Navy Dive Manual Rev-6 Change A Chapter 20

Front 1

The Diving Supervisor is responsible to ensure that every member of the diving team...? (4 things)

Back 1

1 Is thoroughly familiar with all recompression procedures.
2 Knows the location of the nearest, certified recompression facility.
3 Knows how to contact a qualified DMO if one is not at the site.
4 Has successfully completed Basic Life Support training.

Front 2

T/F Because all possible outcomes cannot be anticipated, deviation from treatment protocols can be made by the Diving Supervisor

Back 2

False. Deviation from these protocols shall be made only with the recommendation of a Diving Medical Officer (DMO).

Front 3

Can any Medical Officers are DMO modify the treatment protocols?

Back 3

No. Only DMOs with subspecialty codes 16U0 or
16U1 can modify treatment protocols as warranted by the patient’s condition.

Front 4

Where can a Dive Sup get emergency consultation 24 hours a day? (2 places)

Back 4

Primary: Navy Experimental Diving Unit (NEDU)
Secondary: Navy Diving Salvage and Training Center (NDSTC)

Front 5

What is the cause of arterial gas embolism?

Back 5

Arterial gas embolism is caused by entry of gas bubbles into the arterial circulation as a result of Pulmonary Over inflation Syndrome (POIS).

Front 6

What is the basic rule for the diagnosis of Arterial Gas Embolism?

Back 6

Any diver who has obtained a breath of compressed gas from any source at depth, & who surfaces unconscious, loses consciousness, or has any obvious neurological symptoms within :10 minutes of surfacing must be assumed to be suffering from AGE.

Front 7

Should a diver who surfaces unconscious and then recovers when exposed to fresh air be treated as if he has AGE?

Back 7

Not necessarily, he should first receive a neurological evaluation to rule out AGE.

Front 8

How should victims of near-drowning who have no neurological symptoms should be treated or evaluated?

Back 8

They should carefully evaluated by a DMO for pulmonary aspiration.

Front 9

T or F. For a diver with no pulse or respirations, CPR or the use of an AED should be started only after getting the diver to treatment depth.

Back 9

False. For a diver with no pulse or respirations CPR and use of the of an AED is a higher priority than recompression.

Front 10

How long would you wait for an AED before pressing a pulseless diver to treatment depth?

Back 10

If an AED can be administered within 10 minutes, the stricken diver should be kept on the surface until a pulse is obtained.

Front 11

What would you do with a pulseless diver if there is no AED available within :10

Back 11

If defibrillation is not available and a DMO is not present, compress the diver to 60' and continue CPR and attempt to contact a DMO.

Front 12

T or F. If an AED becomes available within :30 minutes, the pulseless diver shall be brought to the surface at 30 fpm and defibrillated when appropriate on the surface.

Back 12

False. Only bring the diver to the surface if an AED if available with in :20.

Front 13

How long should resuscitation be atempted at depth?

Back 13

Resuscitation efforts shall continue until the diver recovers, the tenders are unable to continue CPR, or a physician pronounces the patient dead.

Front 14

Where will you find the guidelines for performing neurological examinations and the examination checklist to assist in evaluating decompression sickness?

Back 14

Appendix 5A

Front 15

Describe the symptoms Type I DCS.

Back 15

Type I decompression sickness includes joint pain,(musculoskeletal or pain-only symptoms) and symptoms involving the skin (cutaneous symptoms), or swelling and pain in lymph nodes.

Front 16

What is the most commom sympotom of DCS, and where is it normally located?

Back 16

The most common symptom of DCS is joint pain. The pain may be mild or excruciating. The most common sites of joint pain are the shoulder, elbow, wrist, hand, knee, and ankle.

Front 17

How is pain in the abdominal, thoracic, and hip areas treated?

Back 17

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.

Front 18

What is the most common symptom of Cutaneous (Skin) Symptoms?

Back 18

Cutaneous (Skin) Symptoms. The most common skin manifestation of decompression sickness is itching.

Front 19

How is cutis marmorata treated?

Back 19

Mottling or marbling of the skin, known as cutis marmorata, may precede a symptom of serious decompression sickness and shall be treated by recompression as Type II decompression sickness.

Front 20

How will you treat a Type I symptom if a full neuro cannot be completed before recompression?

Back 20

If a full neurological exam is not completed
before initial recompression, treat as a Type II symptom.

Front 21

After recommpressing the diver to 60', you have no change in the pain and verify the diver had a orthopedic injury rather than decompression sickness, how do you treat?

Back 21

If the DMO feels the pain can be related to a specific trauma or injury, a TT 5 may be completed. If a DMO is not consulted, TT 6 shall be used.

Front 22

What categorys are Type II symptoms divided in to? (3)

Back 22

Type II symptoms are divided into three categories:
1 neurological
2 inner ear (staggers)
3 cardiopulmonary (chokes).

Front 23

Describe paresthesias.

Back 23

A tingling, pricking, creeping, “pins and needles,” or “electric” sensation on the skin,

Front 24

What are some of the commom symptoms of Type II Neurological Symptoms?

Back 24

Numbness, paresthesias, decreased sensation to touch, muscle weakness, paralysis, mental status changes, or motor performance alterations are the most common symptoms.

Front 25

What are some symptoms of Type II inner ear decompression sickness?

Back 25

The symptoms of inner ear decompression
sickness include: tinnitus (ringing in the ears), hearing loss, vertigo, dizziness, nausea, and vomiting.

Front 26

What is another term for inner ear decompression sickness?

Back 26

Staggers.

Front 27

When is inner ear decompression sickness most common?

Back 27

Inner ear decompression sickness has occurred most often in helium-oxygen diving and during decompression when the diver switched from breathing helium-oxygen to air.

Front 28

How do you differentiate Inner ear decompression sickness from inner ear barotrauma?

Back 28

Typically, rapid involuntary eye movement (nystagmus) is not present in cerebellar decompression sickness.

Front 29

What is another name for cardiopulmonary symptoms?

Back 29

Chokes

Front 30

What is the treatment depth of a diver with pneumothorax but DCS and AGE have been ruled out by a complete and thorough neumo?DCS or AGE are present.

Back 30

Recompression is not used for pneumothorax if no other signs of DCS or AGE are present.

Front 31

What are the symptoms for Type II cardiopulmonary symptoms (chokes)?

Back 31

Chokes may start as chest pain aggravated by inspiration and/or as an irritating cough. Increased breathing rate is usually observed.

Front 32

True or False. The initial treatment for AGE and Type II DCS are the same?

Back 32

True.

Front 33

What is the initial treatment for Type II DCS?

Back 33

Type II Decompression Sickness is treated with initial compression to 60'.

Front 34

How can you help the chance of recurrence of Type II DCS

Back 34

To limit recurrence, severe Type II symptoms warrant full extensions at 60 fsw even if symptoms resolve during the first oxygen breathing period.

Front 35

How do you decide between TT6 and TT6A?

Back 35

If symptoms are improved within the first O2 period, then continue on a TT6. If severe symptoms are unchanged or worsen within the first :20 at 60', assess the patient during descent and compress to depth of relief, not to exceed to 165'.

Front 36

What are the treatments for symptomatic omitted decompression?

Back 36

Compressed immediately to 60'. If surfaced from 50' or shallower begin TT6. If from a greater depth, compress to depth of significant improvement not to exceed 165' and begin TT6A. Consultat with DMO as soon as possible. For uncontrolled ascent deeper than 165', the Sup may use TT8 at the depth of relief, not to exceed 225'.

Front 37

What is the major difference between altitude decompression sickness and hyperbaric decompression sickness?

Back 37

The only major difference is spinal cord involvement are less common and symptoms of brain involvement are more frequent in altitude decompression sickness.
Simple pain, still accounts for the majority of symptoms.

Front 38

What is the treatmeent for altitude decompression sickness where only joint pain was present but resolved before reaching one ata from altitude?

Back 38

Then treat with 2 hours of 100% O2 on the surface followed by 24 hours of observation.

Front 39

What is the treatmeent for altitude decompression sickness for all other symptoms other than joint pain relieved before reaching one ata?

Back 39

For other symptoms or if joint pain is present after return to one ata, transferr to a recompression facility on 100% O2 and treated on the appropriate treatment table, even if the symptoms resolve while in transport.

Front 40

What are the primary objectives of recompression treatment? (3)

Back 40

1 Compress gas bubbles, thus relieving local pressure and restarting blood flow.
2 Allow sufficient time for bubble resorption.
3 Increase blood oxygen content and thus oxygen delivery to injured tissues.

Front 41

When is treatment gas used?

Back 41

For treatment depths deeper than 60', use treatment gas if available.

Front 42

When will you use Air Treatment Tables?

Back 42

Use TT 1A if pain is relieved at 66' or less. If pain is relieved greater than 66' useTT 2A. TT 3 is used for treatment of serious symptoms where O2 cannot be used, and/or if symptoms are relieved within :30 at 165'. If symptoms are not relieved in less than :30 at 165', use TT 4.

Front 43

Recompression Treatment When No Recompression Chamber is Available.

Back 43

If recompression of the patient is not immediately necessary, transporte to the nearest recompression chamber or the Sup may elect to complete in-water recompression.

Front 44

Should you use 100% when transporting a patient?

Back 44

Always have the patient breathe 100% oxygen during transport, if available.

Front 45

How will you treat a patient if they get relieve durring transport?

Back 45

If symptoms of DCS or AGE are relieved or improve after breathing 100% O2, still be recompressed as if the original symptom(s) were still present.

Front 46

How do you transport a patient by unpressurized aircraft?

Back 46

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.

Front 47

When will you use In-Water Recompression?

Back 47

Recompression in the water should be the last resort, used when there is no prospect of reaching a recompression facility within a reasonable timeframe (12–24 hours).

Front 48

When using in-water recompression should you use air or O2?

Back 48

In-water recompression using air is always LESS preferable than in-water recompression using O2.

Front 49

What Treatment Table do you use for in-water recomprssion on air?

Back 49

Follow a TT 1A. If the depth is too shallow for full treatment according to TT 1A. Recompress the to maximum available depth. Remain at maximum depth for :30, then decompress according to TT 1A

Front 50

How will you treat a patien using in-water recompression on O2?

Back 50

Descend to 30' remain at 30' for :60 for Type I and :90 for Type II. Ascend to 20' even if symptoms are still present.
Decompress to the surface by taking :60 stops at 20' and 10'. After surfacing, continue breathing 100% O2 for an 3 hours.

Front 51

What is TT5 used for? (6)

Back 51

1. Type I DCS (except for cutis marmorata)when a complete neuro shows no symptoms at 60',
2. Asymptomatic omitted decompression
3. Treatment of resolved symptoms following in-water recompression
4. Follow-up treatments for residual symptoms
5. Carbon monoxide poisoning
6. Gas gangrene

Front 52

What is TT6 used for? (9)

Back 52

1. Arterial gas embolism
2. Type II DCS symptoms
3. Type I DCS symptoms with no complete relief within :10 at 60'.
4. Where pain is severe and immediate recompression must be instituted before a neuro can be completed.
5. Cutis marmorata
6. Severe carbon monoxide poisoning, cyanide poisoning, or smoke inhalation
7. Asymptomatic omitted decompression
8. Symptomatic uncontrolled ascent
9. Recurrence of symptoms shallower than 60'.

Front 53

What is Treatment Table 6A used for

Back 53

For AGE or DCS symptoms when severe symptoms remain unchanged or worsen within the first 20 minutes at 60'.

Front 54

How do you treat deterioration or recurrence of symptoms during ascent to 60'?

Back 54

If deterioration or recurrence of symptoms is noted during ascent to 60', treat as a recurrence of symptoms.

Front 55

What is TT4 used for?

Back 55

TT4 is used when it is determined that the patient would receive additional benefit at depth of significant relief, not to exceed 165 fsw.

Front 56

How long do you stay at depth on a TT4?

Back 56

The time at depth shall be between 30 to 120 minutes,

Front 57

How nuch time must a tender be on O2 when on a TT4?

Back 57

Both the patient and tender must breathe O2for at least 4 hours (eight :25 O2, & :05 air periods), beginning no later than 2 hours before ascent from 30' has begun.

Front 58

What is the TT7 used for?

Back 58

Treatment Table 7. is an extension at 60'
of Treatment Table 6, 6A, or 4. It is considered a heroic measure for treating non-responding severe AGE or life-threatening DCS and is not designed to treat all residual symptoms that do not improve at 60'

Front 59

How much a inside tender use when on a TT7?

Back 59

When using TT 7, tenders breathe chamber atmosphere throughout treatment and decompression.

Front 60

What is the TT8 used for?

Back 60

Mainly for treating deep uncontrolled ascents when more than :60 of decompression have been missed. Compress to depth of relief not to exceed 225 fsw.

Front 61

What is a TT9?

Back 61

An HBO treatment table providing :90 of O2 breathing at 45'. This table is used only on the recommendation of a DMO.

Front 62

What is a TT9 used for?

Back 62

1. Residual symptoms remaining after initial treatment of AGE/DCS
2. Selected cases of carbon monoxide or cyanide poisoning
3. Smoke inhalation

Front 63

What is the minimum manning requirements any recompression operation?

Back 63

The minimum team for conducting any
recompression operation shall consist of 3 individuals. Dive Sup, Inside Tender, & Outside Tender.

Front 64

What is required before releasing any patient from any treatment?

Back 64

In all cases a DMO must be consulted prior to releasing a patient from treatment.

Front 65

What is the minimum and maximum O2 percentage in the chamber atmosphere?

Back 65

Minimum19% O2 and Maximum 25%.

Front 66

What is themaximum CO2 level percentage?

Back 66

Chamber carbon dioxide level is not to exceed 1.5 percent SEV (11.4 mmHg).

Front 67

When given by mouth how much fluid should a patient drink over the course of a TT5 or TT6?

Back 67

One to two liters of water, juice, or non-carbonated drink, over the course of a TT5 or 6, is usually sufficient.

Front 68

When should patients be given IVs?

Back 68

Patients with Type II symptoms, or symptoms of AGE, should be considered for IV fluids. Stuporous or unconscious patients should always be given IV fluids,

Front 69

What is the drip rate for a patients IV in the chamber?

Back 69

IV should be started as soon as possible and kept dripping at a rate of 75 to 100 cc/hour,

Front 70

What IV fluids should be started as soon as possible?

Back 70

Isotonic fluids
1. Lactated Ringer’s Solution
2. Normal Saline

Front 71

What IV fluids should not be used in the chamber?

Back 71

Avoid solutions containing glucose (Dextrose) if brain or spinal cord injury is present.

Front 72

If the patient cannot empty a full bladder, a urinary catheter shall be inserted as soon as possible. What should you use to inflate the catheter ballons?

Back 72

Always inflate catheter balloons with liquid, not air.

Front 73

What is considered adequate urine output?

Back 73

Adequate fluid is being given when urine output is at least 0.5cc/kg/hr.

Front 74

For non-diving medical personnel may be qualified as Inside Tenders they must... (4 things)

Back 74

1. Qualify through Navy Diver Inside Tender PQS and have...
2. Current diving physical exam
3. Conformance to Navy physical standards 4 Have a diver candidate pressure test.

Front 75

T/F When deeper than 45 feet, at least one chamber occupant must breathe air.

Back 75

True. During treatments, all chamber occupants may breathe 100% O2 at depths of 45' or shallower without locking in additional personnel. Deeper than 45', at least one chamber occupant must breathe air

Front 76

At what depths will tenders breath O2?

Back 76

All tender O2 breathing times in table are conducted at 30',and/or on ascent from 30' to the surface.

Front 77

What are the tender's O2 requierments with previous hyperbaric exposure within 18 hours,

Back 77

- TT5, add an ADDITIONAL :20 O2 breathing period to the times in the table.
- TT6 or TT6A, add an ADDITIONAL :60 O2 breathing period to the times in the table.

Front 78

What do you do if the tender’s O2 breathing obligation exceeds the table stay time at 30 fsw.

Back 78

Extend the time at 30' to meet these obligations if patient’s condition permits. Otherwise, administer O2 to the tender to the limit allowed by the TT and observe on the surface for 1 hour for symptoms of DCS.

Front 79

What is the tender's O2 obligation on a TT6 if there is one extention at 30' or 60'?

Back 79

:30

Front 80

What is the tender's O2 obligation on a TT6 if there is more than one extension extention at 30' or 60'?

Back 80

:60

Front 81

What is the tender's O2 obligation on a TT6A if there is more than one extension extention at 30' or 60'?

Back 81

:90

Front 82

What is the tender's O2 obligation on a TT6A if there is one extention at 30' or 60'?

Back 82

:60

Front 83

What are the normal tender surface intervals for all treatment tables?

Back 83

Tenders should allow at least 18 hours between consecutive treatments on Tables 1A, 2A, 3, 5, 6, and 6A
At least 48 hours between consecutive treatments on Tables 4, 7, and 8.

Front 84

T or F. Never go slower than 20' per minute durring decesnt to get a patient to 60'.

Back 84

False. Descent rates may be decreased as necessary to allow the patient to equalize; however, it is vital to attain treatment depth in a timely manner for a suspected AGE patient.

Front 85

What are the treatment gas mixes and appropriate depths?

Back 85

100% O2 0-60
50/50 61-165
64/36 (HeO2 only) 166-225

Front 86

On which Treatment Table are likely to see CNS oxygen toxicity?

Back 86

Acute CNS oxygen toxicity may develop on any oxygen treatment table.

Front 87

On which Treatment Table are likely to see pulmonary oxygen toxicity?

Back 87

During prolonged treatments on TTs 4, 7, or 8, and with repeated TTs 6, pulmonary oxygen toxicity may also develop

Front 88

What is the acronym for the CNS O2 toxicity symptoms, and what do the letters stand for?

Back 88

VENTID-C
Vision, Ears,
Nausea, Twitching\Tingling,
Irritability, Dizziness,
Convulsions

Front 89

CNS oxygen toxicity is unlikely in resting individuals at chamber depths of _____or shallower and very unlikely at _____ or shallower?

Back 89

50' 30'

Front 90

Finish this procedure...
- At the first sign of CNS O2 toxicity, the patient should be removed from oxygen and allowed to breathe chamber air....

Back 90

Fifteen minutes after all symptoms have subsided, resume oxygen breathing.

Front 91

For TTs __ __ __ resume treatment at the point of interruption. For TTs __ __ __ no compensatory lengthening of the table is required.

Back 91

TTs 5, 6, 6A
TTs 4, 7, 8

Front 92

For TTs 5, 6, & 6A. If symptoms of CNS oxygen toxicity develop a second time or if the first symptom is a convulsion...

Back 92

Off O2. Wait for all symptoms to completely subside. Decompress 10' at a rate of 1 fsw/min. For a convulsion, begin travel when the patient is fully relaxed and breathing normally. Resume O2 breathing at shallower depth at point of interruption.