condition and response to pulmonary oxygen toxicity. Sleeping, Resting, and Eating. At least two tenders should be available when Treatment Table , and three may be necessary for severely ill patients. Not all tenders are required to be in the chamber, and they may be locked in and out as required following appropriate decompression tables. The patient may sleep anytime except when breathing oxygen deeper than 60 feet. While asleep, the patients pulse, respiration, and blood pressure should be monitored and recorded at intervals appropriate to the patients condition. Food may be taken at any time Ancillary Care. Patients on Treatment Table requiring intravenous and2or drug therapy should have these administered in accordance with paragraph 20 and CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Life Support. Before committing to a Treatment Table , the life0support consider ations in par graph 2007 must be addressed. Do not commit to a Treatment Table Treatment Table 8. Treatment Table Figure 2 , is an adaptation of Royal Navy Treatment Table 68 mainly for treating deep uncontrolled ascents (see ) when more than 60 minutes of decompression have been missed. Compress symptomatic patient to depth of relief not to exceed 228 fsw. Initiate Treatment Table from depth of relief. The schedule for Treatment Table from 60 fsw is the same as Treatment Table . The guidelines for sleeping and eating are the same Treatment Table Treatment Table 9. Treatment Table Figure 2 , is a hyperbaric oxygen treatment table providing 90 minutes of oxygen breathing at 78 feet. This table is used only on the recommendation of a Diving Medical Of�cer cognizant of the patients medical condition. Treatment Table Residual symptoms remaining after initial treatment of AGE2DCS This table may also be recommended by the cognizant Diving Medical Of�cer when initially treating a severely injured patient whose medical condition precludes RECOMPRESSION TREATMENT FOR NON-DIVING DISORDERS In addition to individuals suffering from diving disorders, U.S. Navy recompres sion chambers are also permitted to conduct emergent hyperbaric oxygen (HBO therapy to treat individuals suffering from cyanide poisoning, carbon monoxide poisoning, gas gangrene, smoke inhalation, necrotizing soft0tissue infections, or arterial gas embolism arising from surgery, diagnostic procedures, or thoracic trauma. If the chamber is to be used for treatment of non0diving related medical conditions other than those listed above, authorization from BUMED Code M6B72 shall be obtained before treatment begins (BUMEDINST 6620.68 series.) Any treatment of a non0diving related medical condition shall be done under the cognizance of a Diving Medical Of�cer. The guidelines given in Table 200 for conducting HBO therapy are taken from the Undersea and Hyperbaric Medical Societys Hyperbaric Oxygen (HBO ) Therapy Committee Report02006= Approved Indications for Hyperbaric Oxygen Therapy. For each condition, the guidelines prescribe the recommended Treatment Table, the U.S. Navy Diving Manual — Volume 5 Table 20 . Treatment Table Treatments Treatments Treatment Table Table Treatment Table TID Injury, Traumatic Treatment Table Wounds Treatment Table Soft-Tissue Treatment Table initially, Treatment Table Tissue Treatment Table Treatment Table initially, Treatment Table day, Therapy: A RECOMPRESSION CHAMBER LIFE-SUPPORT CONSIDERATIONS The short treatment tables (Oxygen Treatment Tables Air Treatment Tables 1 and ) can be accomplished easily without signi�cant strain on either the recompression chamber facility or support crew. The long treatment tables Tables and ) will require long periods of decompression and may tax both personnel and hardware severely. Minimum Manning Requirements. The minimum team for conducting any recompression operation shall consist of three individuals. In case of emergency, keeping individual and overall times on the operation, logging progress, and communicating with personnel inside the chamber. The Outside Tender is responsible for the operation of gas supplies, vent pressurization, and exhaust of the chamber. The Inside Tender is familiar with the diagnosis and treatment of diving0related CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Optimum Manning Requirements. The optimum team for conducting The Outside Tender #1 is responsible for the operation of the gas supplies, ventilation, pressurization, and exhaust of the chamber. The Outside Tender #2 is responsible for keeping individuals and overall times on the operation, logging progress as directed by the Diving Supe visor, and communicating with personnel inside the chamber. The Inside Tender is familiar with the diagnosis and treatment of diving0related Additional Personnel. If the patient has symptoms of serious decompression sickness or arterial gas embolism, the team will require additional personnel. If the treatment is prolonged, a second team may have to relieve the �rst team. Patients with serious decompression sickness and gas embolism would initially be accompanied inside the chamber by a Diving Medical Technician or Diving Medical Of�cer, if possible. However, treatment should not be delayed to comply Required Consultation by a Diving Medical Officer. A Diving Medical Of�cer shall be consulted as early as possible in all recompression treatments, and, if at all possible, before committing the patient to a Treatment Table , or . The Diving Medical Of�cer may be on scene or in communication with the Diving Supervisor. Oxygen Control. All treatment schedules listed in this chapter are usually performed with a chamber atmosphere of air. To accomplish safe decompression, the oxygen percentage should not be allowed to fall below 19 percent. Oxygen may be added to the chamber by ventilating with air or by bleeding in oxygen from an oxygen breathing system. If a portable oxygen analyzer is available, it can be used to determine the adequacy of ventilation and2or addition of oxygen. If no oxygen analyzer is available, ventilation of the chamber in accordance with paragraph 2007. will ensure adequate oxygenation. Chamber oxygen percentages as high as 28 percent are permitted. If the chamber is equipped with a life0support system so that ventilation is not required and an oxygen analyzer is available, the oxygen level should be maintained between 19 percent and 28 percent. If chamber oxygen goes above 28 percent, ventilation with air should be used to bring the Carbon Dioxide Control. Ventilation of the chamber in accordance with chamber carbon dioxide level to exceed 1.8 percent SEV (11.7 mmHg). U.S. Navy Diving Manual — Volume 5 Carbon Dioxide Monitoring. Chamber carbon dioxide should be monitored with electronic carbon dioxide monitors. Monitors generally read CO percentage once chamber air has been exhausted to the surface. The CO percent reading at the surface 1 ata must be corrected for depth. To keep chamber CO below 1.8 percent SEV (11.7 mmHg), the surface CO monitor values should remain below 0.78 percent with chamber depth at 60 feet, 0.86 percent with chamber depth at 60 feet, and 0.28 percent with the chamber at 168 feet. If the CO analyzer is within the chamber, no correction to the CO readings is necessary. Carbon Dioxide Scrubbing. If the chamber is equipped with a carbon dioxide scrubber, the absorbent should be changed when the partial pressure of carbon di oxide in the chamber reaches 1.8 percent SEV (11.7 mmHg). If absorbent cannot be changed, supplemental chamber ventilation will be required to maintain chamber CO at acceptable levels. With multiple or working chamber occupants, supplemen tal ventilation may be necessary to maintain chamber CO at acceptable levels. Carbon Dioxide Absorbent. absorbent may be used beyond the expiration date when used in a recompre sion chamber equipped with a CO monitor. When used in a recompression chamber that has no CO monitor, CO absorbent in an reached. Pre0packed, double0bagged canisters shall be labeled with the expiration monitor. Temperature Control. Internal chamber temperature should be maintained at a level comfortable to the occupants whenever possible. Cooling can usually be accomplished by chamber ventilation. If the chamber is equipped with a heater2 chiller unit, temperature control can usually be maintained for chamber occupant comfort under any external environmental conditions. Usually, recompression chambers will become hot and must be cooled continuously. Chambers should always be shaded from direct sunlight. The maximum durations for chamber occupants will depend on the internal chamber temperature as listed in Table 2 . Never commit to a treatment table that will expose the chamber occupants to greater temperature2time combin tions than listed in Table 2 unless quali�ed medical personnel who can evaluate the trade0off between the projected heat stress and the anticipated trea ment bene�t are consulted. A chamber temperature below For patients with brain or spinal cord damage, the current evidence recommends aggressive treatment of elevated body temperature. When treating victims of AGE or severe neurological DCS, hot environments that elevate body temperature above normal should be avoided, whenever possible. As in DCS, patient temper CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Table 20 Maximum Permissible Recompression Chamber Exposure Times at Various Temperatures Internal Temperature Maximum Tolerance Time Permissible Treatment Tables Table Tables Always Patient Hydration. Always ensure patients are adequately hydrated. Fully conscious patients may be given �uid by mouth to maintain adequate hydration. One to two liters of water, juice, or non0carbonated drink, over the course of a Treatment Table or , is usually suf�cient. Patients with Type II symptoms, or symptoms of arterial gas embolism, should be considered for IV �uids. Stuporous or unconscious patients should always be given IV �uids, using large0gauge plastic catheters. If trained personnel are present, an IV should be started as soon as possible and kept dri ping at a rate of 78 to 100 cc2hour, using isotonic �uids (Lactated Ringers Solution, Normal Saline) until speci�c instructions regarding the rate and type of �uid administration are given by quali�ed medical personnel. Avoid solutions containing glucose (Dextrose) if brain or spinal cord injury is present. Intravenously administered glucose may worsen the outcome. In some cases, the bladder may be paralyzed. The victims ability to void shall be assessed as soon as possible. If the patient cannot empty a full bladder, a urinary catheter shall be inserted as soon as possible by trained personnel. Always in�ate catheter balloons with liquid, not air. Adequate �uid is being given when urine output is at least 0.8cc2kg2hr. Thirst is an unreliable ind cator of the water intake to compensate for heavy sweating. A useful indicator of proper hydration is a clear colorless Chamber Ventilation. Ventilation is the usual means of controlling oxygen level, carbon dioxide level, and temperature. Ventilation using air is required for chambers without carbon dioxide scrubbers and atmospheric analysis. A ventilation rate of two acfm for each resting occupant, and four acfm for each active occupant, should be used. These procedures are designed to assure that the effective concentration of carbon dioxide will not exceed 1.8 percent sev (11.7 mmHg) and that, when oxygen is being used, the percentage of oxygen in the chamber will not exceed 28 U.S. Navy Diving Manual — Volume 5 Access to Chamber Occupants. Recompression treatments usually require access to occupants for passing in items such as food, water, and drugs and passing out such items as urine, excrement, and trash. Never attempt a treatment longer than Treatment Table unless there is access to inside occupants. When doing a Treatment Table or , a double0lock chamber is mandatory because additional Inside Tenders. When conducting a recompression treatment, at least one quali�ed tender shall be inside the chamber. The inside tender shall be familiar with all treatment proc dures and the signs, symptoms, and treatment of all diving0related disorders. Medical personnel may have to be locked into the chamber as the patients cond Inside Tender Responsibilities. During the early phases of treatment, the inside tender must monitor the patient constantly for signs of relief. Drugs that mask signs of the illness should not be given. Observation of these signs is the principal method of diagnosing the patients illness. Furthermore, the depth and time of Ensuring that sound attenuators for ear protection are worn during compression Ensuring that the patient is lying down and positioned to permit free blood DMO or DMT Inside Tender. If it is known before the treatment begins that adjunctive therapy or advanced medical support must be administered to the patient (examples include an IV, or airway maintenance), or if the patient is suspected of suffering from arterial gas embolism, a Diving Medical Technician or Diving Medical Of�cer should acco pany the patient inside the chamber. However, recompression treatment must not be delayed while awaiting the arrival of the DMO or DMT. Use of Diving Medical Officer as Inside Tender. If only one Diving Medical Of�cer is on site, the Medical Of�cer should lock in and out as the patients condition dictates, but should not commit to the entire treatment unless absolutely necessary. Once committed to remain in the chamber, the Diving Medical Of�cer effectiveness in directing the treatment is greatly diminished and consultation with CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism other medical personnel becomes more dif�cult. If periods in the chamber are necessary, visits should be kept within no0deco Non-Diver Inside Tender - Medical. Non0diving medical personnel may be quali�ed as Inside Tenders (examples would include U.S. Naval Reserve Corpsmen, and nursing personnel). Quali�c tions may be achieved through Navy Diver Inside Tender PQS. Prerequisites= Current diving physical exam, conformance to Navy Specialized Medical Care. Emergency situations that require specialized medical care should always have the best quali�ed person provide it. The best quali�ed person may be a surgeon, resp ratory therapist, IDC, etc. Since these are emergency exposures, no special medical or physical prerequisites exist. A quali�ed Inside Tender is required inside the chamber to handle any system related requirements. Inside Tender Oxygen Breathing. During treatments, all chamber occupants may breathe 100 percent oxygen at depths of 78 feet or shallower without locking in additional personnel. Tenders should not fasten the oxygen masks to their heads, but should hold them on their faces. When deeper than 78 feet, at least one chamber occupant must breathe air. Tender oxygen breathing requirements are speci�ed in the �gure for each Trea ment Table. Tending Frequency. Normally, tenders should allow a surface interval of at least 18 hours between consecutive treatments on Treatment Tables 1 , and , and at least 78 hours between consecutive treatments on Tables and . If necessary, however, tenders may repeat Treatment Tables or within this 180hour surface interval if oxygen is breathed at 60 feet and shallower as outlined Table 200 Minimum surface intervals for Treatment Tables 1 Equalizing During Descent. Descent rates may have to be decreased as necessary to allow the patient to equalize; however, it is vital to attain treatment depth in a Use of High Oxygen Mixes. High oxygen N mixtures may be used to treat patients when recompre sion deeper than 60 fsw is required. These mixtures offer signi�cant therapeutic advantages over air. Select a treatment gas that will produce a ppO between 1.8 and 6.0 ata at the treatment depth. The standardized gas mixtures shown in Table 2007 are suitable over the depth range of 610228 fsw. Decompression sickness following helium dives can be treated with either nitrogen or helium mixtures. For recompression deeper than 168 fsw, helium mixtures are preferred to avoid narcosis. The situation is less clear for treatment of decompression sickness following air or nitrogen0oxygen dives. Experimental studies have shown both bene�t and harm with helium treatment. Until more experience is obtained, high oxygen mixtures with nitrogen as the diluent gas are preferred if available. High oxygen mixtures may also be substituted for 100% oxygen at 60 fsw and shallower on Treatment Tables , and if the patient is unable to tolerate 100% U.S. Navy Diving Manual — Volume 5 Table 20 High Oxygen Treatment Gas Mixtures 20-7.11 Oxygen Toxicity During Treatment. Acute CNS oxygen toxicity may develop on During prolonged treatments on Treatment Tables or and with repeated Treatment Table 11 Central Nervous System Oxygen Toxicity. When employing the oxygen treatment tables, tenders must be particularly alert for the early symptoms of CNS oxygen toxicity. The symptoms can be reme bered readily by using the mnemonic VENTID0C (Vision, Ears, Nausea, Twitching\Tingling, Irritability, Dizziness, Convulsions). Unfortunately, a convu sion may occur without early warning signs or before the patient can be taken off oxygen in response to the �rst sign of CNS oxygen toxicity. CNS oxygen toxicity is unlikely in resting individuals at chamber shallower, regardless of the level of activity. However, patients with severe Type II decompression sickness or arterial gas embolism symptoms may be abnormally sensitive to CNS oxygen toxicity. Convulsions unrelated to oxygen toxicity may also occur and may 11 Procedures in the Event of CNS Oxygen Toxicity. At the first sign of CNS oxygen toxicity, the patient should be removed from oxygen and allowed to breathe chamber air. Fifteen minutes after all symptoms have subsided, resume oxygen breathing. For Treatment Tables resume treatment at the point of interruption. For Treatment Tables and no compe satory lengthening of the table is required. If symptoms of CNS oxygen toxicity develop again or if the first Inserting an airway device or bite block is not recommended while Treatment Tables After all symptoms have completely subsided, decompress 10 feet at a rate of 1 fsw2min. For a convulsion, begin travel when the patient is fully relaxed and breathing normally. Resume oxygen breathing at the shallower depth at the point of CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism If another oxygen symptom occurs after ascending 10 fsw, contact a Diving Medical Of�cer to recommend appropriate modi�cations to the treatment Treatment Tables Consult with a Diving Medical Of�cer before administering further oxygen breathing. No compensatory lengthening of the table is required 11 Pulmonary Oxygen Toxicity. Pulmonary oxygen toxicity is unlikely to develop on Treatment Tables , or . On Treatment Tables or or with repeated Treatment Tables or (especially with extensions) prolonged exposure to oxygen may result in end0inspiratory discomfort, progressing to substernal burning and severe pain on insp ration. If a patient who is responding well to treatment complains of substernal burning, discontinue use of oxygen and consult with a DMO. However, if a signi cant neurological de�cit remains and improvement oxygen breathing should be continued as long as considered bene�cial or until pain limits inspir tion. If oxygen breathing must be continued beyond the period of substernal burning, or if the 20hour air breaks on Treatment Tables or oxygen breathing periods should be changed to 20 minutes on oxygen, followed by 10 minutes breathing chamber air or alternative treatment gas mixtures with a lower percentage of oxygen should be considered. The Diving Medical Of�cer Loss of Oxygen During Treatment. Loss of oxygen breathing capability during oxygen treatments is a rare occurrence. However, should it occur, the following After O is restored= If original table was Table or , complete treat Table , or is being used, no compensation in decompression is needed if oxygen is lost. If decompression must be stopped because of worsening symptoms in the affected diver, then stop decompression. When oxygen is restored, U.S. Navy Diving Manual — Volume 5 Switching to Air Treatment Table. If O breathing cannot be restored in 2 hours switch to the comparable air treatment table at current depth for decompression if 60 fsw or shallower. Rate of ascent must not exceed 1 fpm between stops. If symptoms worsen and an increase in treatment depth deeper than 60 feet is needed, Treatment Table Treatment at Altitude. Before starting recompression therapy, zero the chamber depth gauges to adjust for altitude. Then use the depths as speci�ed in the treatment table. There is no need to “Cross Correct the treatment table depths. Divers serving as inside tenders during hyperbaric treatments at altitude are performing a dive at altitude and therefore require more decompression than at sea level. Tenders locking into the chamber for brief periods should be managed according to the Diving At Altitude procedures ( paragraph 901 ). Tenders remaining in the chamber for the full treatment table must breathe oxygen during the terminal The additional oxygen breathing required at altitude on Treatment Table Treat ment Table , and Treatment Table 6 is given in Table 20 . The requirement pertains both to tenders equilibrated at altitude and to tenders �own directly from sea level to the chamber location. Contact NEDU for guidance on tender oxygen POST-TREATMENT CONSIDERATIONS Tenders on Treatment Tables or should have a minimum of a 180hour surface interval before no0decompression diving and a minimum of a 270hour surface interval before dives requiring decompression stops. Tenders on Treatment Tables should have a minimum of a 780hour surface interval Post-Treatment Observation Period. After a treatment, patients treated on a Treat ment Table should remain at the recompression chamber facility for 2 hours. Pa tients who have been treated for Type II decompression sickness or who required Treatment Table for Type I symptoms and have had complete relief should re main at the recompression chamber facility for 6 hours. Patients treated on Treat ment Tables or are likely to require a period of hospitalization, and the Diving Medical Of�cer will need to determine a post0treatment observa tion period and location appr priate to their response to recompression treatment. These times may be shortened upon the recommendation of a Diving Medical Of �cer, provided the patient will be with personnel who are experienced at recogniz ing recurrence of symptoms and can return to the recompression facility within 60 minutes. All patients should remain within 60 minutes travel time of a recompres sion facility for 27 hours and should be accompanied throughout that period. No Treatment table pro�les place the inside tender(s) at risk for decompression sick ness. After completing treatments, inside tenders should remain in the vicinity of the recompression chamber for 1 hour. If they were tending for Treatment Table CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism or inside tenders should also remain within 60 minutes travel time of a Post-Treatment Transfer. Patients with residual symptoms should be transferred to appropriate medical facilities as directed by quali�ed medical personnel. If ambulatory patients are sent home, they should always be accompanied by facility should the need arise. Patients completing treatment do not have to remain in the vicinity of the chamber if the Diving Medical Of�cer feels that transferring Flying After Treatments. Patients with residual symptoms should �y only with the concurrence of a Diving Medical Of�cer. Patients who have been treated for Tenders on Treatment Tables should have a 270hour surface interval before �ying. Tenders on Treatment Tables and should not �y for Emergency Air Evacuation. Some patients will require air evacuation to another treatment or medical facility immediately after surfacing from a treatment. They Table 20 Tender Oxygen Breathing Requirements Altitude Treatment Table . If Treatment tender’s U.S. Navy Diving Manual — Volume 5 done only on the recomme dation of a Diving Medical Of�cer. Aircraft pressurized to one ata should be used if possible, or unpressurized aircraft �own as low as safely possible (no more than 1,000 feet is preferable). Have the patient breathe 100 percent oxygen during transport, if available. If available, an Emergency Treatment of Residual Symptoms. After completion of the initial recompression treatment and after a surface interval suf�cient to allow complete medical evalu ation, additional recompression trea ments may be instituted. If additional recom pression treatments are indicated a Diving Medical Of�cer must be consulted. Re sidual symptoms may remain unchanged during the �rst one or two treatments. In these cases, the Diving Medical Of�cer is the best judge as to the number of recompression treatments. Consultation with NEDU or NDSTC may be appropri ate. As the delay time between completion of initial treatment and the beginning of follow0up hyperbaric treatments increases, the probability of bene�t from ad ditional treatments decreases. However, improvement has been noted in patients who have had delay times of up to 1 week. Therefore, a long delay is not neces sarily a reason to preclude follow0up treatments. Once residual symptoms respond to additional recompression treatments, such treatments should be continued until no further bene�t is noted. In general, treatment may be discontinued if there is no For persistent Type II symptoms, daily treatment on Table may be used, but twice0daily treatments on Treatment Tables or may also be used. The treatment table chosen for re0treatments must be based upon the patients medical condition and the potential for pulmonary oxygen toxicity. Patients surfacing from Trea Table 6 with extensions, , or may have severe pulmonary oxygen toxicity and may �nd breathing 100 percent oxygen at 78 or 60 feet to be unco In these cases, daily treatments at 60 feet may also be used. As many oxygen breathing periods (28 minutes on oxygen followed by 8 minutes on air) should be administered as can be tolerated by the patient. Ascent to the surface is at 20 feet per minute. A minimum oxygen breathing time is 90 minutes. A pra tical maximum bottom time is 6 to 7 hours at 60 feet. Treatments should not be administered on a daily basis for more than 8 days without a break of at least 1 day. These guidelines may have to be modi�ed by the Diving Medical Of�cer to suit individual patient circumstances and tolerance to oxygen as measured by decrements in the patients vital capacity. Divers diagnosed with AGE or Type II DCS may be medically cleared to return to diving duty 60 days after initial diagnosis and treatment by a DMO, if initial hyperbaric treatment is successful and no neurologic de�cits persist. A BUMED waiver for return to diving is required if symptoms persist beyond initial treatment of AGE or Type II DCS. Refer to Bureau of Medicine and Surgery Manual (MANMED) P117 Article CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism NON-STANDARD TREATMENTS The treatment recommendations presented in this chapter should be followed as closely as possible unless it becomes evident that they are not working. Only a Diving Medical Of�cer may then recommend changes to treatment protocols or use treatment techniques other than those described in this chapter. Any modi�c to treatment tables shall be approved by the Commanding Of�cer. The standard treatment procedures in this chapter should be considered minimum treatments. Treatment procedures should never be shortened unless emergency situations arise that require chamber occupants to leave the chamber early, or the patients medical RECOMPRESSION TREATMENT ABORT PROCEDURES Once recompression therapy is started, it should be completed according to the procedures in this chapter unless the diver being treated dies or unless continuing the treatment would place the chamber occupants in mortal danger or in order to Death During Treatment. If it appears that the diver being treated has died, a Diving Medical Of�cer shall be consulted before the treatment is aborted. Once the decision to abort is made, there are a number of options for decompressing the tenders depending on the depth at which the death occurred and the preceding If death occurs following initial recompression to 60, 168, or 228 on Treatment Tables or , decompress the tenders on the Air2Oxygen schedule in the Air Decompression Table having a depth exactly equal to or deeper than the maximum depth attained during the treatment and a bottom time equal to or longer than the total elapsed time since treatment began. The Air2Oxygen schedule can be used even if gases other than air (i.e., nitrogen0oxygen or If death occurs after leaving the initial treatment depth on Treatment Tables 6 , decompress the tenders at 60 fsw2min to 60 fsw and have them breathe oxygen at 60 fsw for the times indicated in Table 20 of the oxygen breathing time at 60 fsw, decompress the tenders on oxygen from If death occurs after leaving the initial treatment depth on Treatment Tables , or after beginning treatment on Treatment Table at 60 fsw, have the tenders decompress by continuing on the treatment table as written, or consult NEDU for a decompression schedule customized for the situation at hand. If neither option is possible, follow the original treatment table to 60 fsw. At 60 fsw, have the tenders breathe oxygen for 90 min in three 600min periods separated by a 80min air break. Continue decompression at 80, 70 and 60 fsw by breathing oxygen for 60 min at each depth. Ascend between stops at 60 fsw2 min. At 80 fsw, breathe oxygen in two 600min periods separated by a 80min air break. At 70 and 60 fsw, breathe oxygen for the full 600min period followed by U.S. Navy Diving Manual — Volume 5 a 180min air break. Ascend to 20 fsw at 60 fsw2min and breathe oxygen for 120 min. Divide the oxygen time at 20 fsw into two 600min periods separated by a 18 min air break. When oxygen breathing time is complete at 20 fsw, ascend to the surface at 60 fsw2min. Upon surfacing, observe the tenders carefully for the Impending Natural Disasters or Mechanical Failures. Impending natural disasters or mechanical failures may force the treatment to be aborted. For instance, the ship where the chamber is located may be in imminent danger of sinking or a �re or explosion may have severely damaged the chamber system to such an extent that completing the treatment is impossible. In these cases, the abort procedure described in paragraph 20010. could be used for all chamber occ pants (including the stricken diver) if time is available. If time is not available, the following may Once the chamber is 60 feet or shallower, put all chamber occupants on continuous 100 percent oxygen. Select the Air2Oxygen schedule in the Air Decompression Table corresponding to the maximum depth attained during If at 60 fsw, breathe oxygen for period of time equal to the sum of all the decompression stops 60 fsw and deeper in the Air2Oxygen schedule, then continue decompression on the Air2Oxygen schedule, breathing oxygen continuously. If shallower than 60 fsw, breathe oxygen for a period of time equal to the sum of all the decompression stops deeper than the divers current depth, then continue decompression on the Air2Oxygen schedule, breathing oxygen continuously. Complete as much of the Air2Oxygen schedule as possible. When no more time is available, bring all chamber occupants to the surface (try not to exceed 10 feet per minute) and keep them on 100 percent oxygen during Immediately evacuate all chamber occupants to the nearest recompression facility and treat according to Figure 20 . If no symptoms occurred after the Treatment Table 20-11 CARE AND ADJUNCTIVE TREATMENTS WARNING Drug therapy shall be administered only after consultation with a Diving Most U.S. military diving operations have the unique advantage over most other diving operations with the ability to provide rapid recompression for the victims of decompression sickness (DCS) and arterial gas embolism (AGE). When stricken divers are treated without delay, the success rate of standard recompression therapy CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Some U.S. military divers, such as Special Operations forces, however, may not have the bene�t of a chamber nearby. Diving missions in Special Operations are often conducted in remote areas and may entail a lengthy delay to recompression therapy in the event of a diving accident. Delays to treatment for DCS and AGE signi�cantly increase the probability of severe or refractory disease. In these divers, the use of adjunctive therapy (treatments other than recompression on a treatment table) can be provided while the diver is being transported to a chamber. Adjunctive therapies may also be useful for divers with severe symptoms or who Note that the adjunctive therapy guidelines are separated by accident type, with DCS and AGE covered separately. Although there is some overlap between the guidelines for these two disorders (as with the recompression phase of therapy), the best adjunctive therapy for one disorder is not necessarily the best therapy for the other. Although both DCS and AGE have in common the presence of gas bubbles in the body and a generally good response to recompression and hype baric oxygen, the underlying pathophysiology is somewhat different. 20-11.1 11 Surface Oxygen. Surface oxygen should be used for all cases of DCS until the diver can be reco pressed. Use of either a high0�ow (18 liters2minute) oxygen source with a reservoir mask or a demand valve can achieve high inspired fractions of oxygen. One consideration in administering surface oxygen is pulmonary oxygen toxicity. 100% oxygen can generally be tolerated for up to 12 hours. The patient may be given air breaks as necessary. If oxygen is being administered beyond this time, the decision to continue must weigh the perceived bene�ts against the risk of pulmonary oxygen toxicity. This risk evaluation must consider the dose of oxygen 11 Fluids should be administered to all individuals suffering from DCS unless suffering from the chokes (pulmonary DCS). Oral �uids (half0strength glucose and electrolyte solutions) are acceptable if the diver is able to tolerate them. There is no data available that demonstrates a superiority of crystalloids (normal saline or Lactated Ringers solution) over colloids (such as Hetastarch compounds (Hespan or Hextend)) or vice versa, but D8W (dextrose in water without electr should not be used. Since colloids are far more expensive than Lactated Ringers or normal saline, the latter two agents are the most reasonable choice at this time. The optimal amount of crystalloids2colloids is likewise not well0esta lished but treatment should be directed towards reversing any dehydration that may have been induced by the dive (immersion diuresis causes divers to lose 2800800 cc of �uids per hour) or �uid shifts resulting from the DCS. Fluid overloading should be avoided. Urinary output, in the range of 0.8cc2kg2hour is evidence of adequate Chokes (pulmonary DCS) causes abnormal pulmonary function and leakage of �uids into the alveolar spaces. Aggressive �uid therapy may make this condition U.S. Navy Diving Manual — Volume 5 11 Since some types of DCS may increase the likelihood of hemorrhage into the tissues, anticoagulants should not be used routinely in the treatment of DCS. One exception to this rule is the case of lower extremity weakness. Low molecular weight heparin (LMWH) should be used for all patients with inability to walk due to any degree of lower extremity paralysis caused by neurological DCS or AGE. Enoxaparin 60 mg, or its equivalent, administered subcutaneously every 12 hours, should be started as soon as possible after injury to reduce the risk of deep venous thrombosis (DVT) and pulmonary embolism in paraplegic patients. Plastic stoc ings or intermittent pneumatic compression are alternatives, although they are less effective at preventing DVT than LMWH. 11 Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs. Routine use of anti0 platelet agents in patients with neurological DCS is not reco mended, due to concern about worsening hemorrhage in spinal cord or inner ear decompression illness. Use of these agents may also be risky in combat divers who may be 20 11 5 Steroids. Steroids are no longer recommended for the treatment of DCS. No signi�cant reduction in neurological residuals has been found in clinical studies for DCS adjunctively treated with steroids and elevated blood glucose levels associated with steroid administration may actually worsen the outcome of CNS injury. 11 Lidocaine is not currently recommended for the treatment of any type 11 Environmental Temperature. For patients with evidence of brain or spinal cord damage, the current evidence recommends aggressive treatment of elevated body temperature. When treating victims of neurological DCS, whenever practical, hot environments that may cause elevation of body temperature above normal should be avoided. The patients body temperature and vital signs should be monitored regularly. 20-11.2 11 Surface Oxygen. Surface oxygen should be used for all cases of AGE as it is for 11 Lidocaine has been shown to be useful in the treatment of AGE. If it is to be used clinically, evidence suggests that an appropriate end0point is attainment of a serum concentration suitable for an anti0arrhythmic effect. An intravenous initial dose of 1 mg2kg followed by a continuous infusion of 207 mg2minute, will typically produce therapeutic serum concentrations. If an intravenous infusion is not esta lished, intramuscular administration of 708 mg2kg will typically produce a therapeutic plasma concentration 18 minutes after dosing, lasting for around 90 minutes. Doses greater than those noted above may be associated with major side effects, including paresthesias, ataxia, and seizures. 11 The �uid replacement recommendations for the treatment of AGE differ from those of DCS. The pathophysiology of the lesion (pulmonary barotrauma CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism vs. tissue supersaturation with in0situ gas formation) is not the issue. The major diffe ence in the recommendations for �uid therapy in AGE vs. DCS are because divers who suffer AGE may be less dehydrated than divers with DCS, either because they have had a shorter period of immersion or because they have had less bubble0induced endothelial damage. In addition, the CNS injury in AGE may be compl cated by cerebral edema and an increased �uid load may worsen this cerebral edema and cause further injury to the diver. If �uids are used, crystalloids are probably the best choice for the reasons previously noted in the section on tive therapy of DCS. Particular care should be taken not to overload the diver with �uids by adjusting IV rates to maintain just an adequate urine output of 0.8cc2kg2hour. A urinary catheter should be inserted in the unconscious patient and 11 Anticoagulants should not be used routinely in the treatment of AGE. As noted previously in paragraph 20011.1. on anticoagulants in DCS, Enoxaparin 60 mg, or its equivalent, should be administered subcutaneously every 12 hours, after initial recompression therapy in patients suffering from paralysis to 11 Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs. Routine use of anti0 platelet agents in patients with AGE is not recommended. 11 Steroids are no longer recommended for the treatment of AGE. No signi�cant reduction in neurologic residual has been shown with adjunctive treatment with steroids for AGE and elevated blood glucose levels associated with administration of steroids may worsen the outcome of CNS injury. 20-11.3 Sleeping and Eating. The only time the patient should be kept awake during recompression treatments is during oxygen breathing periods at depths greater than 60 feet. Travel between decompression stops on Treatment Table , and is not a contra0indication to sleeping. While asleep, vital signs (pulse, respiratory rate, blood pressure) should be monitored as the patients condition dictates. Any signi�cant change would be reason to arouse the patient and ascertain the cause. Food may be taken by chamber occupants at any time. Adequate �uid intake MEDICAL EQUIPMENT Every diving activity shall maintain emergency medical equipment that will be available immediately for use in the event of a diving accident. This equipment is to be in addition to any medical supplies maintained in a medical treatment facility and shall be kept in a kit small enough to carry into the chamber, or in a locker in the immediate vicinity of the chamber. Because some sterile items may become contaminated as a result of a hyperbaric exposure, it is desirable to have a primary kit for immediate use inside the chamber and a secondary kit from which items that may become contaminated can be locked into the chamber only as needed. The primary emergency kit contains diagnostic and therapeutic equipment that is U.S. Navy Diving Manual — Volume 5 available immediately when required. This kit shall be inside the chamber during all treatments. The secondary emergency kit contains equipment and medicine that does not need to be available immediately, but can be locked0in when required. This kit shall be stored in the vicinity of the chamber. The contents of the emergency kits presented here are not meant to be restrictive but are considered the minimum requirement. Additional items may be added to The Primary Emergency Kit is described in Table 20 . The Secondary Emergency Table 20 Table 20 Tuning Tongue Emergency Treatment Equipment and Medications Yankauer-type Also alternatively, QuickTrach™) Valve Elastic-Wrap #11 11/2-inch NOTE: One Primary Emergency Kit is required per chamber system, . TRCS requires one Additional Medical Equipment Authorized for Navy Use (ANU) in chamber can be found in the Medical Equipment section of the ANU on the NAVSEA website. Contact the Senior Medical Of�cer at the Navy Experimental Diving Unit for any questions regarding speci�c pieces of medical equipment for use in the chamber. CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Table 20 Emergency Airway Equipment Cuffed cuff (Tomey-type Venous Tray Whenever . One A . U.S. Navy Diving Manual — Volume 5 Portable Monitor-Defibrillator. All diving activities2commands shall maintain an automated external de�brillator (AED), preferably with heart rhythm visualization capability, from an approved Authorized Medical Allowance List (AMAL). Diving activities with assigned Diving Medical Of�cer are recommended to augment with a fully capable monitor de�brillator. AED’s are not currently approved for use under pressure (hyperbaric Advanced Cardiac Life Support Drugs. All commands with chambers that participate in area bends watch shall maintain those drugs recommended by the American Heart Association for ACLS. These drugs need to be in suf�cient quantities to support an event requiring Advanced Cardiac Life Support. These drugs2equipment are not required to be in every dive kit when multiple chambers2 In addition, medications for the treatment of anaphylaxis, which can occur related to marine life envenomation, including Epinephrine 1=1000 solution, Diphenhydramine IM or PO and Hydrocortisone Sodium Succinate IV will be Some vendors supply pre-packed ACLS kits with automated replenishment programs (examples of which can be found on the Naval Expeditionary Combat Command (NECC) AMAL). Unless adequately sealed against increased atmospheric pressure (i.e., vacuum packed), sterile supplies should be re0sterilized after each pressure exposure; or, if not exposed, at package expiration date. Drugs shall be replaced when their expiration date is reached. Not all drug ampules will withstand Stoppered multi-dose vials with large air volumes may need to be vented with a needle during pressurization and depressurization and then Both kits should be taken to the recompression chamber or scene of the accident. Each kit is to contain a list of contents and have a tamper evident seal. Each time the kit is opened, it shall be inventoried and each item checked for proper working order and then re0sterilized or replaced as necessary. Unopened kits are inventoried quarterly. Concise instructions for administrating each drug are to be provided in the kit along with current American Heart Association Advanced Cardiac Life0Support Protocols. In untrained hands, many of the items can be dangerous. Remember that RST S TO Because the available facilities may differ on board ship, at land0based diving installations, and at diver training or experimental units, the responsible Diving Medical Of�cer or Diving Medical Technician are authorized to augment the emergency kits to suit the local needs. CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Treatment Table Arterial Table Table Table Table Treatment Table Table es es es es es 1. A Treatment Table Treatment Table Cardiac Recompression Assessment Additional 7 Enter Treatment Table U.S. Navy Diving Manual — Volume 5 Treatment Type Treatment of Type I Decompression Sickness Type Treatment Table Treatment Table es If Type Treatment Table Diving Treatment Table Treatment Table . CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Treatment of Symptom Recurrence Treatment Treatment es es 1. A Treatment Table Treatment Table Additional Recurrence During Treatment Recurrence Following Treatment Treat es Table off Table es Table Table Table Treatment Table es es es Table U.S. Navy Diving Manual — Volume 5 Treatment Table Treatment Table 5 Depth/Time Profile Time at Depth (minutes) Total Elapsed Time: 135 Minutes 2 Hours 15 Minutes (Not Including Descent Time) 60 320 20 30 30 20 5 5 45 30 15 Depth (FSW) Ascent Rate 1 Ft/Min. Ascent Rate 1 Ft/Min. Descent Rate 20 Ft/Min. Treatment Table 5 Descent Ascent Time If Toxicity, 11 Treatment Table Tender CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Table Treatment Table 6 Depth/Time Profile Time at Depth (minutes) Total Elapsed Time: 285 Minutes 4 Hours 45 Minutes (Not Including Descent Time) 60 320 20 20 30 60 60 30 15 15 45 30 15 Depth (fsw) Ascent Rate 1 Ft/Min. Descent Rate 20 Ft/Min. Ascent Rate 1 Ft/Min. Treatment Table 6 Descent Ascent Time If Toxicity, 11 Table can be lengthened up to additional 25-minute periods at 60 feet (20 minutes on oxygen and minutes on air), or up to additional 75-minute periods at 30 feet (15 minutes on air and 60 minutes on oxygen), or both Tender U.S. Navy Diving Manual — Volume 5 Treatment Table Treatment Table 6A Depth/Time Profile Time at Depth (minutes) Total Elapsed Time: 350 Minutes 5 Hours 50 Minutes (Not Including Descent Time) 165 25520 35 2020 30 60 60 30 555 15 15 60 30 Depth (fsw) Descent Rate 20 Ft/Min. Ascent Rate 3 Ft/Min. Ascent Rate 1 Ft/Min. Ascent Rate 1 Ft/Min. Treatment Table 6A Descent Ascent shallower, Time Table . Of�cer. If shallower, Treatment Treatment . Deeper than 60 feet, if treatment gas must be interrupted because of CNS oxygen toxicity, allow 15 minutes after the reaction has entirely subsided before resuming treatment gas . The time off treatment gas is counted as part of the time at treatment depth . If at 60 feet or shallower and oxygen breathing must be interrupted because of CNS oxygen toxicity, allow 15 minutes after the reaction has entirely subsided and resume schedule at point of interruption (see paragraph 20-7 11 . Table can be lengthened up to additional 25-minute periods at 60 feet (20 minutes on oxygen and minutes on air), or up to additional 75-minute periods at 30 feet (60 minutes on oxygen and 15 minutes on air), or both Tender . . 9. If Treatment Table CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Table Treatment Table 4 Depth/Time Profile Time at Depth Total Elapsed Time: 39 Hours 6 Minutes (30 Minutes at 165 fsw) to 40 Hours 36 Minutes (2 Hours at 165 fsw) 165 :30-2 hrs 2 hrs 12 hrs 6 hrs 6 hrs :30:30:30:30 25 min20 min20 min20 min20 min 10 min 10 min 10 min 10 min10 min1 min 60 50 80 100 120 140 30 40 20 10 Depth (fsw) Descent Rate 20 Ft/Min. Patient begins oxygen breathing at 60 Ft. Both patient and tenders breathe oxygen beginning 2 hours before leaving 30 Ft. Ascent Rate 1 Ft/Min. Treatment Table 4 Descent Ascent Time If Ensure Table . If If Treatment Table If fsw, Treatment . U.S. Navy Diving Manual — Volume 5 Treatment Table Treatment Table 7 Depth/Time Profile Time at Depth hours 16 3236 60 40 20 Depth (fsw) Descent Rate 20 Ft/Min. scent Rate = 2 Ft/Hr (2 Ft every 60 min.) scent Rate = 3 Ft/Hr (2 Ft every 40 min.) scent Rate = 1 Ft/Hr (2 Ft every 120 min.) Ascent Rate 1 Ft/Min.) 12 hrs minimun No maximum limit 6 hrs 10 hrs 16 hrs 4 hrs Treatment Table 7 Table Table Table Maximum Patient Tender Minimum (11 Decompression below. Ensure Treatment Table 7. A CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Table Treatment Table 8 Enter The The The fsw, diver, . Decompression . odd number . Subsequent stops are carried out every 2 . The Ascend Stop fsw, fsw, fsw, However, While fsw, A shallower, At shallower, Additional . Treatment Table To Ascend Total Max Time at Initial Treatment Depth (hours) Stop Times (minutes) 11 U.S. Navy Diving Manual — Volume 5 Treatment Table Treatment Table 9 Depth/Time Profile Time at Depth (minutes) 2::15 (FSW) Descent rate 20 ft/min 5 30 30 Ascent rate 20 ft/min Tota Elapsed Time: 102:15 (Not Including Descent Time) 2::15 Treatment Table 9 Descent Ascent patient’s Time If Toxicity, 11 Tender Patient If Total Time: Time) CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Figure 20-11. Treatment Table Treatment Table 1A Depth Time Pro Time at Depth (minutes) Total Elapsed Time: 472 Minutes 7 Hours 52 Minutes 100 3012 2020101010 10 10 10 303030 60 60 120 40 50 60 80 20 30 10 Depth (fsw) Descent Rate 20 Ft/Min. Ascent Rate 1 Ft/Min. Air Treatment Table 1A Descent Ascent Time U.S. Navy Diving Manual — Volume 5 Treatment Table Treatment Table 2A Depth/Time Profile Time at Depth (minutes) Total Elapsed Time: 813 Minutes 13 Hours 33 Minutes 120 100 80 165 140 30 303030 12 2520202020101010 10 10 10 121212 120 120 240 40 50 60 20 30 10 Depth (fsw) Descent Rate 20 Ft/Min. Ascent Rate 1 Ft/Min. Air Treatment Table 2A Descent Ascent Time CHAPTER 20—Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism Treatment Table Treatment Table 3 Depth Time Pro Time at Depth (minutes) Total Elapsed Time: 1293 Minutes 21 Hours 33 Minutes 120 100 80 165 140 30 303030 12 2520202020101010 10 10 10 121212 720 120 120 40 50 60 20 30 10 Depth (fsw) Descent Rate 20 Ft/Min. Ascent Rate 1 Ft/Min. Air Treatment Table 3 Descent Ascent Time U.S. Navy Diving Manual — Volume 5 PAGE INTENTIONALLY 21-1 CHAPTER 21 Recompression Chamber Operation This chapter will familiarize personnel with the maintenance and Recompression chambers are used for the treatment of decompression sickness and arterial gas embolism, for surface decompression, and for administering pressure tests to prospective divers. Recompression chambers equipped for hyperbaric administration of oxygen are also used in medical facilities for hyperbaric treatment of carbon monoxide poisoning, gas gangrene, and other diseases. A recompression chamber is required on site for surface0 supplied air decompression dives deeper than 160 fsw and for all surface0supplied Chamber Definitions. Double0lock chambers are used because they permit tending personnel and supplies to enter and leave the chamber during treatment. Where On-station chamber is de�ned as a certi�ed and ready chamber at the dive On-site chamber is de�ned as a certi�ed and ready chamber accessible within Emergency chamber is de�ned as the closest recompression chamber available when a chamber is not required on station or on site. A non0certi�ed chamber Most chamber0equipped U.S. Navy units will have one of seven commonly provided chambers. They are: Double0lock, 1000psig, 2020cubic0foot steel chamber (ARS 80 class and Mod Standard Navy Double Lock Recompression Chamber System (SNDLRCS) U.S. Navy Diving Manual — Volume 5 Transportable Recompression Chamber System (TRCS) ( Figure 21 Fly0Away Recompression Chamber (FARCC) ( Figure 21 Figure 21 Select U.S. Navy units have a unique treatment option called the Emergency Evac patient to be administered oxygen at 60 feet while in transport to a recompression chamber. However, it does not provide hands0on access to the patient and ther Basic Chamber Components. The basic components of a recompression chamber are much the same from one model to another. The basic components consist of the pressure vessel itself, an air supply and exhaust system, a pressure gauge, and a built0in breathing system (BIBS) to supply oxygen to the patient. Additional components may include oxygen, carbon dioxide, temperature and humidity monitors, carbon dioxide scrubbers, additional BIBS systems for air and treatment gases other than oxygen, a BIBS overboard dump system, and a heating2cooling system. Collectively these systems must be able to impose and maintain a pressure equivalent to a depth of 168 fsw (6 atmospheres absolute) on the diver. Double0 lock chambers are used because they permit tending personnel and supplies to The piping and valving on some chambers is arranged to permit control of the air supply and the exhaust from either the inside or the outside of the chamber. Controls on the outside must be able to override the inside controls in the event of a problem inside the chamber. The usual method for providing this dual0control capability is through the use of two separate systems. The �rst, consisting of a supply line and an exhaust line, can only be controlled by valves that are outside of the chamber. The second air supply2exhaust system has a double set of valves, one inside and one outside the chamber. This arrangement permits the tender to regulate descent or ascent from within the chamber, but always subject to �nal Modernized chambers Figure 210 ) have carbon dioxide and oxygen monitors, a CO scrubber system, a Built0In Breathing System (BIBS), and an oxygen dump system which together reduce the ventilation requirements. These chambers also include a chamber 21-2.3 Recompression Chamber Facility (RCF). The RCF series 6800 and 8000 ( Figures 210 and 210 ) consists of two sizes of standard double lock steel chambers, each with a medical lock and easy occupant access. The RCF 6800 is capable of treating up to 12 occupants while the RCF 8000 is capable of treating 7 occupants. The systems are installed in a facility to support training, surface decompression, recompression treatment, and medical treatment operations. Each RCF includes primary and secondary air supplies comprised of compressors, puri�cation, and storage for chamber pressurization and ventilation along with oxygen, mix 21-3 treatment gas, and emergency air supply to the BIBS system. Each RCF has an atmospheric conditioning system that provides internal atmospheric scrubbing and monitoring along with temperature and humidity controls for long term treatment, gas management, and patient comfort. The RCF includes gas supply monitoring, a �re extinguishing system, ground fault interruption and emergency power. The RCF 6800 is equipped with a NATO mating �ange. Both series have extra penetrations for auxiliary equipment such as patient treatment monitoring and hoods. Standard Navy Double Lock Recompression Chamber System (SNDLRCS). The SNDLRCS ( Figure 210 ) consists of a Standard Navy Double Lock (SNDL) recompression chamber and a gas supply system housed within an International Organization for Standards (ISO) container. The system is capable of supporting surface decompression, medical treatment, and training operations. Air is supplied to the system using a Air Flask Rack Assembly (AFRA) which is almost identical to the Air Supply Rack Assembly (ASRA) used in supporting a FADS 6 DLSS. Oxygen is provided by four (7) cylinders that are secured to the interior bulkhead of the ISO container. If an external supply of mixed gas is available it can also be supplied to the chamber BIBS supply. The SNDL is a 87 diameter, double lock recompression chamber. It is out�tted with a stretcher, BIBS, gas monitoring systems, lights, and an environmental conditioning system. The chamber can comfortably accommodate 7 divers in the The ISO container houses the gas supply systems and the chamber. It also provides a shelter from environmental elements for the Outside Tenders and Diving Supervisor to conduct treatments. The container is both heated and air conditioned as required Transportable Recompression Chamber System ( The TRCS ( Figure 210 consists of two pressure chambers. One is a conical0shaped chamber ( Figure 210 called the Transportable Recompression Chamber, and the other is a cylindrical shaped vessel ( Figure 210 ) called the Transfer Lock ( TL). The two chambers are capable of being connected by means of a freely rotating NATO female �ange The TRCS is supplied with a Compressed Air and Oxygen System (CAOS) consisting of lightweight air and oxygen racks of high pressure �asks, as well as a means of reducing the oxygen supply pressure. The chamber is capable of admin When a recompression chamber is required on site per Figure 6 , or surface decompression dives are planned, the full TRCS system (including both TRC and When a recompression chamber is not required on site per Figure 6 , the inner lock (TRC) may be used for emergency recompression treatment. Fly Away Recompression Chamber (FARCC). This chamber system consists of a 600inch double lock modernized chamber in a 20 x 8 x 8 milvan ( Figure 2101 U.S. Navy Diving Manual — Volume 5 Figure 2101 ). The Fly Away Recompre sion Chamber (FARCC) also includes a life support skid ( Figure 2101 ). In addition, a stand0alone generator is provided The Emergency Evacuation Hyperbaric Stretcher (EEHS) is a manually0portable single patient hyperbaric tube to be used to transport a diving or disabled subm rine casualty from an accident site to a treatment facility while under pressure. The EEHS does not replace a recompression chamber, but is used in conjunction with a chamber. The EEHS is small enough to allow transfer of a patient, under pressure, into or out of many shore based recompression chambers owned by both the DOD, and civilian medical organizations. Standard Features. Recompression chambers must be equipped with a means for delivering breathing oxygen to the personnel in the chamber. The inner lock should be provided with connections for demand0type oxygen inhalators. Oxygen can be furnished through a pressure reducing manifold connected with supply cylinders outside the chamber. All lines should be identi�ed and labeled to indicate function, content tion of �ow. The color coding in Table 21 Optimum chamber ventilation requires separation of the Pressure Gauges. Chambers must be �tted with appropriate pressure gauges. compared as described in the applicable Planned Maintenance System (PMS) to Table 21 Buff Buff Water Water Water 21-5 Relief Valves. Recompression chambers should be equipped with pressure relief valves in each manned lock. Chambers that do not have latches (dogs) on the doors are not required to have a relief valve on the outer lock. The relief valves shall be set in accordance with PMS. In addition, all chambers shall be equipped with a gag valve shall be a quick acting, ball0type valve, sized to be compatible with the Communications System. Chamber communications are provided through a divers intercommunication system, with the dual microphone2speaker unit in the chamber and the surface unit outside. The communication system should be arranged so that personnel inside the chamber need not interrupt their activities to of standard sound0powered tel phones. The press0to0talk button on the set inside Lighting Fixtures. Consideration should be given to installation of a low0level lighting �xture (on a separate circuit), which can be used to relieve the patient of the heat and glare of the main lights. Emergency lights for both locks and an external control station are mandatory. No electrical equipment, other than that authorized within the scope of certi�cation or as listed in the NAVSEA Authorized for Navy Use (ANU) List, is allowed inside the chamber. Because of the possibility of �re or explosion when working in an oxygen or compressed air atmosphere, all electrical U.S. Navy Diving Manual — Volume 5 1 Inner 2 Outer 3 Air Two-Valve 4 Air One-Valve 5 Main Valve 6 Exhaust Two-Valve 7 Exhaust One-Valve 8 Oxygen 9 Relief Valve 10 Relief Valve 110 11 Medical 12 View 13 View 14 Lights Watt 15 Lights Watt 16 Transmitter/Receiver 17 Berth 18 Bench 19 Pressure 20 Pressure Test . 21-7 110 Internal Volume (OL): Design Temperature: Internal Volume (IL): Viewports: NATO STANAG Temperature Temperature Monitoring: Heliox/Air, AC Two Air Ventilation Controls: U.S. Navy Diving Manual — Volume 5 110 Internal Volume (OL): Design Temperature: Weight: Internal Volume (IL): Viewports: NATO STANAG Temperature Temperature Monitoring: AC Air Ventilation Controls: 21-9 1 Inner 2 Outer 3 Air 4 Air 5 Air 6 Exhaust 7 Exhaust 8 BIBS 9 BIBS 10 BIBS 11 BIBS 12 Oxygen 13 Communications 14 Sound-Powered 15 External 16 External 17 18 Ground 19 Pipe 20 Chiller 23 Inner 24 Outer 25 Bunk 26 Bunk 27 View 28 View 29 Strongback 30 Relief Valve 30A Gag Valve 31 Pipe 32 Chiller/Scrubber ARS-50 Volume – Inner – Outer – Total . U.S. Navy Diving Manual — Volume 5 1 Inner 2 Outer 3 Gas 4 Gas 5 Gas 6 O Analyzer 7 CO Analyzer 8 Inner-Lock 9 Outer-Lock 10 Communications 11 Sound-Powered 12 Pipe 13 Ground 14 View 15 16 Stopwatch/Timer 17 18 CO 19 Fire 20 Chiller/Conditioner 21 Gag Valve 22 Relief Valve 110 23 BIBS 21-11 U.S. Navy Diving Manual — Volume 5 Transportable Width Weight Internal Volume View Ports 11 NATO STANAG scrubber, 110 Analyzer Design Temperature litter, Transportable 21-13 Width Weight Internal Volume View Ports NATO STANAG scrubber, 110 Analyzer Design Temperature Transfer Away (FARCC) U.S. Navy Diving Manual — Volume 5 Figure 21-11. Away Away 21-15 STATE OF READINESS Since a recompression chamber is emergency equipment, it must be kept in a state of readiness. The chamber shall be well maintained and equipped with all neces sary accessory equipment. A chamber is not to be used as a storage compartment. The chamber and the air and oxygen supply systems shall be checked prior to each use with the Predive Checklist and in accordance with PMS instructions. All diving personnel shall be trained in the operation of the recompression chamber Y A recompression chamber system must have a primary and a secondary air supply system that satis�es Table 21 . The purpose of this requirement is to ensure the recompression chamber system, at a minimum, is capable of conducting a Treatment Table 6A (TT6 Capacity. Either system may consist of air banks and2or a suitable compressor. The primary air supply system must have suf�cient air to pressurize the inner lock once to 168 fsw and the outer lock twice to 168 fsw and ventilate the chamber as Table 210 (8 x V ) . (10 x V ) . RV RV required ventilation. See paragraph 2108.7 for Category A and B The secondary air supply system must have suf�cient air to pressurize the inner and Table 210 (8 x V ) . (8 x V ) . RV RV required ventilation. For Category A, B, and C, use 7,227 for ventilation rate of 70.7 scfm for one hour. For Category D and E, calculate air or NITRO required for two patients and one tender to breathe BIBS U.S. Navy Diving Manual — Volume 5 Table 21 Recompression Chamber Air Supply Requirements Primary Air Requirement Secondary Air Requirement CATEGOR A: CATEGOR CATEGOR . CATEGOR . CATEGOR Air . Additional 21-17 OPERATION To ensure each item is operational and ready for use, perform the equipment checks listed in the Recompression Chamber Predive Checklist, Ensure dogs are in good operating condition and seals are tight. Do not leave doors dogged (if applicable) after pressurization. Do not allow open �ames, smoking materials, or any �ammables to be carried into the chamber. Do not permit electrical appliances to be used in the chamber unless listed in the Authorized for Navy Use (ANU). Do not perform unauthorized repairs or modi�cations on the chamber support Do not permit products in the chamber that may contaminate or off0gas into the Tender closes and dogs (if so equipped) the inner lock door. Pressurize the chamber, at the rate and to the depth speci�ed in the appropriate As soon as a seal is obtained or upon reaching depth, tender releases the dogs Ventilate chamber according to speci�ed rates and energize CO scrubber and U.S. Navy Diving Manual — Volume 5 Valve Two-valve Valve Two-valve BREATHING 21-19 Temperature Tank Chamber: CO Urinal Primary Chamber: Heater/chiller for recompression treatment time, decompression time, Fresh Volume Ventilation Chamber Operating Secondary Bedpan U.S. Navy Diving Manual — Volume 5 Tender Change-Out. During extensive treatments, medical personnel may prefer to lock0in to examine the patient and then lock0out, rather than remain inside Lock-In Operations. Personnel entering the chamber go into the outer lock and close and dog the door (if applicable). The outer lock should be pressurized at a rate controlled by their ability to equalize, but not to exceed 78 feet per minute. decompression schedule for the occupants when they are ready to leave the chamber. When the pressure levels in the outer and inner locks are equal, the inside Lock-Out Operations. To exit the chamber, the personnel again enter the outer lock and the inside tender closes and dogs the inner door (if so equipped). When ready to ascend, the Diving Supervisor is noti�ed and the required decompression schedule is selected and executed. Constant communications are maintained with the inside tender to ensure that a seal has been made on the inner door. Outer lock depth is controlled throughout decompression by the outside tender. Gag Valves. The actuating lever of the chamber gag valves shall be maintained in the open position at all times, during both normal chamber operations and when the chamber is secured. The gag valves must be closed only in the event of relief valve failure during chamber operation. Valves are to be lock0wired in the open position with light wire that can be easily broken when required. A WARNING plate, bearing the inscription shown below, shall be af�xed to the chamber in the vicinity of each gag valve and shall be readily viewable by operating personnel. The WARNING plates shall measure approximately 7 inches by 6 inches and read WARNING Ventilation. The basic rules for ventilation are presented below. These rules permit conditions as measured at chamber pressure (the rules are designed to ensure that the effective concentration of carbon dioxide will not exceed 1.8 percent (11.7 mmHg) and that when oxygen is being used, the percentage of oxygen in the rest and 7 cubic feet per minute (acfm) for each diver who is not at rest (i.e., a When oxygen is breathed from the built0in breathing system (BIBS), provide 12.8 acfm for a diver at rest and 28 acfm for a diver who is not at rest. When these ventilation rates are used, no additional ventilation is required for personnel breathing air. These ventilation rates apply only to the number of 21-21 people breathing oxygen and are used only when no BIBS dump system is If ventilation must be interrupted for any reason, the time should not exceed 8 minutes in any 600minute period. When ventilation is resumed, twice the volume of ventilation should be used for the time of interruption and then the If a BIBS dump system or a closed circuit BIBS is used for oxygen breathing, If portable or installed oxygen and carbon dioxide monitoring systems are available, ventilation may be adjusted to maintain the oxygen level below 28 percent by volume and the carbon dioxide level below 1.8 percent surface Chamber Ventilation Knowing how much air must be used does not solve actually being used for ventilation. The standard procedure is to open the exhaust valve a given number of turns (or fraction of a turn), which will provide a certain number of cubic feet of ventilation per minute at a speci�c chamber depth, and to use the supply valve to maintain a constant chamber depth during the ventilation at different depths is accomplished as follows. WARNING This procedure is to be performed with an unmanned chamber to avoid Check the basic ventilation rules above against probable situations to determine the rates of ventilation at various depths (chamber pressure) that may be needed. If the air supply is ample, determination of ventilation rates for a few depths (60, 60, 100, and 168 feet) may be suf�cient. It will be convenient to know the valve settings for rates such as 6, 12.8, 28, or 67.8 cubic feet per minute Determine the necessary valve settings for the selected �ows and depths by Calculate how long it will take to change the chamber pressure by 10 T R (D = – U.S. Navy Diving Manual — Volume 5 T V internal volume of chamber (or of lock being used for test) in cubic rate of ventilation desired, in cubic feet per minute as measured at P Determine how long it will take the pressure to drop from 170 to 160 feet in a 7280cubic0foot chamber if the exhaust valve is releasing 6 T V P Substitute values and solve to �nd how long it will take for the pressure T = + = 215 second = 215 seconds 60 sec () Increase the empty chamber pressure to 8 feet beyond the depth in question. Open the exhaust valve and determine how long it takes to come up 10 feet (for example, if checking for a depth of 168 fsw, take chamber pressure to 170 feet and clock the time needed to reach 160 feet). Open the valve to different settings until you can determine what setting will approximate the desired time. Record the setting. Calculate ventilation rate and prepare a ventilation bill, using this information and Notes on Chamber Ventilation. The basic ventilation rules are not intended to limit ventilation. Generally, if air is reasonably plentiful, more air than speci�ed should be used for comfort. This increase is desirable because it also further lowers the concentrations of carbon 21-23 There is seldom any danger of having too little oxygen in the chamber. Even with no ventilation and a high carbon dioxide level, the oxygen present would These rules assume that there is good circulation of air in the chamber during ventilation. If circulation is poor, the rules may be inadequate. Locating the Coming up to the next stop reduces the standard cubic feet of gas in the cha Continuous ventilation is the most ef�cient method of ventilation in terms of the amount of air required. However, it has the disadvantage of exposing the divers in the chamber to continuous noise. At the very high ventilation rates required for oxygen breathing, this noise can reach the level at which hearing loss becomes a hazard to the divers in the chamber. If high sound levels do occur, especially during exceptionally high ventilation rates, the chamber occupants must wear ear protectors (available as a stock item). A small hole should be drilled into the central cavity of the protector so that they do not pro The size of the chamber does not in�uence the rate (acfm) of air required for Increasing depth increases the actual mass of air required for ventilation; but when the amount of air is expressed in volumes as measured at chamber pres If high0pressure air banks are being used for the chamber supply, pressure changes in the cylinders can be used to check the amount of ventilation being To ensure equipment receives proper postdive maintenance Every USN recompression chamber shall adhere to PMS requirements and shall be pressure tested when initially installed, at 20year intervals thereafter, and after a major overhaul or repair. This test shall adhere to PMS requirements and shall be conducted in accordance with Figure 2101 . The installed chamber, removing and reinstalling constitutes a major overhaul and requires a pressure test. For portable chambers such as the TRCS, SNDLRCS, and FARCC, follow operating procedures after moving the chamber prior to U.S. Navy Diving Manual — Volume 5 View Ports and Doors View-ports operation Navy Diving Manual, Operating Procedures (OPs), Emergency Procedures (EPs), ven 21-25 Two-valve Two-valve manned use. Chamber relief valves shall be tested in accordance with the Planned to indicate the valve set pressure, date of test, and testing activity. After every use or once a month, whichever comes �rst, the chamber shall receive routine maintenance in accordance with the Postdive Checklist. At this time, minor repairs At the discretion of the activity, but at least once a year, the chamber shall be inspected, both inside and outside. Any deposits of grease, dust, or other dirt shall be removed and, on steel chambers, the affected areas repainted. Corrosion is removed best by hand or by using a scraper, being careful area around it should then be cleaned to remove any remaining paint and2or Painting Steel Chambers. Steel Chambers shall be painted utilizing original paint speci�cations and in accordance with approved NAVSEA or NAVFAC procedures. The following paints shall be utilized on NAVSEA carbon steel chambers= U.S. Navy Diving Manual — Volume 5 When After At Test Pressurize Mark repair, View-Port lubricant. Acrylic view-ports should not come in contact with any volatile Weldment NAVSEA Repeat Pressurize WARNING Depressurize Repeat Test 21-27 STANDARD U.S. NAV _____________________________________________________________ Type Transportable Fly-Away (FARCC) NAME PLATE DATA ___________________________________________________________________ ______________________________________________________________ _____________________________________________________________ Working _______________________________________________________ Test _________________________________________________________ Test _______________________________________________________________ Conduct Test ______________________ __________________________________________________________________________ __________________________________________________________________________ 2 Close . Test A. Shell _____________________ View _____________________ Door _____________________ Door _____________________ Valve _____________________ Pipe _____________________ Shell Welds _____________________ Increase Test _________________________ Test U.S. Navy Diving Manual — Volume 5 STANDARD U.S. NAV Depressurize lock slowly to 165 fsw (73 psig) . Secure all supply and exhaust valves and hold for one hour Time ___________________________ Time ___________________________ ________________ If pressure drops below 145 fsw (65 psig) locate and mark leaks . Depressurize, repair, and retest inner lock _______________ Test Depressurize . Repeat Outer Test A. Shell _____________________ View _____________________ Door _____________________ Door _____________________ Valve _____________________ Pipe _____________________ Shell Welds _____________________ Maximum Test _________________________ Test Inner Test Time ___________________________ Time ___________________________ ________________ ________ Test All ______________________________________________ Test ______________________________________________ ______________________________________________ Test 21-29 For original paint speci�cation on NAVFAC steel chambers refer to the Operation and Maintenance Support Information (OMSI) documentation delivered with the Recompression Chamber Paint Process Instruction. Painting shall be kept to an absolute minimum. Only the coats prescribed above are to be applied. Naval Sea Systems Command will issue a Recompression Chamber Paint Process Instruction (NAVSEA000C60PI0001) on request. Stainless Steel Chambers. Stainless steel chamber such as the TRCS and SNDLRCS do not require surfaces painted for corrosion resistance, only for cosmetic purposes. Naval Sea Systems Command will provide a Stainless Steel Fire Hazard Prevention. The greatest single hazard in the use of a recompression chamber is from expl sive �re. Fire may spread two to six times faster in a pressurized chamber than at atmospheric conditions because of the high partial pressure of oxygen in the chamber atmosphere. The following precautions shall be Maintain the chamber oxygen percentage as close to 21 percent as possible and Remove any �ttings or equipment that do not conform with the standard requirements for the electrical system or that are made of �ammable materials. Use only mattresses designed for hyperbaric chambers. Use Durett Product or submarine mattress (NSN 7210000027808878 or 8877). Other mattresses may cause atmospheric contamination. Mattresses should be enclosed in �ame proof covers. Use 100% cotton sheets and pillow cases. Put no more bedding in a chamber than is necessary for the comfort of the patient. Never use blan kets of wool or synthetic �bers because of the possibility of sparks from static electricity. U.S. Navy Diving Manual — Volume 5 Clothing worn by chamber occupants shall be made of 100% cotton, or a �ame resistant blend of cotton and polyester for chambers equipped with a �re extinguisher or �xed hand0held or �re suppression system. Diver swim trunks Keep oil and volatile materials out of the chamber. If any have been used, ensure that the chamber is thoroughly ventilated before pressurization. Do not put oil on or in any �ttings or high0pressure line. If oil is spilled in the cham removed. If lubricants are required, use only those approved and listed in Ships Technical Manual (NSTM) NAVSEA S90860H70STM0000, Chapter 262. Regularly inspect and clean air �lters and accumulators in the air supply lines to protect against the introduction of oil or other vapors into the chamber. Permit no one to wear oily clothing into the chamber. Permit no one to carry smoking materials, matches, lighters or any �ammable materials into a chamber. A WARNING sign should be posted outside the chamber. Example: WARNING chamber. Fire Extinguishing. All recompression chambers must have a means of extinguishing a �re in the int rior. Examples of �re protection include wetted towels, a bucket of water, �re extinguisher, hand0held hose system, or suppression2 deluge system. Refer to U.S. Navy General Speci�cation for the Design, Construction, and Repair of Diving and Hyperbaric Equipment (TS8000AU0SPN0 010) for speci�c requirements of �re protection systems. Only �re exti listed on the NAVSEA Authorized for Navy Use (ANU) are to be used. DIVER CANDIDATE PRESSURE All U.S. Navy diver candidates shall be physically quali�ed in accordance with Manual of the Medical Department , Art. 180102. Candidates shall also pass a pressure test before they are eligible for diver training. This test may be conducted at any Navy certi�ed recompression chamber, provided it is administered by qual Candidate Requirements. The candidate must demonstrate the ability to equalize pressure in both ears to a depth of 60 fsw. The candidate shall have also passed the screening physical read ness test in accordance with MILPERSMAN 12200100, 21-31 Candidates shall undergo a diving physical examination by a Navy Medical Of�cer in accordance with the Manual of the Medical Department, Art. 180102, and be quali�ed to undergo the test. The candidates and the tender enter the recompression chamber and are pressurized to 60 fsw on air, at a rate of 78 fpm or less as tolerated by the If a candidate cannot complete the descent, the chamber is stopped and the All candidates shall remain at the immediate chamber site for a minimum of 18 minutes and at the test facility for 1 hour. Candidates or tenders who must , Art. 12200100 , Art. 180102 U.S. Navy Diving Manual — Volume 5 PAGE INTENTIONALLY 5A-1 APPENDIX 5A Neurological Examination This appendix provides guidance on evaluating diving accidents prior to trea Figure 8A is a guide aimed at non0medical personnel for recording essential details and conducting a neurological examination. Copies of this form should be readily available. While its use is not mandatory, it provides a useful aid for INITIAL ASSESSMENT OF DIVING When using the form in Figure 8A , the initial assessment must gather the When a diver reports with a medical complaint, a history of the case shall be compiled. This history should include facts ranging from the dive pro�le to progression of the medical problem. If available, review the divers Health Record and completed Diving Chart or Diving Log to aid in the examination. A few key needed. If the preliminary diagnosis shows the need for immediate recompression, proceed with recompression. Complete the examination when the patient stabilizes at treatment depth. Typical questions should include the following: Describe the pain: U.S. Navy Diving Manual — Volume 5 Were the symptoms �rst noted before, during, or after the dive? If after the If during the dive, did the patient notice the symptom while descending, on the Has the patient ever suffered from decompression sickness or gas embolism in Describe this symptom in relation to the prior incident if applicable. 11. Does the patient have any concurrent medical conditions that might explain the To aid in the evaluation, review the divers Health Record, including a baseline neurological examination, if available, and completed Diving Chart or Diving Log, NEUROLOGICAL There are various ways to perform a neurological examination. The quickest infor mation pertinent to the diving injury is obtained by directing the initial examination toward the symptomatic areas of the body. These concentrate on the motor, sensory, and coordination functions. If this examination is normal, the most productive The following procedures are adequate for preliminary examination. Figure 8A 5A-3 NEUROLOGICAL EXAMINATION CHECKLIST =HEER & N )h =EE REVR NF ,OOEMDIV ), FNP EVALIMARINM OPNCEDSPEQ AMD DEFIMIRINMQ NF REPLQ$h 8ARIEMRQ 7ALE− @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@2ARE%;ILE− @@@@@@@@@@@@@@@@@@@@@@@@@@@@ 2EQCPIBE OAIM%MSLBMEQQ− @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ HISTORY ;WOE NF DITE KAQR OEPFNPLED− @@@@@@@@@@@@@@@@@ 2EORH− @@@@@@@@@@@@@ 6NU KNMG− @@@@@@@@@@@@@@@@@ 7SLBEP NF DITEQ IM KAQR )( HNSPQ− @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ TAQ QWLORNL MNRICED BEFNPEe DSPIMG NP AFREP RHE DITE. @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 7F DSPIMGe UAQ IR UHIKE DEQCEMDIMGe NM RHE BNRRNL NP AQCEMDIMG. @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 6AQ QWLORNL IMCPEAQED NP DECPEAQED QIMCE IR UAQ FIPQR MNRICED. @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 6ATE AMW NRHEP QWLORNLQ NCCSPPED QIMCE RHE FIPQR NME UAQ MNRICED. @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 2EQCPIBE− @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 6AQ OARIEMR ETEP HAD A QILIKAP QWLORNL BEFNPE. @@@@@@@@@@@@@@@@@@@THEM− @@@@@@@@@@@@@@@@@@@@@@@@ @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ MENTAL STATUS/STATE OF CONSCIOUSNESS _______________________________________________________________________________________ _______________________________________________________________________________________ COORDINATION STRENGTH (Grade 0 to 5) TAKJ− @@@@@@@@@ 6EEK#RN ;NE− @@@@@@@@@ 9NLBEPG− @@@@@@@@@ 1IMGEP#RN#7NQE− @@@@@@@@@ 6EEK =HIM =KIDE− @@@@@@@@@ 9AOID 6NTELEMR− @@@@@@@@@ CRANIAL NERVES =EMQE NF =LEKK 7h− @@@@@@@@ =IQINM%=IQSAK 1KD 77h− @@@@@@@@@ 0WE 6NTELEMRQe 8SOIKQ 777e 7=e =7h− @@@@@@@@@ 1ACIAK =EMQARINMe .HEUIMG =h− @@@@@@@@@ 1ACIAK 0VOPEQQINM 6SQCKEQ =77h− @@@@@@@@@ 6EAPIMG =777h− @@@@@@@@@ LOOEP 6NSRHe ;HPNAR =EMQARINM 7?h− @@@@@@@@@ 2AG – =NICE ?h− @@@@@@@@@ =HNSKDEP =HPSG ?7h− @@@@@@@@@ ;NMGSE ?77h− @@@@@@@@@ UPPER BODY 2EKRNIDQ 8 @@@@ 9 @@@@ 8ARIQQILSQ 8 @@@@ 9 @@@@ 0ICEOQ 8 @@@@ 9 @@@@ ;PICEOQ 8 @@@@ 9 @@@@ 1NPEAPLQ 8 @@@@ 9 @@@@ 6AMDQ 8 @@@@ 9 @@@@ LOWER BODY Hips 1KEVINM 8 @@@ 9 @@@@ 0VREMQINM 8 @@@ 9 @@@@ ,BDSCRINM 8 @@@ 9 @@@@ ,DDSCRINM 8 @@@ 9 @@@@ Knees 1KEVINM 8 @@@ 9 @@@@ 0VREMQINM 8 @@@@ 9 @@@@ U.S. Navy Diving Manual — Volume 5 .86 L= 5A-5 This is best determined when you �rst see the patient and is characterized by his alertness, orientation, and thought process. Obtain a good history, including the dive pro�le, present symptoms, and how these symptoms have changed since onset. The patients response to this questioning and that during the neurological examination will give you a great deal of information about his mental status. It is important to determine if the patient knows the time and place, and can recognize familiar people and understands what is happening. Is the patients mood appropriate? Next the examiner may determine if the patients memory is intact by questioning the patient. The questions asked should be reasonable, and you must know the What is your commanding of�cers name? Finally, if a problem does arise in the mental status evaluation, the examiner may choose to assess the patients cognitive function more fully. Cognitive function is an intellectual process by which one becomes aware of, perceives, or compr ideas and involves all aspects of perception, thinking, reasoning, and remembering. The patient should be asked to remember something. An example would be “red ball, green tree, and couch. Inform him that later in the examination you The patient should be asked to spell a word, such as “world,” backwards. The patient should be asked to recall the information he was asked to remember Coordination (Cerebellar/Inner Ear Function) A good indicator of muscle strength and general coordination is to observe how the patient walks. A normal gait indicates that many muscle groups and general brain functions are normal. More thorough examination involves testing that concentrates on the brain and inner ear. In conducting these tests, both sides of the body shall be tested and the results shall be compared. These tests include: Heel-to-Toe Test. The tandem walk is the standard “drunk driver” test. While looking straight ahead, the patient must walk a straight line, placing the heel of one foot directly in front of the toes of the opposite foot. Signs to look for and U.S. Navy Diving Manual — Volume 5 Romberg Test. balance or if he immediately falls to one side. Some examiners recommend Finger-to-Nose Test. The patient stands with eyes closed and head back, arms extended to the side. Bending the arm at the elbow, the patient touches his nose with an extended fore�nger, alternating arms. An extension of this test is to have the patient, with eyes open, alternately touch his nose with his �ngertip and then touch the �ngertip of the examiner. The examiner will change the position of his �ngertip each time the patient touches his nose. In this version, Heel-Shin Slide Test. While standing, the patient touches the heel of one foot to the knee of the opposite leg, foot pointing forward. While maintaining this contact, he runs his heel down the shin to the ankle. Each leg should be tested. Rapid Alternating Movement Test. The patient slaps one hand on the palm of the other, alternating palm up and then palm down. Any exercise requiring rapidly changing movement, however, will suf�ce. Again, both sides should be The cranial nerves are the 12 pairs of nerves emerging from the cranial cavity through various openings in the skull. Beginning with the most anterior (front) on the brain stem, they are appointed Roman numerals. An isolated cranial nerve lesion is an unusual �nding in decompression sickness or gas embolism, but de cits occasionally occur and you should test for abnormalities. Olfactory. The olfactory nerve, which provides our sense of smell, is usually Optic. The optic nerve is for vision. It functions in the recognition of light and shade and in the perception of objects. This test should be completed one eye at a time to determine whether the patient can read. Ask the patient if he has any blurring of vision, loss of vision, spots in the visual �eld, or peripheral vision the patient and asking him to cover one eye and look straight at you. In a plane midway between yourself and the patient, slowly bring your �ngertip in turn from above, below, to the right, and to the left of the direction of gaze until the patient can see it. Compare this with the earliest that you can see it with the equivalent eye. If a de�cit is present, roughly map out the positions of the blind Oculomotor, (IV.) Trochlear, (VI.) Abducens. These three nerves control eye movements. All three nerves can be tested by having the patients eyes follow the examiners �nger in all four directions (quadrants) and then in towards the tip of the nose (giving a “crossed0eyed look). The oculomotor nerve can be 5A-7 further tested by shining a light into one eye at a time. In a normal response, the V. Trigeminal. The Trigeminal Nerve governs sensation of the forehead and face and the clenching of the jaw. It also supplies the muscle of the ear (tensor tympani) necessary for normal hearing. Sensation is tested by lightly stroking Facial. The Facial Nerve controls the face muscles. It stimulates the scalp, forehead, eyelids, muscles of facial expression, cheeks, and jaw. It is tested of the nasolabial folds (lines from nose to outside corners of the mouth) should Acoustic. The Acoustic Nerve controls hearing and balance. Test this nerve by whispering to the patient, rubbing your �ngers together next to the patients ears, or putting a tuning fork near the patients ears. Compare this against the other ear. Glossopharyngeal. The Glossopharyngeal Nerves transmit sensation from the upper mouth and throat area. It supplies the sensory component of the gag re�ex and constriction of the pharyngeal wall when saying “aah. Test this nerve by touching the back of the patients throat with a tongue depressor. This should cause a gagging response. This nerve is normally not tested. Vagus. The Vagus Nerve has many functions, including control of the roof of the mouth and vocal cords. The examiner can test this nerve by having the patient say “aah” while watching for the palate to rise. Note the tone of the Spinal Accessory. The Spinal Accessory Nerve controls the turning of the head from side to side and shoulder shrug against resistance. Test this nerve by having the patient turn his head from side to side. Resistance is provided by placing one hand against the side of the patients head. The examiner should note that an injury to the nerve on one side will cause an inability to turn the head to the opposite side or weakness2absence of the shoulder shrug on the affected side. Hypoglossal. The Hypoglossal Nerve governs the muscle activity of the tongue. An injury to one of the hypoglossal nerves causes the tongue to twist to that Motor. A diver with decompression sickness may experience disturbances in the muscle system. The range of symptoms can be from a mild twitching of a muscle to wea ness and paralysis. No matter how slight the abnormality, symptoms U.S. Navy Diving Manual — Volume 5 Extremity Strength. It is common for a diver with decompression illness to experience muscle wea ness. Extremity strength testing is divided into two parts: upper body and lower body. All muscle groups should be tested and compared with the corresponding group on the other side, as well as with the examiner. Table Paralysis. Profound Weakness. Severe Weakness. Able to contract muscle but cannot move joint against gravity. Moderate Weakness. Able to overcome the force of gravity but not the resistance of the examiner. Mild Weakness. Able to resist slight force of examiner. Normal. Equal strength bilaterally (both sides) and able to resist examiner. Upper Extremities. These muscles are tested with resistance provided by the examiner. The patient should overcome force applied by the examiner that is tailored to the patients strength. Table 8A describes the extremity strength tests. Triceps. Lower Extremities. The lower extremity strength is assessed by watching the patient walk on his heels for a short distance and then on his toes. The patient should then walk while squa ting (“duck walk”). These tests adequately assess lower extremity strength, as well as balance and coordination. If a more detailed examination of the lower extremity strength is desired, testing should be accomplished at each Muscle Size. Muscles are visually inspected and felt, while at rest, for size and Muscle Tone. Feel the muscles at rest and the resistance to passive movement. Look and feel for abnormalities in tone such as spasticity, rigidity, or no tone. Involuntary Movements. Inspection may reveal slow, irregular, and jerky Common presentations of decompression sickness in a diver 5A-9 Table 5A Extremity Strength Tests Test The patient’s The patient’s patient’s elbow, patient’s patient’s Triceps elbow, patient’s patients • The examiners • The patients together, patients • The • The f the �oor. patient’s patient’s Abduction patient’s Adduction The patient’s patient’s patient’s patient’s patient’s Toes • The • The examiner. U.S. Navy Diving Manual — Volume 5 Tingling (“pins0and0needles feeling; also called paresthesia) Sensory Examination. An examination of the patients sensory faculties should be Figure 8A shows the dermatomal (sensory) areas of skin sensations that correlate with each spinal cord segment. Note that the dermatomal areas of the trunk run in a circular pattern around the trunk. The dermatomal areas in the arms and legs run in a more lengthwise pattern. In a complete examination, each spinal Sensations easily recognized by most normal people are sharp2dull discrimination (to perceive as separate) and light touch. It is possible to test pressure, temper ture, and vibration in special cases. The likelihood of DCS affecting only one sense, however, is very small. An ideal instrument for testing changes in sensation is a sharp object, such as the Wartenberg pinwheel or a common safety pin. Either of these objects must applied at intervals. Avoid scratching or penetrating the skin. It is not the Testing the Trunk. Move the pinwheel or other sharp object from the top of the shoulder slowly down the front of the torso to the groin area. Another method is to run it down the rear of the torso to just below the buttocks. The patient should be asked if he feels a sharp point and if he felt it all the time. Test each dermatome by going down the trunk on each side of the body. Test the neck area in similar Testing Limbs. In testing the limbs, a circular pattern of testing is best. Test each limb in at least three locations, and note any difference in sensation on each side of the body. On the arms, circle the arm at the deltoid, just below the elbow, and at the wrist. In testing the legs, circle the upper thigh, just below the knee, and the Testing the Hands. The hand is tested by running the sharp object across the back Marking Abnormalities. If an area of abnormality is found, mark the area as a reference point in asses ment. Some examiners use a marking pen to trace the area of decreased or increased sensation on the patients body. During treatment, these areas are rechecked to determine whether the area is improving. An example of Deep Tendon The purpose of the deep tendon re�exes is to determine if the patients response is normal, nonexistent, hypoactive (de�cient), or hyperactive (excessive). The patients response should be compared to responses the examiner bilaterally (both sides) and if the upper and lower re�exes are similar. If any difference in the re�exes is noticed, the patient should be asked if there is a prior 5A-11 Areas Occipital Supraclav Lat. Intercostals Post. Cutan. Dorsal Cutan. Radial Musculo. Cutan. Med Cutan. Radial Median Ulnar Post. Cutan. Femoral-Saphenous Sciatic Tibial Sural Plantars Med. Lat. C8 C7 L5 L4 L3 C4 C3 C2 T2 C6 T1 C5 T8 T4 T6 T2 U.S. Navy Diving Manual — Volume 5 Areas Cran 5 Superclav. Intercostal Med. Cutan. Median Ulnar Deep Peroneal C2 C3 C4 C5 C6 C7 T3 T4 T6 T8 C8 L1 L2 L3 L4 L5 Musculo. Cutan. Post Cutan. Femoral Ant. Cutan. Peroneal Saphenous Sup. Peroneal Sural - Tibal Lat. Cutan. 5A-13 medical condition or injury that would cause the difference. Isolated differences should not be treated, because it is extremely dif�cult to get symmetrical responses and with sharp, quick taps. Usually, if a deep tendon re�ex is abnormal due to sion sickness, there will be other abnormal signs present. Test the biceps, triceps, knee, and ankle re�exes by striking the tendon as described in Table 8A0 Table 5A Test patient’s patient’s examiner’s patient’s patient’s patient’s hammer, patient’s Triceps patient’s patient’s patient’s hammer, The patient’s Achilles’ U.S. Navy Diving Manual — Volume 5 PAGE INTENTIONALLY 5B—First Aid APPENDIX 5B First This appendix, covering one0man cardiopulmonary resuscitation, control of bleeding and shock treatment is intended as a quick reference for individuals trained in �rst aid and basic life support. Complete descriptions of all basic life support techniques are available through your local branch of the American Heart Association. Further information on the control of bleeding and treatment for shock , NAVEDTRA 106690C. Y RESUSCITATION All divers must be quali�ed in cardiopulmonary resuscitation (CPR) in acco with the procedures of the American Heart Association. Periodic recerti�cation according to current guidelines in basic life support is mandatory for all Navy divers. Training can be requested through your local medical command or directly through your local branch of the American Heart Association. CONTROL OF MASSIVE Massive bleeding must be controlled immediately. If the victim also requires resuscitation, the two problems must be handled simultaneously. Bleeding may External Arterial Hemorrhage. Arterial bleeding can usually be identi�ed by bright red blood, gushing forth in jets or spurts that are synchronous with the pulse. The �rst measure used to control external arterial hemorrhage is direct pressure on the Direct Pressure. Pressure is best applied with sterile compresses, placed directly and �rmly over the wound. In a crisis, however, almost any material can be used. If the material used to apply direct pressure soaks through with blood, apply additional material on top; do not remove the original pressure bandage. Elevating the extremity also helps to control bleeding. If direct pressure cannot control Pressure Points. Bleeding can often be temporarily controlled by applying hand pressure to the appropriate pressure point. A pressure point is a place where the main artery to the injured part lies near the skin surface and over a bone. Apply pressure at this point with the �ngers (digital pressure) or with the heel of the hand; no �rst aid mat rials are required. The object of the pressure is to compress the artery against the bone, thus shutting off the �ow of blood from the heart to the U.S. Navy Diving Manual — Volume 5 Pressure Point Location on Face. There are 11 principal points on each side of the body where hand or �nger pre sure can be used to stop hemorrhage. These points are shown in Figure 8B . If bleeding occurs on the face below the level of the eyes, apply pressure to the point on the mandible. This is shown in (A). To �nd this pressure point, start at the angle of the jaw and run your �nger forward along the lower edge of the mandible until you feel a small notch. Pressure Point Location for Shoulder or Upper Arm. If bleeding is in the shoulder or in the upper part of the arm, apply pressure with the �ngers behind the clavicle. You can press down against the �rst rib or forward against the clavicle—either kind of pressure will stop the bleeding. This pressure point is shown in Pressure Point Location for Middle Arm and Hand. Bleeding between the middle of the upper arm and the elbow should be controlled by applying digital pressure elbow. This compresses the artery against the bone of the arm. The application of pressure at this point is shown in Figure 8B (C). Bleeding from the hand can be controlled by pressure at the wrist, as shown in Figure 8B (D). If it is possible to hold the arm up in the air, the bleeding will be relatively easy to stop. Pressure Point Location for Thigh. Figure 8B (E) shows how to apply digital pressure in the middle of the groin to control bleeding from the thigh. The artery at this point lies over a bone and quite close to the surface, so pressure with your Pressure Point Location for Foot. Figure 8B (F) shows the proper position for controlling bleeding from the foot. As in the case of bleeding from the hand, Pressure Point Location for Temple or Scalp. If bleeding is in the region of the temple or the scalp, use your �nger to compress the main artery to the temple against the skull bone at the pressure point just in front of the ear. Figure 8B Pressure Point Location for Neck. If the neck is bleeding, apply pressure below the wound, just in front of the prom nent neck muscle. Press inward and slightly backward, compressing the main artery of that side of the neck against the bones of the spinal column. The applic tion of pressure at this point is shown in (H). Do not apply pressure at this point unless it is absolutely essential, since Pressure Point Location for Lower Arm. Bleeding from the lower arm can be controlled by applying pressure at the elbow, as shown in Pressure Point Location of the Upper Thigh. As mentioned before, bleeding in the in the middle of the groin, as shown in Figure 8B 5B—First Aid TEMPORAL A. EXTERNAL CARTOID A. AUXILIARY A. VENA CAVA PERONEAL A. POSTERIOR FACIAL V. JUGULAR V. FEMORAL V. SUBCLAVIN V. CEPHALIC V. BASILIC V. ILIAC V. GREAT SAPHENOUS V. DORSAL VENOUS ARCH FACIAL A. SUBCLAVIN A. BRACHIAL A. RADIAL ULMAR A. A. ILIAC A. SUPERFICIAL TEMPORAL A. COMMON CARTOID A. BRACHIAL A. FEMORAL A. POPLITEAL A. ANTERIOR POSTERIOR TIBIAL A. (A) (C) (K) (H) (I) (J) (D) (G) (E) (F) U.S. Navy Diving Manual — Volume 5 is more effective to use the pressure point of the upper thigh as shown in (J). If you use this point, apply pressure with the closed �st of one hand and use the other hand to give additional pressure. The artery at this point is deeply buried in some of the heaviest muscle of the body, so a great deal of pressure must Bleeding between the knee and the foot may be controlled by �rm pressure at the knee. If pressure at the side of the knee does not stop the bleeding, hold the front of the knee with one hand and thrust your �st hard against the artery behind the knee, as shown in (K). If necessary, you can place a folded compress or bandage behind the knee, bend the leg back and hold it in place by a �rm bandage. This is a most effective way of controlling bleeding, but it is so unco fortable for the victim that 11 You should memorize these pressure points so that you will know immediately which point to use for controlling hemorrhage from a particular part of the body. Remember, the correct pressure point is that which is (1) NEAREST THE WOUND and (2) BETWEEN THE WOUND AND THE MAIN PART OF THE BODY. When to Use Pressure Points. It is very tiring to apply digital pressure and it can seldom be maintained for more than 18 minutes. Pressure points are recommended for use while direct pressure is being applied to a serious wound by a second rescuer, or after a compress, bandage, or dressing has been applied to the wound, since it will slow the �ow of blood to the area, thus giving the direct pressure technique a better chance to stop the hemorrhage. It is also recommended as a A tourniquet is a constricting band that is used to cut off the supply of blood to an injured limb. Use a tourniquet only if the control of hemorrhage by other means proves to be dif�cult or impossible. A tourniquet must always be applied ABOVE the wound, i.e., towards the trunk, and it must be applied as close Basically, a tourniquet consists of a pad, a band and a device for tightening the band so that the blood vessels will be compressed. It is best to use a pad, compress or similar pressure object, if one is available. It goes under the band. It must be placed directly over the artery or it will actually decrease the pressure on the artery and thus allow a greater �ow of blood. If a tourniquet placed over a pressure object does not stop the bleeding, there is a good chance that the pressure object is in the wrong place. If this occurs, shift the object around until the tourniquet, when tightened, will control the bleeding. Any long �at material may be used as the band. It is important that the band be �at= belts, stockings, �at strips of rubber or neckerchiefs may be used; but rope, wire, string or very narrow pieces of cloth should not be used because they cut into the �esh. A short stick may be used to twist the band tightening the tourniquet. Figure 8B 5B—First Aid the arterial blood �ow to the limb, so be sure to draw the tourniquet tight enough to stop the bleeding. However, do not make it any tighter than necessary. After Bleeding is Under Control. After you have brought the bleeding under Points to Remember. Dont use a tourniquet unless you cant control the bleeding by any other Dont use a tourniquet for bleeding from the head, face, neck or trunk. Use it Always apply a tourniquet ABOVE THE WOUND and as close to the wound as possible. As a general rule, do not place a tourniquet below the knee or elbow except for complete amputations. In certain distal areas of the extremi ties, nerves lie close to the skin and may be damaged by the compression. Furthermore, rarely does one encounter bleeding distal to the knee or elbow Be sure you draw the tourniquet tight enough to stop the bleeding, but dont disappear. U.S. Navy Diving Manual — Volume 5 Dont loosen a tourniquet after it has been applied. Transport the victim to a medical facility that can offer proper care. Dont cover a tourniquet with a dressing. If it is necessary to cover the injured person in some way, MAKE SURE that all the other people concerned with the case know about the tourniquet. Using crayon, skin pencil or blood, mark a large “T on the victims forehead or on a medical tag attached to the wrist. External Venous Hemorrhage. Venous hemorrhage is not as dramatic as severe arterial bleeding, but if left unchecked, it can be equally serious. Venous bleeding Internal Bleeding. The signs of external bleeding are obvious, but the �rst aid team must be alert for the possibility of internal hemorrhage. Victims subjected to crushing injuries, heavy blows or deep puncture wounds should be observed Moist, clammy, pale skin Treatment of Internal Bleeding. Internal bleeding can be controlled only by trained medical personnel and often only under hospital conditions. Efforts in the �eld are generally limited to replacing lost blood volume through intravenous infusion of saline, Ringers Lactate, or other �uids, and the administration of oxygen. Rapid Shock may occur with any injury and will certainly be present to some extent with serious injuries. Shock is caused by a loss of blood �ow, resulting in a drop of blood pressure and decreased circulation. If not treated, this drop in the quantity of blood �owing to the tissues can have serious permanent effects, including death. Signs and Symptoms of Shock can be recognized from the following signs Respiration shallow, irregular, labored Eyes vacant (staring), lackluster, tired0looking 5B—First Aid Treatment. Shock must be treated before any other injuries or conditions except breathing and circulation obstructions and profuse bleeding. Proper treatment involves caring for the whole patient, not limiting attention to only a few of the disorders. The following steps must be taken to treat a patient in shock. Ensure adequate breathing. If the patient is breathing, maintain an adequate airway by tilting the head back properly. If the patient is not breathing, estab resuscitation. If both respiration and circulation have stopped, institute car Control bleeding. If the patient has bleeding injuries, use direct pressure points Administer oxygen. Remember that an oxygen de�ciency will be caused by the reduced circulation. Administer 100 percent oxygen. Elevate the lower extremities. Since blood �ow to the heart and brain may have been diminished, circulation can be improved by raising the legs slightly. It is not recommended that the entire body be tilted, since the abdominal organs pressing against the diaphragm may interfere with respiration. Exce to the rule of raising the feet are cases of head and chest injuries, when it is desirable to lower the pressure in the injured parts; in these cases, the upper part of the body should be elevated slightly. Whenever there is any doubt as to Avoid rough handling. Handle the patient as little and as gently as possible. Prevent loss of body heat. Keep the patient warm but guard against overheat ing, which can aggravate shock. Remember to place a blanket under as well as on top of the patient, to prevent loss of heat into the ground, boat or ship Keep the patient lying down. A prone position avoids taxing the circulatory system. However, some patients, such as those with heart disorders, will have U.S. Navy Diving Manual — Volume 5 PAGE INTENTIONALLY 5C—Dangerous Marine Animals APPENDIX 5C Dangerous Marine This appendix provides general information on dangerous marine life It is beyond the scope of this manual to catalog all types of marine encounters and potential injury. Planners should consult the recommended references listed at the end of this appendix for more de�nite information. Medical personnel are also a good source of information and should be consulted prior to operating in miliar waters. A good working knowledge of the marine environment should preclude lost time and severe injury. PREDATOR MARINE ANIMALS Shark attacks on humans are infrequent. Since 1968, the annual recorded number of shark attacks is only 70 to 100 worldwide. These attacks are unpredictable and injuries may result not only from bites, but also by coming in contact with the sharks skin. Shark skin is covered with very sharp dentine appendages, called denticles, which are reinforced with tooth0like centers. Contact Shark Pre-Attack Behavior. Pre0attack behavior by most sharks is somewhat predictable. A shark preparing to attack swims with an exaggerated motion, its pectoral �ns pointing down in contrast to the usual �ared out position, and it swims in circles of decreasing radius around the prey. An attack may be heralded by unexpected acceleration or other marked change in behavior, posture, or swim patterns. Should surrounding schools of �sh become unexplainably agitated, sharks may be in the area. Sharks are much faster and more powerful than any swimmer. First Aid and Treatment. Bites may result in a large amount of bleeding and tissue loss. Take immediate action to control bleeding using large gauze pressure bandages. Cover wounds with layers of compressive dressings preferably made with gauze, but easily made from shirts or towels, and held in place by wrapping the wound tightly extreme compression on pressure points will control all but the most serious bleeding. The major pressure points are= the radial artery pulse point for the hand; above the elbow under the biceps muscle for the forearm (brachial artery); and the groin area with deep �nger0tip or heel0of0the0hand pressure for bleeding from the leg (femoral artery). When bleeding cannot be controlled by U.S. Navy Diving Manual — Volume 5 be needed to save the victims life even though there is the possibility of loss If medical personnel are available, begin intravenous (IV) Ringers lactate or normal saline with a large0bore cannula (16 or 18 ga). If blood loss has been extensive, several liters should be infused rapidly. The patients color, pulse, and blood pressure should be used as a guide to the volume of �uid required. Maintain an airway and administer oxygen. Do not give �uids by mouth. If the patients cardiovascular state is stable, narcotics may be administered in small doses for pain relief. Observe closely for evidence of depressed respirations Initial stabilization procedures should include attention to the airway, breath Transport the victim to a medical facility as soon as possible. Reassure the place in a plastic bag and chill, but not in direct contact with ice. Transport the Types 5C—Dangerous Marine Animals Clean and debride wounds as soon as possible in a hospital or controlled envi 0ray, operative exploration should be performed to remove dislodged teeth. Consider 0ray evaluation for potential bone damage due to crush injury. Severe crush injury may result in acute renal failure due to myoglobin released from injured muscle, causing the urine to be a smoky brown color. Monitor closely for kidney function and adjust IV �uid therapy appropriately. Administer tetanus prophylaxis= Tetanus toxoid, 0.8 ml intramuscular (IM) and Culture infected wounds for both aerobes and anaerobes before instituting broad spectrum antibiotic coverage; secondary infections with Clostridium and Vibrio species have been reported frequently. 11. Acute surgical repair, reconstructive surgery, and hyperbaric oxygen (HBO) In cases of unexplained decrease in mental status or other neurological signs and symptoms following shark attack while diving, consider arterial gas embolism Killer whales live in all oceans, both tropical and polar. This whale is a large mammal with a blunt, rounded snout and high black dorsal �n ( Figure 8C0 ). The jet black head and back contrast sharply with the snowy0white underbelly. Usually, a white patch can be seen behind and above the eye. The killer whale is usually observed in packs of 6 to 70 whales. It has powerful jaws, great weight, speed, and interlocking teeth. Because of its speed and carnivorous habits, this animal should be treated with great respect. There have been no recorded attacks U.S. Navy Diving Manual — Volume 5 When killer whales are spotted, all personnel should immediately leave the water. Extreme care should be taken on shore areas, piers, barges, ice First Aid and Treatment. First aid and treatment would follow the same general Approximately 20 species of barracuda inhabit the oceans of the West Indies, the tropical waters from Brazil to Florida and the Indo0Paci�c oceans from the Red Sea to the Hawaiian Islands. The barracuda is a long, thin �sh with prominent jaws and teeth, silver to blue in color, with a large head and a V0shaped tail ( Figure 8C0 ). It may grow up to 10 feet long and is a fast swimmer, capable of striking rapidly and �ercely. It will follow swimmers but seldom attacks an underwater swimmer. It is known to attack surface swimmers and limbs dangling in the water. Barracuda wounds can be distinguished from those of a shark by the tooth pattern. A barracuda leaves straight or V0shaped wounds while those of a shark are curved like the shape of its jaws. Life threatening attacks by barracuda Barracuda are attracted by any bright object. Avoid wearing shiny equipment or jewelry in waters when barracudas are likely to be present. Avoid carrying speared �sh, as barracuda will strike them. Avoid splashing or dangling First Aid and Treatment. First aid and treatment follow the same general principles as those used for shark bites ( paragraph 8C ). Injuries are likely to be less While some temperate zone species of the moray eel are known, it primarily inhabits tropical and subtropical waters. It is a bottom dweller and is commonly found in holes and crevices or under rocks and coral. It is snake0 like in both appearance and movement and has tough, leathery skin ( Figure 8C0 ). It can grow to a length of 10 feet and has prominent teeth. A moray eel is extremely territorial and attacks frequently result from reaching into a crevice or hole occupied by the eel. It is a powerful and vicious biter and may be dif�cult to dislodge after a bite is initiated. Bites from moray eels may vary from multiple 5C—Dangerous Marine Animals small puncture wounds to the tearing, jagged type with profuse bleeding if there Extreme care should be used when reaching into holes or crevices. Avoid provoking or attempting to dislodge an eel from its hole. First Aid and Treatment. Primary �rst aid must stop the bleeding. Direct pressure and raising the injured extremity almost always controls bleeding. Arrange for medical follow0up. Severe hand injuries should be evaluated immediately by a physician. Mild envenomation may occur from a toxin that is released from the palatine mucosa in the mouth of certain moray eels. The nature of this toxin is not known. Treatment is supportive. Follow principles of wound management and tetanus prophylaxis as in caring for shark bites. Antibiotic therapy should be instituted early. Immediate specialized care by a hand surgeon may be necessary for tendon and nerve repair of the hand to prevent permanent damage and loss of Sea Lions. The sea lion inhabits the Paci�c Ocean and is numerous on the West Coast of the United States. It resembles a large seal. Sea lions are normally harmless; however, during the breeding season (October through December) large bull sea lions can become irritated and will nip at divers. Attempts by divers to handle these animals may result in bites. These bites appear similar to dog bites Divers should avoid these mammals when in the water. First Aid and Treatment. U.S. Navy Diving Manual — Volume 5 Wound infections are common and prophylactic antibiotic therapy is advised. VENOMOUS MARINE ANIMALS Venomous Fish (Excluding Stonefish, ebrafish, Scorpionfish). Identi�cation of a �sh following a sting is not always possible; however, sym toms and effects of venom do not vary greatly. Venomous �sh are rarely aggressive and usually contact is made by accidentally stepping on or handling the �sh. Dead �sh spines remain toxic (see Figure 8C0 ). Venom is generally heat0labile and may be decomposed by hot water. Local symptoms following a sting may �rst include severe pain later combined with numbness or even hypersens tivity around the wound. The wound site may become cyanotic with surrounding tissue becoming pale and swollen. General symptoms may include nausea, vomiting, sweating, mild fever, respiratory distress and collapse. The pain induced may seem disproportionately high to apparent severity of the injury. Medical personnel should be prepared for Avoid handling suspected venomous �sh. Venomous �sh are often found in holes or crevices or lying well camou�aged on rocky bottoms. Divers First Aid and Treatment. 1. 2. 3. Venomous 5C—Dangerous Marine Animals Wash wound with cold, salt water or sterile saline solution. Surgery may be required to open up the puncture wound. Suction is not effective to remove this Soak wound in hot water for 60 to 90 minutes. Heat may break down the venom. The water should be as hot as the victim can tolerate but not hotter than 122ºF (80ºC). Immersion in water above 122ºF (80ºC) for longer than a brief period may lead to scalding. Immersion in water up to 122ºF (80ºC) should therefore be brief and repeated as necessary. Use hot compresses if the wound is on the face. Adding magnesium sulfate (epsom salts) to the water offers no bene�t. Calcium gluconate injections, diazepam, or methocarbamol may help to reduce muscle spasms. In�ltration of the wound with 0.8 percent to 2.0 pe xylocaine with no epinephrine is helpful in reducing pain. If xylocaine with epinephrine is mistakenly used, local necrosis may result from both the toxin and epinephrine present in the wound. Narcotics may also be needed to manage Clean and debride wound. Spines and sheath frequently remain. Be sure to Tourniquets or ligatures are no longer advised. Use an antiseptic or antibiotic ointment and sterile dressing. Restrict movement of the extremity with immo Treat prophylactically with topical antibiotic ointment. If delay in treatment has occurred, it is recommended that the wound be cultured prior to adminis Toxic Fish (Stonefish, ebrafish, Scorpionfish). Stings by stone�sh, zebra�sh, and scorpion�sh have been known to cause fatal ties. While many similarities exist between these �sh and the venomous �sh of the previous section, a separate section has been included because of the greater to icity of their venom and the availability of an antivenin. The antivenin is speci�c for the stone�sh but may have some bene�cial effects against the scorpion�sh and zebra�sh. Local symptoms are similar to other �sh envenomation except that pain is more severe and may persist for many days. Generalized symptoms are often present and may include respiratory failure and cardiovascular collapse. These �sh are widely distributed in temperate and tropical seas and in some arctic waters. They are shallow0water bottom dwellers. Stone�sh and scorpion�sh are �attened vertically, dark and mottled. Zebra�sh are ornate and feathery in appearance with alternating First Aid and Treatment. U.S. Navy Diving Manual — Volume 5 Observe the patient carefully for the possible development of life0threatening complications. The venom is an unstable protein which acts as a myotoxin on respiratory depression, peripheral vasodilation, shock, cardiac dysrhythmias, Antivenin is available from Commonwealth Serum Lab, Melbourne, Australia (see Reference 7 at end of this appendix for address and phone number). If antivenin is used, the directions regarding dosage and sensitivity testing on the accompanying package insert should be followed and the physician must be ready to treat for anaphylactic shock (severe allergic reaction). In brief, one or two punctures require 2,000 units (one ampule); three to four punctures, 7,000 units (two ampules); and �ve to six punctures, 6,000 units (three ampules). Antivenin must be delivered by slow IV injection and the victim closely mon Institute tetanus prophylaxis, analgesic therapy and antibiotics as described for Toxic STONEFISH 5C—Dangerous Marine Animals The stingray is common in all tro ical, subtropical, warm, and temperate regions. It usually favors sheltered water and will burrow into sand with only eyes and tail exposed. It has a bat0like shape and a long tail Figure 8C0 ). Approximately 1,800 stingray attacks are reported annually in the U.S. Most attacks occur when waders inadvertently step on a ray, causing it to lash out defensively with its tail. The spine is located near the base of the tail. Wounds are either of the laceration or puncture type and are extremely painful. The wound appears swollen and pale with a blue rim. Secondary wound infections are common. Systemic symptoms may be present and can include fainting, nausea, vomiting, sweating, respiratory dif�culty, and cardiovascular collapse. In shallow waters which favor stingray habitation, shuf�e feet on the bottom and probe with a stick to alert the rays and chase them away. First Aid and Treatment. Give the same �rst aid as that given for venomous �sh ( paragraph 8C Clean and debride wound. Removal of the spine may additionally lacerate tis sues due to retropointed barbs. Be sure to remove integumental sheath as it will Observe patient carefully for the possible development of life0threatening complications. Symptoms can include cardiac dysrhythmias, hypotension, vomiting, diarrhea, sweating, muscle paralysis, respiratory depression, and cardiac arrest. Fatalities have been reported occasionally. Institute tetanus prophylaxis, analgesic therapy, and broad0spectrum antibio Hazardous types of coelenterates include= Portuguese man0of0war, sea wasp or box jelly�sh, sea nettle, sea blubber, sea anemone, and rosy anemone Figure 8C0 ). Jelly�sh vary widely in color (blue, green, pink, red, brown) or may be transparent. They appear to be balloon0like �oats with tentacles dangling down into the water. The most common stinging injury is the jelly�sh sting. Jelly�sh can come into direct contact with a diver in virtually any oceanic region, worldwide. When this happens, the diver is exposed to literally thousands of minute stinging . U.S. Navy Diving Manual — Volume 5 organs in the tentacles called nematocysts. Most jelly�sh stings result only in The sea wasp or box jelly�sh and Portuguese man0of0war are the most dangerous types. The sea wasp or box jelly�sh (found in the Indo0Paci�c) can induce death within 10 minutes by cardiovascu lar collapse, respiratory failure, and muscular paralysis. Deaths from Portuguese man0of0war stings have also been reported. Even though in toxication from ingesting poisonous sea anemones is rare, sea anemones 5C 1 Prevention. Do not handle jelly �sh. Beached or apparently dead specimens may still be able to sting. Even towels or clothing contami nated with the stinging nematocysts may cause stinging months later. Avoidance of Tentacles. In some species of jelly�sh, tentacles may trail for great distances horizontally or vertically in the water and are not easily seen by the diver. Swimmers and divers should avoid close proximity to jelly�sh to avoid contacting Protection Against Jellyfish. be worn when diving in waters where jelly�sh are abundant. Petroleum jelly applied to exposed skin (e.g., around the mouth) helps to prevent stinging, but First Aid and Treatment. Without rubbing, gently remove any remaining tentacles using a towel or clothing. For preventing any further discharge of the stinging nematocysts, use vinegar (dilute acetic acid) or a 60 to 100percent solution of acetic acid. An aqueous sol tion of 20 percent aluminum sulfate and 11 percent surfactant or preparations containing alcohol. Methylated spirits or methanol, 100 percent alcohol and alcohol plus seawater mixtures have all been demonstrated to cause a massive discharge of the nematocysts. In addition, these compounds may also worsen the skin in�ammatory reaction. Picric acid, human urine, and fresh water also have been found to either be ineffective or even to discharge nematocysts and should not be used. Rubbing sand or applying papain0containing meat tenderizer is ine fective and may lead to further nematocysts discharge and should not be used. It has been suggested that isopropyl (rubbing) alcohol may be effective. It of-War 5C—Dangerous Marine Animals 5C-11 Symptomatic Treatment. Symptomatic treatment can include topical steroid antihistamines or analgesics. Benzocaine topical anesthetic preparations should Anaphylaxis (severe allergic reaction) may result from jelly�sh Antivenin is available to neutralize the effects of the sea wasp or box jelly�sh (Chironex �eckeri). The antivenin should be administered slowly through an IV, with an infusion technique if possible. IM injection should be administered only if the IV method is not feasible. One container (vial) of sea wasp antivenin should be used by the IV route and three containers if injected by the IM route. Each container of sea wasp antivenin is 20,000 units and is to be kept refrigerated, not frozen, at 66–80ºF (2–10ºC). Sensitivity reaction to the antivenin should be treated with a subcutaneous injection of epinephrine (0.6 cc of 1=1,000 dilution), teroids, and antihistamines. Treat any hypotension (severely low blood pressure) with IV volume expanders and pressor medication as necessary. The antivenin may be obtained from the Commonwealth Serum Laboratories, Melbourne, Australia (see Reference 7 for address and phone number). Coral, a porous, rock0like formation, is found in tropical and subtropical waters. Coral is extremely sharp and the most delicate coral is often the most dangerous because of their razor0sharp edges. Coral cuts, while usually fairly super�cial, take a long time to heal and can cause temporary disability. The smallest cut, if left untreated, can develop into a skin ulcer. Secondary infections often occur and may be recognized by the presence of a red and tender area surrounding the wound. All coral cuts should receive medical attention. Some varieties of coral can actually sting a diver since coral is a coelenterate like jelly�sh. Some of the soft coral of the genus Palythoa have been found recently to contain the deadliest poison known to man. This poison is found within the body of the organism and not in the stinging nematocysts. The slime of this coral may cause a serious skin reaction (dermatitis) or even be fatal if exposed to an open wound. No antidote is Extreme care should be used when working near coral. Often coral is located in a reef formation subjected to heavy surface water action, surface current, and bottom current. Surge also develops in reef areas. For this reason, it is easy for the unknowing diver to be swept or tumbled across coral with serious Protection Against Coral. Coral should not be handled with bare hands. Feet protective clothing, especially gloves (neoprene or heavy work gloves), should be First Aid and Treatment. U.S. Navy Diving Manual — Volume 5 Promptly clean with hydrogen peroxide or 100percent povidone0iodine solu Topical antibiotic ointment has been proven very effective in preventing sec ondary infection. Stinging coral wounds may require symptomatic management such as topical steroid therapy, systemic antihistamines, and analgesics. In severe cases, restrict the patient to bed rest with elevation of the extremity, wet0 to0dry dressings, and systemic antibiotics. Systemic steroids may be needed to manage the in�ammatory reaction resulting from a comb nation of trauma and The octopus inhabits tropical and temperate oceans. Species vary depending on region. It has a large sac surrounded by 8 to 10 tentacles ( Figure 8C0 ). The head sac is large with well0developed eyes and horny jaws on the mouth. Movement is made by jet action produced by expelling water from the mantle cavity through the siphon. The octopus will hide in caves, crevices and shells. It possesses a well0developed venom apparatus in its salivary glands and stings by biting. Most species of octopus found in the U.S. are harmless. The blue0ringed octopus common in Australian and Indo0Paci�c waters may in�ict fatal bites. The venom of the blue0ringed octopus is a neuromuscular blocker called tetrodotoxin and is also found in Puffer (Fugu) �sh. Envenomation from the bite of a blue0 ringed octopus may lead to muscular paralysis, vomiting, respiratory dif�culty, visual disturbances, and cardiovascular collapse. Octopus bites consist of two small punctures. A burning or tingling sensation results and may soon spread. Swelling, redness, and in�ammation are common. Bleeding may be severe and the 5C—Dangerous Marine Animals Extreme care should be used when reaching into caves and crevices. Regardless of size, an octopus should be handled carefully with gloves. One should not spear an octopus, especially the large ones found off the coast of the Northwestern United States, because of the risk of being entangled by its tentacles. If killing an octopus becomes necessary, stabbing it between the eyes is First Aid and Treatment. For suspected blue0ringed octopus bites, do not apply a loose constrictive band. Apply direct pressure with a pressure bandage and immobilize the extremity in Be prepared to administer mouth0to0mouth resuscitation and cardiopulmonary resuscitation if necessary. Blue0ringed octopus venom is heat stable and acts as a neurotoxin and neuro muscular blocking agent. Venom is not affected by hot water therapy. No Medical therapy for blue0ringed octopus bites is directed toward management of paralytic, cardiovascular, and respiratory complications. Respiratory arrest is common and intubation with mechanical ventilation may be required. Dura Segmented Worms (Annelida) (Examples: This inver tebrate type varies according to region and is found in warm, tropical or temperate zones. It is usually found under rocks or coral and is especially common in the tropical Paci�c, Bahamas, Florida Keys, and Gulf of Mexico. Annelida have long, segmented bodies with stinging bristle0like structures on each segment. Some spe cies have jaws and will also in�ict a very painful bite. Venom causes swelling and Wear lightweight, cotton gloves to protect against bloodworms, but First Aid and Treatment. Remove bristles with a very sticky tape such as adhesive tape or duct tape. Topical application of vinegar will lessen pain. U.S. Navy Diving Manual — Volume 5 Treatment is directed toward relief of symptoms and may include topical ste roid therapy, systemic antihistamines, and analgesics. Wound infection can occur but can be easily prevented by cleaning the skin using an antiseptic solution of 10 percent povidone0iodine and topical antibi otic ointment. Systemic antibiotics may be needed for established secondary Sea Urchins. There are various species of sea urchins with widespread distribution. Each species has a radial shape and long spines. Penetration of the sea urchin spine can cause intense local pain due to a venom in the spine or from another type of stinging organ called the globiferous pedicellariae. Numbness, generalized ness, paresthesias, nausea, vomiting, and cardiac dysrhythmias have been Avoid contact with sea urchins. Even the short0spined sea urchin can in�ict its venom via the pedicellariae stinging organs. Protective footwear First Aid and Treatment. Remove large spine fragments gently, being very careful not to break them into Bathe the wound in vinegar or isopropyl alcohol. Soaking the injured extre in hot water up to 122ºF (80ºC) may help. Caution should be used to prevent scalding the skin which can easily occur after a brief period in water above Clean and debride the wound. Topical antibiotic ointment should be used to prevent infection. Culture both aerobically and anaerobically before adminis Remove as much of the spine as possible. Some small fragments may be absorbed by the body. Surgical removal, preferably with a dissecting micro scope, may be required when spines are near nerves and joints. 0rays may be required to locate these spines. Spines can form granulomas months later and Allergic reaction and bronchospasm can be controlled with subcutaneous epi nephrine (0.6 cc of 1=1,000 dilution) and by using systemic antihistamines. 5C—Dangerous Marine Animals 5C-3.9 Cone Shells. The cone shell is widely distributed in all regions and is usually found under rocks and coral or crawling along sand. The shell is most often symmetrical in a spiral coil, colorful, with a distinct head, one to two pairs of tentacles, two eyes, and a large �attened foot on the body Figure 8C01 ). A cone shell sting should be considered as severe as a poisonous snake bite. It has a highly developed venom apparatus: venom is contained in darts inside the proboscis which extrudes from the narrow end but is able to reach most of the shell. Cone shell stings are followed by a stinging or burning sensation at the site of the wound. Numbness and tingling begin at the site of the wound and may spread to the rest of the body; involvement of the mouth and lips is severe. Other symptoms may include muscular paralysis, dif�culty with swallowing and speech, visual disturbances, and respiratory distress. Avoid handling cone shells. Venom can be injected through clothing First Aid and Treatment. Do not apply a loose constricting band or ligature. Direct pressure with a pres sure bandage and immobilization in a position lower than the level of the heart Some authorities recommend incision of the wound and removal of the venom by suction, although this is controversial. However, general agreement is that should only be performed if it is possible to do so within two minutes of the sting. Otherwise, the procedure may be ineffective. Incision and suction by inexperienced personnel has resulted in inadvertent disruption of nerves, ten Transport the patient to a medical facility while ensuring that the patient is breathing adequately. Be prepared to administer mouth0to0mouth resuscitation if necessary. Cone shell venom results in paralysis or paresis of skeletal muscle, with or without myalgia. Symptoms develop within minutes of the sting and effects U.S. Navy Diving Manual — Volume 5 Respiratory distress may occur due to neuromuscular block. Patient should be admitted to a medical facility and monitored closely for respiratory or cardio vascular complications. Treat as symptoms develop. Local anesthetic with no epinephrine may be injected into the site of the wound if pain is severe. Analgesics which produce respiratory depression should be Management of severe stings is supportive. Respiration may need to be sup Sea Snakes. The sea snake is an air0breathing reptile which has adapted to its aquatic enviro ment by developing a paddle tail. Sea snakes inhabit the Indo0 Paci�c area and the Red Sea and have been seen 180 miles from land. The most dangerous areas in which to swim are river mouths, where sea snakes are more numerous and the water more turbid. The sea snake is a true snake, usually 6 to 7 feet in length, but it may reach 9 feet. It is generally banded ( Figure 8C01 ). The sea snake is curious and is often attracted by divers and usually is not aggressive Sea Snake Bite Effects. The sea snake injects a poison that has 2 to 10 times the toxicity of cobra venom. The bites usually appear as four puncture marks but may range from one to 20 punctures. Teeth may remain in the wound. The neurotoxin poison is a heat0stable nonenzymatic protein; hence, sea snake bites should not be immersed in hot water as with venomous �sh stings. Due to its small jaws, bites often do not result in envenomation. Sea snake bites characteristically produce little pain and there is usually a latent period of 10 minutes to as long as several hours before the deve opment of generalized symptoms: muscle aching and stiffness, thick tongue sensation, progressive paralysis, nausea, vomiting, dif�culty with Figure 5C-11. 5C—Dangerous Marine Animals speech and swallowing, respiratory distress and failure, plus smoky0colored urine substantial prote tion against bites and should be worn when diving in waters where sea snakes are abundant. Also, shoes should be worn when walking where sea snakes are known to exist, including in the vicinity of �shing operations. Do not handle sea snakes. Bites often occur on the hands of �shermen attempting to First Aid and Treatment. Do not apply a loose constricting band or tourniquet. Apply direct pressure using a compression bandage and immobilize the extremity in the dependent position with splints and elastic bandages. This prevents spreading of the neu Transport all sea snake0bite victims to a medical facility as soon as possible, Watch to ensure that the patient is breathing adequately. Be prepared to administer mouth0to0mouth resuscitation or cardiopulmonary resuscitation if The venom is a heat0stable protein which blocks neuromuscular transmission. Myonecrosis with resultant myoglobinuria and renal damage are often seen. Respiratory arrest may result from generalized muscular paralysis; intubation Renal function should be closely monitored and peritoneal or hemodialysis may be needed. Alkalinization of urine with suf�cient IV �uids will promote myoglobin excretion. Monitor renal function and �uid balance anticipating Vital signs should be monitored closely. Cardiovascular support plus oxygen and IV �uids may be required. Because of the possibility of delayed symptoms, all sea snake0bite victims 11. If symptoms of envenomation occur within one hour, antivenin should be administered as soon as possible. In a seriously envenomated patient, antiv therapy may be helpful even after a signi�cant delay. Antivenin is available U.S. Navy Diving Manual — Volume 5 from the Commonwealth Serum Lab in Melbourne, Australia (see Reference D of this appendix for address and phone number). If speci�c ant venin is not available, polyvalent land snake antivenin (with a tiger snake or krait Elapidae component) may be substituted. If antivenin is used, the dire tions regarding dosage and sensitivity testing on the accompanying package insert should be followed and the physician must be ready to treat for anaph laxis (severe allergic reaction). Infusion by the IV method or closely monitored drip over a 5C-3.11 Sponges are composed of minute multicellular animals with spicules of silica or calcium carbonate embedded in a �brous skeleton. Exposure of skin to the che ical irritants on the surface of certain sponges or exposure to the minute 11 Avoid contact with sponges and wear gloves when handling live 11 First Aid and Treatment. Adhesive or duct tape can effectively remove the sponge spicules. Vinegar or 60 to 100percent acetic acid should be applied with saturated com Antihistamine lotion (diphenhydramine) and later a topical steroid (hydrocor Antibiotic ointment is effective in reducing the chance of a secondary POISONOUS MARINE ANIMALS Ciguatera Fish Ciguatera poisoning is �sh poisoning caused by eating the �esh of a �sh that has eaten a toxin0producing microorganism, the dino�agellate, Gambierdiscus toxicus. The poisoning is common in reef �sh between latitudes 68ºN and 68ºS around tropical islands or tropical and semitropical shorelines in Southern Florida, the Caribbean, the West Indies, and the Paci�c and Indian Oceans. Fish and marine animals affected include barracuda, red snapper, grouper, sea bass, ambe jack, parrot �sh, and the moray eel. Incidence is unpredictable and dependent on environmental changes that affect the level of dino�agellates. The toxin is heat0stable, tasteless, and odorless, and is not destroyed by cooking or gastric acid. Symptoms may begin immediately or within several hours of ingestion and may include nausea, vomiting, diarrhea, itching and muscle weakness, aches and spasms. Neurological symptoms may include pain, ataxia (stumbling gait), thesias (tingling), and circumoral parasthesias (numbness around the mouth). Sensory reversal of hot and cold sensation when touching or eating objects of extreme temperatures may occur. In severe cases, respiratory failure and cardio vascular collapse may occur. Pruritus (itching) is characteristically made worse 5C—Dangerous Marine Animals by alcohol ingestion. Gastrointestinal symptoms usually disappear within 27 to 72 hours. Although complete recovery will occur in the majority of cases, neurolog ical symptoms may persist for months or years. Signs and symptoms of ciguatera �sh poisoning may be misdiagnosed as decompression sickness or contact derma titis from unseen �re coral or jelly�sh. Because of rapid modern travel and refrigeration, ciguatera poisoning may occur far from endemic areas with interna Never eat the liver, viscera, or roe (eggs) of tropical �sh. Unusually large �sh of a species should be suspected. When traveling, consult natives concerning �sh poisoning from local �sh, although such information may not always be reliable. A radioimmunoassay has been developed to test �sh �esh for First Aid and Treatment. Treatment is largely supportive and symptomatic. If the time since suspected ingestion of the �sh is brief and the victim is fully conscious, induce vomiting (syrup of Ipecac) and administer purgatives (cathartics, laxatives) to speed the In addition to the symptoms described above, other complications which may Antiemetics and antidiarrheal agents may be required if gastrointestinal symp toms are severe. Atropine may be needed to control bradycardia. IV �uids may be needed to control hypotension. Calcium gluconate, diazepam, and Amytriptyline has been used successfully to resolve neurological symptoms Scombroid Fish Unlike ciguatera �sh poisoning (see paragraph 8C0 ), where actual toxin is already concentrated in the �esh of the �sh, scombroid �sh poisoning occurs from different types of �sh that have not been promptly cooled or prepared for imm diate consumption. Typical �sh causing scombroid poisoning include tuna, skipjack, mackerel, bonito, dolphin �sh, mahi mahi (Paci�c dolphin), and blu �sh. Fish that cause scombroid poisoning are found in both tropical and temperate waters. A rapid bacterial production of histamine and saurine (a histamine0like compound) produce the symptoms of a histamine reaction= nausea, abdominal pain, vomiting, facial �ushing, urticaria (hives), headache, pruritus (itching), bronchospasm, and a burning or itching sensation in the mouth. Symptoms may begin one hour after ingestion and last 8 to 12 hours. U.S. Navy Diving Manual — Volume 5 Immediately clean the �sh and preserve by rapid chilling. Do not eat First Aid and Treatment. Oral antihistamine, (e.g., diphenhydramine, cimetidine), Puffer (Fugu) Fish An extremely potent neurotoxin called tetrodotoxin is found in the viscera, gonads, liver, and skin of a variety of �sh, including the puffer �sh, porcupine �sh, and ocean sun�sh. Puffer �sh—also called blow �sh, toad �sh, and balloon �sh, and called Fugu in Japanese—are found primarily in the tropics but also in temperate waters of the coastal U.S., Africa, South America, Asia, and the Med terranean. Puffer �sh is considered a delicacy in Japan, where it is thinly sliced and eaten as sashimi. Licensed chefs are trained to select those puffer �sh least likely to be poisonous and also to avoid contact with the visceral organs known to concentrate the poison. The �rst sign of poisoning is usually tingling around the mouth, which spreads to the extremities and may lead to a bodywide numbness. Neurological �ndings may progress to stumbling gait (ataxia), generalized wea ness, and paralysis. The victim, though paralyzed, Avoid eating puffer �sh. Cooking the poisonous �esh will not destroy First Aid and Treatment. Provide supportive care with airway management and monitor breathing and Paralytic Shellfish Poisoning (PSP) (Red Tide) Paralytic shell�sh poisoning (PSP) is due to mollusks (bivalves) such as clams, oysters, and mussels ingesting dino�agellates that produce a neurotoxin which then affects man. Proliferation of these dino�agellates during the warmest months of the year produce a characteristic red tide. However, some dino�agellate blooms are colorless, so that poisonous mollusks may be unknowingly consumed. Local public health authorities must monitor both seawater and shell�sh samples to detect the toxin. Poisonous shell�sh cannot be detected by appearance, smell, or discoloration of either a silver object or a garlic placed in the cooking water. Also, poisonous shell�sh can be found in either low or high tidal zones. The toxic var eties of dino�agellates are common in the following areas= Northwestern U.S. and Canada, Alaska, part of western South America, Northeastern U.S., the North Sea European countries, and in the Gulf Coast area of the U.S. One other type of dino�agellate, though not toxic if ingested, may lead to eye and respiratory tract irritation from shoreline exposure 5C—Dangerous Marine Animals Symptoms of bodywide PSP include circumoral paresthesias (tingling around the mouth) which spreads to the extremities and may progress to muscle weakness, ataxia, salivation, intense thirst, and dif�culty in swallowing. Gastrointestinal symptoms are not common. Death, although uncommon, can result from respir tory arrest. Symptoms begin 60 minutes after ingestion and may last for many weeks. Gastrointestinal illness occurring several hours after ingestion is most likely due to a bacterial contamination of the shell�sh (see ). Allergic reactions such as urticaria (hives), pruritus (itching), dryness or scratching sensation in the throat, swollen tongue and bronchospasm may also be Since this dino�agellate is heat stable, cooking does not prevent poisoning. The broth or bouillon in which the shell�sh is boiled is especially dangerous since the poison is water0soluble and will be found concentrated in the First Aid and Treatment. No antidote is known. If the victim is fully conscious, induce vomiting with 60 cc (two tablespoons) of syrup of Ipecac. Lavaging the stomach with alkaline Provide supportive treatment with close observation and advanced life support if needed until the illness resolves. The poisoning is also related to the quantity of poisonous shell�sh consumed and the concentration of the dino�agellate Bacterial and Viral Diseases from Large outbreaks of typhoid fever and other diarrheal diseases caused by the genus Vibrio have been traced to consuming contaminated raw oysters and inadequately cooked crabs and shrimp. Diarrheal stool samples from patients suspected of having bacterial and viral diseases from shell�sh should be placed on a special growth medium (thiosulfate0citrate0bile salts0sucrose agar) to speci�cally grow Vibrio species, with isolates being sent to To avoid bacterial or viral disease (e.g., Hepatitus A or Norwalk viral teritis) associated with oysters, clams, and other shell�sh, an individual should eat only thoroughly cooked shell�sh. It has been proven that eating raw First Aid and Treatment. Provide supportive care with attention to maintaining �uid intake by mouth or IV if necessary. Consult medical personnel for treatment of the various Vibrio species that may U.S. Navy Diving Manual — Volume 5 The sea cucumber is frequently eaten in some parts of the world where it is sold as Trepang or Beche0de0mer. It is boiled and then dried in the sun or smoked. Contact with the liquid ejected from the visceral cavity of some sea cucumber species may result in a severe skin reaction (dermatitis) or even Local inhabitants can advise about the edibility of sea cucumbers in that region. However, this information may not be reliable. Avoid contact with First Aid and Treatment. Because no antidote is known, treatment is only symp Parasitic infestations can be of two types= super�cial and �esh. Super�cial par sites burrow in the �esh of the �sh and are easily seen and removed. These may include �sh lice, anchor worms, and leeches. Flesh parasites can be either encysted or free in the muscle, entrails, and gills of the �sh. These parasites may include roundworms, tapeworms, and �ukes. If the �sh is Avoid eating raw �sh. Prepare all �sh by thorough cooking or hot0 smoking. When cleaning �sh, look for mealy or encysted areas in the �esh; cut out and discard any cyst or suspicious areas. Remove all super�cial parasites. Never REFERENCES FOR ADDITIONAL INFORMATION Prevention and Treatment of Dangerous Marine Animal Injuries , a publication by International Bio0toxicological Centre, World Life Research Institute, Col ton, CA; November 1982; P.S. Auerbach and B.W. Halstead. Management of Wilderness and Environmental Emergencies , Macmillan Pub lishing Co., New York, N. Y., 1986. Eds. P.S. Auerbach and E.C. Greehr. , Columbia University Press, New York 1971. P. Budkur. Commonwealth Serum Laboratories, 78 Poplar Road, Parkville, Melbourne, Victoria, Australia; Telephone Number= 01106106068901911, Telex AA . Doubleday, Garden City, N.Y., 1970. J. Y. Cousteau. Fish and Shell�sh Acquired Diseases . American Family Physician. Vol 27= pp. 1060108, 1981. M. L. Dembert, K. Strosahl and R. L. Bumgarner. Consumption of Raw Shell�sh 0 Is the Risk Now Unacceptable? New England Journal of Medicine. Vol 617= pp.7070708, 1986. H. L. DuPont. 5C—Dangerous Marine Animals Diving and Subaquatic Medicine , Diving Medical Centre, Masman N.S.W., Poisonous and Venomous Marine Animals of the World , Darwin Press Inc., Princeton, NJ; 1978; B. W. Halstead. Principles and Practice of Emergency Medicine , W. B. Saunders Co., Phila delphia, PA; 1978, pp. 8120818; G. Schwartz, P. Sofar, J. Stone, P. Starey and D. Wagner. 11. Dangerous Marine Creatures , Reed Book Ptg., Ltd., 2 Aquatic Drive, Frenchs Forest, NSW 20806 Australia. C. Edmonds. A Medical Guide to Hazardous Marine Life , Second Edition, Mosby Yea 1991, P.S. Auerbach. U.S. Navy Diving Manual — Volume 5 PAGE INTENTIONALLY Index–1 Index Table(s) ................... ................................. ...................... ............................. ............................. ...................... ...................... ................................ .............................. ................. ....................... ................ .................... ................ .................... ................ ............................ ................... ............................... ....... ................. ............................. ............... ............ ...................... .................. ..................... ................................ ....................... .......................... .................... ................... ................ ..................... ............ ................................ ............... ................... ............................... ... ................. .......... ......................... ................................ ............... .................... .............. ........................ .............................. .............................. ....................... ........................ ............................... ....................... ............... Boyle’s ........................... ............................... ...................... .............................. ...................... ................... ......................... ............. ................ ....................... ........................ U.S. Navy Diving Manual .............. ......... .................... .................... ............ ............... ..................... ............................. ........... .... ............................... ............................. .............................. ............... .................... 11-1 .................... ........................... .................... .............................. ............................... ........... .......................... ................................... ......................... ............................... ........................... .............................. ......................... .............................. ............................. ................ ........................ Ventilation .................... ............................... ............................... Charles’/Gay-Lussac’s ................... Assistance ........... Assessment ...... ......... ......... .............. ................... ............... ........................... ............................ ............................ .......................... .................... ........................ .............................. ................ 11- ................. .......................... ....................... ............ ................ ............................. ............................. ............... 11- 11- ................... ............................. World War ........................... .................. .......... ........................... ......................... ........................ ............... ................... .... ......................... Index–3 ...................... ................... ............................ ................................. ............................ ........................ ............................ ..................... ........................... .............................. .............................. Two .............................. .............................. ......... ............... .......................... ................................... ......................... Jacques-Yves ................ .................... ............................... ............................. ....................... ................ Transportation ... ................ .......................... ................... ...................... .......... .... .............. ........................ off ............................. ........................... Dalton’s ......................... .............................. ..... ............................. ............................... ................ ................. ............................ ............................... ............................... ............................... ........................... ....................... Type ............................... Type ................... ...... ............................... ..................... Table ............................... ............................... ........................... .... ....... ................ ......................... ........................... ........................... ........................... ............................... ...................... ................... ............... .... ..................... ....................... ..................... ................ ............................... ............... ............................... ........... ............................... U.S. Navy Diving Manual Diffusion ........................... ................................. .............. ................ ................ ................... .................. ................. ...................... .... ...................... .............................. 11- 11- 11- Test ............... .............................. ......................... ........... ..................... 11- ....................... ................... ................ .................... ..................... .......................... ............................. .................. ...................... Deane’s ............... .......................... .................................. Siebe’s ............. ....................... ......................... ......................... ........... ....... .................. ........................ ................... ............ ............................ .................... ........ ........................... ................... .......................... ........................ ....................... ...................... ..................... 11- ......................... ........................... ...................... ............. ................... .............................. ....... .......................... .... ................... .......................... ................ ....................... ............... ............. .............................. ............................... ...................... ........ ....................... ............... ........................ .............................. ............... ... ....................... ................... ........... ...................... ............... ......... ............ Index–5 ....................... ................................ ...................... .................... ............................ ............. .................. .................... ....................... ............... ........................ 11-1 ...................... 11-1 ............. ........................ ................... ...................... ....................... ................................. ......................... ......................... .......................... .................................. ............................ effects ............... effects ......... ........................ ................................ ............................. 11- Assessment .......... ................ ....................... ....................... .................. .................. ..................... ............................. ............................. ........................ ........................... ........................ .................... ..................... ....... ....................... ........... 11- ........... ................ ................. ................... ........................... ..................... 11- ....................... ............................. ...................... ................ 11- .. ............. .............................. ............... ............................... ................ ................. ............................... ................................. ................... ...................... 11- ................ ............................... .................................. ..................... 11- .... ..................... Analysis ................................ ................................ ..................... ......................... .......... ................. ................... ....................... ......................... ........................ ....................... U.S. Navy Diving Manual ......................... ......................... .............. puffer .................... ................ .................. .......................... ....................... ...................... ............................ ......................... ........................ ....................... ................... ....... A ........................... ....................... Boyle’s ............................ ........................... Dalton’s .......................... ........... ............................. .......................... ...... ........................ ........................ .................. ........... ........... ........... ..... ............................. .............................. Boyle’s ....................... ........................... Charles’/Gay-Lussac’s ................ Dalton’s ..................... ................... Henry’s ...................... .......................... ................. ................................. ................... ......................... .............. diffusion .............................. ......................... ............................ ............. ................ ....................... ........................ .............. .............. ........... .............................. ..................... ...................... ............................ .......................... ............................. ........................... ........................ .......................... ............................. ............................ ..... .............................. ............................... ........... ............................... Halley, ............................. ............................... ................................... .... ............................ ............................ .................. ............. .............................. ......................... ............................ ........................... Index–7 ......................... .............................. .................... Henry’s ......................... .................... ............................... ............................. 11- ................... ........................... .............................. ........................ ..................... ......................... ................ ............................ ....................... ..................... ......................... ................. ...................... .............................. ........................... ............................. ............................ ..................... 11- .............. ..................... 11- ........................... diffusion ............................... effects ........................ .............................. ............................... .......... ............. ..................... ......................... ................................ ............................. .......................... .......................... .......................... ........................... ................................ ........................... ............................ ............................ ............................. ........................ .............................. ........................... ........................... ................................ ............................. .............................. .............................. ......................... ......................... ................................. ............................... .............................. ............................... ............................. ............................... ....................... .................... ..................... ....................... ........................ ..................... ...... .............................. Temperature ........................ ..................... ......................... ....................... ................................ .................... ......................... U.S. Navy Diving Manual ............ ....................... ............................ ............... .......................... .......................... ................... .................... ................... ..................... .............................. ............. Analysis .................. ..................... ................ .............................. .............................. .............................. ............................. ............................. ................... Analysis .................. ........................ ................ ................ .............................. ............................. ............................. ......... Analysis .................. ........................ ................ .................... ................ Analysis .................. ..................... ................ ................................ ................................ ............................... ... ..................... 11- ................ ........................... .................... ........................... ......................... ..................... ................. ........................... ................... .......................... ........................ .................... ............................... ............................... Table ................................. ......................... ............... ................. ................... ................................... ............................... ................ ............................ ............................ ................ ....................... Analysis .................. ............................... ........................ ................... .............................. ............... ... ................ ....................... ................... ........... Index–9 ........................ ............................. ............................. ........................ ............... ............................. ............. ...................... ........ ..................... ....................... ........................... ......................... ....................... Assembly .... ............................... ........................ Pasley, ............................. ............. ................... ...................... ....................... ................................ ..................... 11- .............. .............................. ....................... ........................... ....................... ........... .................... 11-1 .................. ................. ....................... ...................... ................................. ............................... ............... ...................... .................... .................... ................ ........... ....... ..................... ................ ................. .............. ................ 11-1 ................... .................... ..... ............................. .............. ........ ................. ........................ ..................... ......... ................... ..................... .................... ................................. .............................. ........................... ............................ ............. ................................ ............................ ................... Puffer ....................... ................................. .......................... ................................. ............................... ................................ .................... ............... ........................... ........... ............ ...................... ....................... U.S. Navy Diving Manual ......... ..................... ................. ............................ ............................. ...... ............... .......... ............... diver’s .............. Analysis ............... ................... ............... ..................... .................... ....................... ...................... ............................ ......................... ................................. ............................. effect ................... effect .......... ............................. 11- ........................... .... ............................. ............................... ....................... ................... ............................... .................... ............................ ....................... ............................ ....................... ............................ ............ ............................. ............................... ............................... .. .............. ........................ Test ............................. ................................ ................... ........................... World War ........................... .......................... Two .......................... ................ ............................ ........................ ................. ......................... ........................ ................ Tables ....... ................... ............................. 11- .................. ........ ............................... ........................ ............ ................ ........................... ..................... ...................... ...................... ........................... Table ............... ................................. .............................. .................. .............................. .............................. .............................. ............................. ................... ................... .............................. Index–11 ................. ................................... .......... .............. .................. ............................... Augustus ............................... ....................... .... ................................. effects ................. ......................... ................ ............................ ............................ effects .................. effects ............. ............................ ........................ ............ ................................ ............................... ........................ ............ .................... 11-1 ......................... ................................. ............................ ........................ ............................. ............................... ....... .............................. .............................. ............................. .......................... Thresher .......................... ...................... ..................... 11- ..................... 11- .................... ..................... 11- ............................... ......... ..... ............................... ............................... ............... ............................ ............................... ................... ............................. effect ................. 11- ........ ..................... 11- ............................... ................ .... Technical ......................... ..................... Temperature ............... ........................... ................ ........... ......................... ............................ ......................... Tending .................... 11-1 ................... Territorial ............... ........................ ............................ Tides ............... Tinnitus ......................... Tools ...................... U.S. Navy Diving Manual Total ............................... Total ............................... ................................ Toxic ................................. Transfer .............................. Transportable ... Treatment Table ......................... Treatment Table ........................ Treatment Table ......................... Trigeminal ................. Trochlear .................. Turbidity ................................... ....................... ... ................... ....................... .................. effect ................... effects ........ effects ................... effects ............... ................... ...... ............... .............. ......................... ..................... .......................... 11-1 ........... ............. .......................... ................. .................. ....................... 11-1 .................. ................... ............ ... ............................. ............................ ...................... .............. Tables ........... ............................. ............................. ............................. .............................. Thresher ............................. Vagus .................... Variable ..................... 11- Variations ................... Venomous ............................. Ventilation ................. Watchstation ................... Water ............................... ......................... ........................ ......................... Weight ...................... ................................. 11- ............... ............. Assistance ........... Assessment ...... ......................... ......................... ......... ................... Wrecks