Diving Accident Management
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It
is desirable to have a standard
approach to the initial management (i.e.
first-aid) of an injured diver.
Coincidentally,
a diver may have a non-diving related illness or injury, but in general,
symptoms and signs following a dive are likely to be due to that dive.
An
injured diver must be removed from the water as quickly as possible. If the
diver is unconscious and beneath the surface of the water, then they should be
surfaced and decompressed in the head upright, normal anatomic position with
special attention being paid by the rescuer to the maintenance of a patent
airway. Surfacing feet first would delay the initiation of mouth to mouth for a
short period. Air would continue to be forced from the lungs by ascent either
way you raise the diver. PADI states that head up is the appropriate method. On
the surface, the 'do-ci-do' left sided position is what is being taught for
mouth to mouth initiation of breathing.
Getting
the unconscious diver to the surface as fast as reasonably possible, head up
and with the regulator in place would be my recommendation. NOAA does not
address this in their new manual and I cannot find any reference to position of
retrieval
in the Navy manual.
in the Navy manual.
A
SCUBA diver in this context should have their regulator placed in their mouth,
but no attempt at "purging" gas into the injured diver should be
made. Divers using rebreathing systems, full-face masks, band masks or helmets
should be "flushed-through' with fresh gas, preferably from an alternative
emergency gas supply, before swimming them to the surface or recovering them to
a platform or bell. Specific techniques for recovery of a diver into and
resuscitation of a diver in a bell or hyperbaric rescue vessel are needed and
must be practiced.
In
the absence of such a platform, the injured diver should be made positively
buoyant by removing their weight-belt and perhaps by inflating their
buoyancy-compensator (providing it neither limits access for the rescuer nor
causes the injured diver to float "face-down'). The injured diver's air tank
should be left in-situ as it acts as a keel. The rescuer should adjust their
own buoyancy by buoyancy-compensator inflation and not by dropping their
weight-belt in case they lose hold of the injured diver and have to recover
them again from underwater.
The
utility of expired-air-resuscitation (EAR) in the water, either directly or via
a snorkel, is debatable. Certainly there is a significant difference between
conducting EAR in a swimming pool and in the ocean in this context, effective
in-water EAR is only possible with continual practice in the ocean and, in
general, an injured diver's best interests are usually served by protecting
their airway and getting them out of the water as quickly as possible.
Effective
EAR and chest compression ( which obviously
should not be attempted in the water )
are life-saving if cardiorespiratory arrest
occurs, regardless of the cause of the
injury.
Techniques
should not vary between the diver who
has drowned and the diver who has
been envenomated, nor should it be
altered for a hypothermic diver (in whom
it must never be abandoned until after
re-warming has been completed).
If
any form of decompression illness (DCI) is suspected, then the diver must be
laid flat and not allowed to sit-up or stand as this may cause bubbles to
distribute from the left ventricle and aorta to the brain. Although such
posture-induced phenomena are unusual (rare), they have a very poor outcome.
This posture must be maintained until the injured diver with DCI is inside a
recompression chamber (RCC). A headdown posture is no longer advocated as it
may increase the return of and subsequent "arterialization" of venous
bubbles, it causes cephalic-venous engorgement such that subsequent middle-ear
inflation (e.g. in a RCC during treatment) is very difficult, it limits access
for resuscitation and assessment, and, in animal-model studies it actually
retards the recovery of brain function in comparison to the horizontal posture.
With
the exception of oxygen toxicity, administration of 100% oxygen is useful in
all diving accidents. Although divers who have pulmonary oxygen toxicity need
to breathe a PiO2 of less than 0.6 Bars, many of those who have had an
oxygen-induced convulsion will subsequently become hypoxic and need oxygen
administration.
To
administer 100% oxygen, a sealing anesthetic-type mask is needed (unless a
mouthpiece and nose-clip in a conscious diver or an endotracheal tube is used)
and a circuit with high gas flow-rates and a gas reservoir must be used. Air
breaks, to retard pulmonary damage, may be needed, but should be minimized as
must all other interruptions. This is one of the reasons why oral rehydration
is not particularly useful.
It
is noteworthy that administration of 100% oxygen is the definitive treatment of
the salt-water aspiration syndrome and most pulmonary barotrauma, including the
majority of pneumothoraces. Indeed, chest cannulation is rarely needed.
As
with oxygen, aggressive intravenous rehydration is probably of benefit to all
injured divers, even those who have drowned. Certainly, such therapy is of
considerable benefit in DCI. Isotonic solutions should be used. Glucose
solutions should be avoided as they have been shown to increase damage in
neurological trauma.
An
indwelling catheter should be inserted (filled with water, not air) and an
accurate fluid balance is essential. A persistent poor urinary output despite
adequate fluid replacement may indicate either persistent hemoconcentration or
bladder dysfunction. Either indicates severe DCI and warrants both bladder
catheterization and further fluid replacement.
There
are no drugs of proven benefit in the treatment of DCI. Corticosteroids,
anti-platelet drugs, aspirin have been tried without success. Lignocaine has
been shown to improve neurological outcome of DCS, particularly when added to
oxygen. Diazepam is used to prevent and treat oxygen convulsions and to control
vestibular symptoms. It makes titration of treatment almost impossible because
it masks the symptoms. Indomethacin is useful only when used in combination
with prostaglandin and heparin.
Nasal
decongestants and analgesics are useful in many divers with aural barotrauma,
and, rarely, antibiotics may be indicated.
Some
chemotherapy is useful for marine animal injuries. Many coelenterate
(jelly-fish) tentacle nematocysts are inactivated by being doused with vinegar.
Fish-sting pain is markedly reduced by immersion of the sting-site in hot
water.
Box jelly fish injury
Box jelly fish
Compression-immobilization
bandages should be used where possible. Analgesia often requires regional or
local anesthetic-blockade and there are specific anti-venoms available for the
box jelly fish (Sea wasp), the stone fish and for sea snakes
In-water
treatment of DCI is practiced and advocated by some, but is logistically
difficult, requires dedicated and effective equipment (e.g. full-face mask;
umbilical and breathing system cleaned for oxygen; cradle, chair or platform
that can be lowered to the desired depth; warm, calm water without current and
dangerous marine animals; and, adequate supplies of oxygen), and clearly should
not be used for unconscious, confused or nauseated divers. In general, the
diver should be retrieved as quickly as possible to a definitive treatment
facility.
As
for any retrieval of an injured person, stabilization of the diver must precede
transportation. This will include resuscitation, delivery of oxygen, insertion
of an intravenous line, correction of hypothermia (in divers in the field this
should be based on passive re-warming using dry clothes and blankets) or
hyperthermia (most likely in closed-diving systems and again the response will
need to be specifically developed and practiced), control of hemorrhage and
splinting of fractures. A record of oxygen administration and fluid balance is
essential.
If
DCI is suspected, then the retrieval must not exceed 1000 ft above sea level. A
transportable recompression chamber is ideal, but hyperbaric transportations
are logistically difficult and considerable time-savings are needed to justify
this activity. Many aircraft can be pressurized to "sea-level' during
flight, although this usually limits the altitude at which they can fly (and
hence makes the retrieval slower and more fuel-expensive). Unpressurized
aircraft are intrinsically unsuitable and must fly at less than 1000 feet,
which is often not possible. Road transport may also be inappropriate depending
upon the road's altitude, contour and surface.
Summary
It is desirable to have a standard approach to the initial management (i.e. first-aid) of an injured diver. An injured diver must be removed from the water as quickly as possible. An injured diver usually requires oxygenation and rehydration. Attention to these, and early adequate retrieval can significantly improve outcome.
It is desirable to have a standard approach to the initial management (i.e. first-aid) of an injured diver. An injured diver must be removed from the water as quickly as possible. An injured diver usually requires oxygenation and rehydration. Attention to these, and early adequate retrieval can significantly improve outcome.
Management where no chamber is
available
a. 100%
O2 by tight-fitting mask in all cases. Continue to treat and transport even if becomes asymptomatic!
b. Oral fluids - 1 liter (non-alcoholic)per hour.
c. IV fluids as soon as possible. Avoid over-loading. One to 2 liters in first hour, then 100 cc per hour. Glucose containing fluids should not be given in the event of neurological DCS.
b. Oral fluids - 1 liter (non-alcoholic)per hour.
c. IV fluids as soon as possible. Avoid over-loading. One to 2 liters in first hour, then 100 cc per hour. Glucose containing fluids should not be given in the event of neurological DCS.
Hyperglycemia
increases the chance of neurological damage.
-Ringer's solution without dextrose. Hartmann's, Lactated Ringer's or Normal saline preferred.
-Normal saline
-LMW Dextran (Dextran 40, Rheomacrodex) in saline (alters the charge of the RBC, preventing Rouleaux formation). 500 cc twice daily. Beware of adverse effects of anaphylaxis and pulmonary edema.
d. Medications
1. Glucocorticoids in neurological DCS.
2. Diazepam (Valium) 10-15 mg IV or per rectum to control seizures and severe vertigo.
3. Aspirin is given by some.
4. Lidocaine is being used by some but is still not yet proven.
e. Catheterization for the paraplegic. Use water in the balloon rather than air. Protect pressure points.
f. Pleurocentesis, if indicated.
Transport, transport, transport! Fly in aircraft pressurized at sea level or as low as possible. Beware driving through mountain passes. Have diver accompanied by a person familiar with the facts.
-Ringer's solution without dextrose. Hartmann's, Lactated Ringer's or Normal saline preferred.
-Normal saline
-LMW Dextran (Dextran 40, Rheomacrodex) in saline (alters the charge of the RBC, preventing Rouleaux formation). 500 cc twice daily. Beware of adverse effects of anaphylaxis and pulmonary edema.
d. Medications
1. Glucocorticoids in neurological DCS.
2. Diazepam (Valium) 10-15 mg IV or per rectum to control seizures and severe vertigo.
3. Aspirin is given by some.
4. Lidocaine is being used by some but is still not yet proven.
e. Catheterization for the paraplegic. Use water in the balloon rather than air. Protect pressure points.
f. Pleurocentesis, if indicated.
Transport, transport, transport! Fly in aircraft pressurized at sea level or as low as possible. Beware driving through mountain passes. Have diver accompanied by a person familiar with the facts.
D tampilkan
ulang oleh dr. Erick Supondha ( hyperbaric & diving medicine
consultant) dokter ahli hiperbarik dan
kesehatan penyelaman , Jakarta Indonesia , telepon 99070050 , sumer by Ernest S
Campbell, MD, FACS
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