JOINT SERVICE SUB AQUA DIVING

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JOINT SERVICE SUB AQUA DIVING

• DIVING
• ILLNESS TREATMENT
• REVIEW

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Objectives

• Revise Basic Life Support (BLS) skills
• For diving incidents
• understand the conditions
• recognise signs and symptoms
• understand how oxygen administration benefits
  these conditions
• Understand appropriate equipment and the
  practicalities of its use
• Revise oxygen administration skills
• breathing casualties
• non-breathing casualties

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Outline

• BLS
• In-Water Rescue
• Medical conditions
• Casualty Assessment
• Oxygen administration equipment
• Oxygen administration in practice

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BASIC LIFE SUPPORT (BLS)
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Lesson Outline

• BLS skills
• Essential rescue skills
• Deteriorate quickly if not frequently exercised
• Advice/techniques evolve

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Assessing the Need

• Indicators of the need for BLS
• no response
• no chest movement
• no feel of air movement

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Priorities

• D r A B C
• Danger to casualty and rescuer
• Response (AVPU)
• Airway
• Breathing
• Compressions

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Clear Airway

• Foreign objects
• Tongue

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Priorities

• Danger to casualty and rescuer
• Response
• A Alert
• V Responds to Voice
• P Responds to Pain
• U Unresponsive
• Airway clear of obstructions
• Breathing check for normal breathing (10 secs.)
• Compressions Cardiac Compressions

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BLS Decision Process
Unresponsive
Leave casualty and get help
No
Yes
Shout for help, open up airway
Breathing normally?
Leave casualty and get help, return give 30CCs
No
Yes

• Stop to recheck only if breathing resumes, else
  continue until
• Qualified help arrives
• Normal breathing
• You are exhausted

Recovery position
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Basic Life Support

• Sequence of 30 compressions 2 breaths by one
  rescuer
• Two rescuers change role every 1-2 minutes
• Monitor effectiveness
• Stop if normal breathing resumes/medical
  assistance arrives

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Basic Life Support - CC

• Place heel of hand in centre of chest
• Place heel of other hand on top of first hand
• Straight arms press down on sternum 5-6 cm
• Repeat at 100-120 times/min

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Basic Life Support - RB
Expired air can sustain life Monitor effectiveness

• Sight
• Feel
• Sound
• Appearance

Continue until qualified help comes, the casualty
is breathing normally or you are exhausted
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Basic Life Support - RB

• Breaths are to be
• No more than 1 second each
• 2 breaths to take no more than 5 seconds
• Dont attempt more than 2 breaths each cycle

• Regurgitation
• Not always normal vomiting
• Monitor exhalation sounds

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Recovery Position

• If casualty breathing place in recovery position

More stable position
The how position
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IN-WATER RESCUE
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In Water Life Support Sequence
Make Buoyant
Extend Airway
RB for 1 minute
Tow, RB - 2 every 15 secs.
Standing depth/Boat 1 min. RB
De-Kit Land
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Rescue - to the surface

• Diver out of gas
• AS Ascent
• Incapable/unconscious diver
• CBL
• Rescue ascents - Urgent
• Ascend directly to surface
• May mean ignoring decompression stops
• Divers safer at surface
• DCI can be treated
• Actions to take in case of oxygen convulsions

Controlled Buoyant Lift
AS ascent
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Surface Tows to Shore

• Summon help
• Ensure casualty buoyant at surface
• Fully inflate BC - face clear of water Consider
  removing weights
• Summon assistance
• Conscious casualty
• Reassure
• Unconscious casualty
• Remove mask, mouthpiece and extend airway
• Non Breathing casualty
• Remove mask, mouthpiece and give RB for 1 minute
  i.e. 10RBs

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Landing Casualty - Shore

• Standing depth
• Continue RB for a further 1 minute
• De-kit and land as quickly as possible WITHOUT
  further rescue breathing
• Lift from water
• Contact emergency services
• Continue BLS

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Landing Casualty - Boat

• Assistance available
• At boat prior to landing Continue RB for a
  further 1 minute
• De-Kit and remove from water as quickly as
  possible WITHOUT further RB
• Contact emergency services
• Continue BLS

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Effective Rescues

• Typical indications
• Nervous or reluctant
• Excuses or repeated questions
• Stress indicators
• Slow kit up or constant fiddling
• Concerns need to be resolved
• Adapt the dive plan
• More suitable dive site
• Peer pressure

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Pre-Dive Buddy Awareness

• Buddy reactions
• Stopping for no reason
• Preoccupation with kit
• Slow response to signals
• Rapid breathing
• Wide staring eyes
• Resolve quickly
• Stop or move to buddy
• OK? Problem?
• Not OK, gentle but firm contact
• Abort dive

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MEDICAL CONDITIONS
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Oxygen Exposure

• At high concentrations oxygen is toxic
• PO2lt0.16 bar does not support life
• Need to remain within accepted oxygen exposure
  limits

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Hypoxia

• What is it
• Lack of oxygen
• PO2lt 0.16 bar

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Hypoxia

• Symptoms
• Inability to think clearly, confusion, sense of
  losing it
• Loss of co-ordination
• Unconsciousness, death
• Primary danger is symptoms may be vague or absent
  
• It can occur suddenly and without warning!

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Hyperoxic

• What is it
• Too much oxygen
• Oxygen becomes toxic at elevated partial
  pressures
• There are two different effects of Hyperoxia
• Whole Body Oxygen Toxicity when PO2gt0.5 bar for
  long periods
• Central Nervous System (CNS) toxicity when
  PO2gt1.4 bar for even short periods

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Whole Body Toxicity

• Cause long exposures to PO2gt0.5 bar
• Monitored to allow for recompression treatment
• Physiological reactions including
• Inflammation in the lungs
• Reduction in vital capacity
• Congestion, oedema, bronchitis, swelling of
  alveolar walls, thickening of pulmonary arteries
• Visual impairment
• Symptoms
• Dry cough, discomfort in breathing cycle,
  increased breathing resistance, shortness of
  breath,
• Severe pain, sub-sternal pain or burning
• Temporary short sightedness (Hyperoxic Myopia)

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CNS Toxicity

• Also known as Acute Oxygen Toxicity
• Reaction to PO2 generally gt 1.4 bar
• Symptoms
• CON - Convulsions
• V - Vision
• E - Ears, hearing disturbances
• N - Nausea
• T - Twitching
• I - Irritability
• D - Dizziness
• Until convulsions begin, minor symptoms
• Can occur in ANY order or combination
• Increase in severity

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CNS Toxicity

• Convulsions
• Tonic phase do not assist
• Muscles become tense
• Casualty becomes rigid and holds breath
• Clonic phase do not assist
• May occur seconds or minutes after the tonic
  phase
• Casualty jerks violently (convulsion)
• Depressive phase - assist
• Casualty relaxes and is unconscious
• Potential loss of mouthpiece
• Loop flood loss of buoyancy
• Need for Basic Life Support?

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CNS Toxicity

• Convulsions
• Phases can occur on surface or after PO2 is
  reduced (Off effect)
• Progressive damage to nervous system with each
  successive convulsion

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Hyperoxia

• Causes
• Inaccurate dive planning
• Failure to analyse gas
• Incorrect marking or fitting of cylinders

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Hyperoxia

• Aggravating factors
• Actual PO2
• Duration of exposure
• Level of exertion
• Cumulative O2 exposure

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Hyperoxia

• Avoidance
• High PCO2 predisposes to oxygen toxicity
• Accurately track your oxygen exposure

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Monitoring Oxygen Exposure

• CNS and Whole Body Toxicity need to be monitored
  separately
• Data for both provided in BSAC Oxygen Toxicity
  Table
• Dive planning software
• Nitrox mixed gas decompression computers

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Hypercapnia

• What is it
• Excess CO2 in the blood
• Cause
• High inspired PCO2
• Poor ventilation of divers lungs at depth due to
  increased gas density
• Absorbent material exhausted in rebreathers
• Channelling in absorbent material rebreathers

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Hypercapnia

• Symptoms
• 0.03 bar PCO2 doubles breathing rate (dyspnea)
• 0.06 bar PCO2 distress, confusion, lack of
  coordination
• 0.10 bar PCO2 severe mental impairment
• 0.12 bar PCO2 loss of consciousness, death

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Hypercapnia

• Further impact
• Increases oxygen toxicity potential
• Increases potential for DCI and narcosis
• Avoidance
• Meticulous preparation monitoring of absorbent
  life - rebreathers
• Avoiding over exertion
• Resolution
• Stop, slow down breathing rate, relax
• Bail out to open circuit - rebreathers

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Decompression illness

• Causes
• inadequate elimination of nitrogen from the body
  during ascent
• Physical damage to the alveoli due to
  overpressure introduces bubbles of air (emboli)
  into the blood
• Patent foramen ovale (PFO) allows bubbles to pass
  from venous to arterial circulation

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Decompression illness

• Signs and symptoms
• Denial!
• Itches, rashes
• Numbness, tingling, joint pains
• Vision disturbances
• Dizziness, nausea, headaches, confusion
• Weakness, paralysis, loss of bladder/bowel
  control
• Shortness of breath
• Shock, unconsciousness
• Any abnormality after a dive
• Signs and symptoms appear from seconds to many
  hours after surfacing

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Decompression illness

• On-site first aid
• Lie casualty down flat
• Keep casualty quiet
• Administer 100 oxygen
• Increased nitrogen pressure gradient
• assists in nitrogen elimination from
• bubbles in blood and tissue
• The higher the percentage of oxygen the
• more effective whenever possible administer
  100
• Improved oxygen supply to tissues where blood
  flow is reduced due to bubble blockage
• Treat for shock
• Evacuate to a recompression facility as soon
• as possible

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Burst Lung

• Cause
• Physical damage to lung tissue from
  over-extension due to over-pressurisation
• Types

Both types can occur in isolation but are usually
accompanied by air embolism
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Burst Lung

• Signs and symptoms
• chest discomfort/pain, bloody froth
• shortness of breath
• changes to vocal tone, crepitation
• shock
• unconsciousness, death
• Signs and symptoms of burst lung are frequently
  accompanied by those for decompression illness

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Burst Lung

• On-site first aid
• Lie casualty down
• Keep casualty quiet
• Administer 100 oxygen
• Assists in re-absorption of the
• nitrogen content of air in
• pneumothorax or emphysema
• Offsets reduced effective lung
• surface area for gas transfer
• due to collapsed lung
• Treat for shock
• Evacuate to a recompression facility as soon as
  possible

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Near Drowning

• Cause
• Respiratory interruption due to fluid inhalation
• Signs and symptoms
• Circumstances
• No breathing
• Cyanosis ashen grey / blue appearance
• Weak or absent pulse

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Near Drowning

• On-site first aid
• Rescue Breathing
• Oxygen-enriched if possible
• Concentration of oxygen reaching the casualtys
  lungs during RBs is increased
• Chest compressions if required
• Recovery position
• Evacuate to medical attention
• Even if apparently fully recovered
• Complications of secondary drowning

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Shock

• Definition
• inadequate circulation leading to tissue damage
  due to inadequate oxygenation and waste removal
• Present to a greater or lesser degree in all
  injuries
• Mechanisms
• reduced blood volume (bleeding, burns, oedema)
• massive dilation of blood vessels (e.g. fainting)
• inadequate cardiac output (e.g. heart attack)
• allergic reaction to drugs, food or stings
• removal from the water after prolonged immersion

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Shock

• Signs and symptoms
• weakness, dizziness
• pallor, sweating
• rapid pulse rate
• rapid breathing, feeling breathless
• unconsciousness

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Shock

• On-site first aid
• Treat prime cause
• Reassure casualty (TLC)
• Keep casualty quiet
• Lay casualty down with legs raised
• (not in the case of DCI or burst lung)
• Keep warm and comfortable
• Administer oxygen
• Increased oxygen dissolved in the blood offsets
  effects of inadequate circulation
• Monitor condition
• Nothing by mouth (except for DCI)
• Evacuate to medical attention

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Shock

• Immersion shock
• Extreme form of blood vessel
• dilation due to prolonged
• immersion
• Muscles relax due to water
• supporting body weight
• If removed from water upright, blood
• can pool in lower limbs potentially
• fatal
• Keep casualty horizontal at all times
• Discourage any movement or activity by the
  casualty

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Carbon Monoxide Poisoning

• Cause
• breathing gas contaminated with carbon monoxide
• Effect
• carbon monoxide combines about 200 times more
  readily with haemoglobin than does oxygen
• interferes with the blood's ability to transport
  oxygen
• may act as a cellular poison

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Carbon Monoxide Poisoning

• Signs and symptoms
• headache
• pale or greyish appearance
• weakness
• dizziness, nausea
• tunnel vision
• vomiting
• rapid pulse
• rapid breathing
• coma
• convulsions

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CASUALTY ASSESSMENT
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Incident Procedure - Front
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Incident Procedure - Back
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OXYGEN ADMINISTRATION IN PRACTICE
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Casualties

• Incident statistics show that the majority of
  casualties will be
• Breathing
• Conscious
• Suffering from decompression
• illness
• Will need the use of a demand
• valve and oro-nasal mask for
• maximum oxygen concentration
• Incidence of casualties requiring
• Rescue Breaths is much lower

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Administering Oxygen

• Start at the earliest opportunity
• Greater nitrogen pressure gradient
• Earliest reduction in tissue hypoxia
• Dont ration oxygen
• Tender loving care (TLC)
• For a second casualty
• Use second demand valve and oro-nasal mask, if
  available
• Otherwise use a pocket mask
• Accept faster consumption of oxygen

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Administering Oxygen

• Be prepared for a possible transient worsening of
  casualtys condition
• Initial reaction of brain to increased
• oxygen
• Oxygen diffusing into bubbles
• Oxygen toxicity
• Not a problem at surface pressure /
• durations involved
• Casualties of underwater O2 toxicity?
• administer O2 on surface once any signs or
  symptoms have disappeared
• No pain killers

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Administering Fluids

• Counter dehydration with fluids
• Still isotonic drinks best, or water/squash
• Do not administer caffeinated or fizzy drinks
• Small amounts, at a rate of approx 1 litre/hour
• Do not allow to interfere with or delay
• Administration of oxygen
• Evacuation to a recompression facility
• Do not administer fluids if
• Casualty is likely to vomit
• Casualty is likely to inhale fluid
• A general anaesthetic may be required
• If no oxygen, fluids alone are beneficial

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Evacuation

• Dont delay call to emergency services
• Coastguard VHF Channel 16
• DDMO / BHA DCI Helplines
• England, Wales N. Ireland 07831 151523
• Scotland 0845 408 6007
• On Land (other)
• Ambulance/Police/Coastguard
• Telephone 999 or 112
• DCI
• Irrespective of any apparent improvement,
  casualty must get medical attention
• Casualtys buddy?
• All relevant information must accompany any
  casualty

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Oxygen Supply Exhausted?

• Closed Circuit Rebreather
• Can be set to deliver 100 oxygen
• Nitrox
• Open Circuit or Semi Closed Circuit
• Rebreather
• Reduces the amount of inspired
• nitrogen
• Not as effective as 100 oxygen
• but better than breathing air
• Common Considerations
• Mouthpiece may not be tolerated
• Oxygen reduced by air inspired via nose

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Missed Decompression

• If a diver misses decompression stops for any
  reason, or is subject to a rapid ascent such that
  it is considered that they may suffer
  decompression illness as a result
• Do not wait for signs/symptoms to appear
• Lay casualty down and keep quiet
• Administer oxygen/fluids
• Seek specialist medical advice on further action
  from the DDMO/ BHA Help lines

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Entonox

• Mixture of oxygen and nitrous oxide
• Nitrous oxide is very soluble in blood
• Large quantity of nitrous oxide passes into
  nitrogen bubbles to re-establish equilibrium
• Causes size of bubbles to increase
• Never administer to a casualty suffering from a
  diving accident
• Do not administer to a casualty of a non-diving
  accident if this follows diving
• Ensure emergency personnel fully understand

- Do this tactfully!
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Final Summary

• Signs symptoms can be similar for different
• conditions
• Knowledge of pre-incident history
• helps
• Oxygen administration TLC
• are beneficial to all diving
• illnesses incidents

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