Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Unit/Page
A
A MEDICS MAIN DUTIES.................................................................................... ABORT SCHEDULES............................................................................................ ADIABATIC COMPRESSION............................................................................... AIR EMBOLOUS.................................................................................................... ANALGESICS......................................................................................................... ANOXIA.................................................................................................................. ANTIBIOTICS & ANTIMICROBIAL AGENTS ................................................. ANTI-DIARRHOEALS........................................................................................... ANTIVENUM ORDERING/STORING.............................................................. ASEPTIC BONE NECROSIS................................................................................. AURAL BAROTRAUMA...................................................................................... 12358488833-
B
BAROTRAUMA..................................................................................................... 3 BAROTRAUMA OF ASCENT............................................................................... 3 BAROTRAUMA OF DESCENT............................................................................ 3 -
C
CARBON DIOXIDE RETENTION....................................................................... 4 CARBON MONOXIDE POISONING................................................................... 4 CARDIVASCULAR SYSTEM (A & P DIAGRAM)............................................. 9 CATHERISATION.................................................................................................. 5 COMPRESSION ARTHRALGIA........................................................................... 3 CORAL CUTS......................................................................................................... 8 CEREBRAL OXYGEN TOXICITY........................................................................ 4 -
D
DCI NEW TERMINOLOGY................................................................................ 2 DCI IN FLIGHT...................................................................................................... 3 DECOMPRESSION PULMONARY BAROTRAUMA........................................ 3 DENTAL BAROTRAUMA.................................................................................... 3 DIGESTIVE SYSTEM (A & P DIAGRAM).......................................................... 9 DISTRESS CALLING............................................................................................ 8 DIVING INCIDENT RECORD.............................................................................. 6 DR ABC CHART.................................................................................................... 6 DRUGS................................................................................................................... 8 DRUGS EAR....................................................................................................... 8 DRUGS GASTRO INTESTINAL TRACT.......................................................... 8DRUGS RESPIRATORY TRACT........................................................................ 8 DRUGS SKIN....................................................................................................... 8 DYSBARIC OSTEONECROSIS............................................................................ 3 DRUGS EYE........................................................................................................ 8 -
E
EAR (A & P DIAGRAM)........................................................................................ 9 -
F
FACIAL SQUEEZE................................................................................................. FEMALE REPRODUCTIVE SYSTEM (A & P DIAGRAM)................................ FIRST AID OF MANEGEMENT IN DIVING ACCIDENTS................................ FLYING AFTER DIVING....................................................................................... 3932-
G
GAS BURDEN......................................................................................................... 2 GASEOUS EXCHANGE (A & P DIAGRAM)....................................................... 9 GIRDLE PAIN.......................................................................................................... 2 -
H
HAZARDS INTRAVENOUS INFUSION............................................................ 5 HEAVY EXTERNAL BLOOD LOSS..................................................................... 5 HIGH PRESSURE NERVOUS SYNDROME........................................................ 3 HOSPITAL VISITS/TRAINING............................................................................. 1 HYDROSTATIC NERVOUS SYNDROME........................................................... 3 HYPERCAPNIA (CO2 POISIONING)................................................................... 4 HYPEROXIA........................................................................................................... 4 HYPOVOALAEMIC SHOCK................................................................................ 5 HYPOXIA................................................................................................................ 4 -
I
INDICATION FOR INFUSION............................................................................... INFUSION EQUIPMENT........................................................................................ INFUSION SET UP.................................................................................................. INNER EAR............................................................................................................. INTERNAL BLEEDING.......................................................................................... INTRAVENOUS INFUSION................................................................................... INTUBATION.......................................................................................................... IV CATHETER (VENFLON) RANGE COLOUR.................................................. 55635565-
L
LIMB PAIN............................................................................................................... 2 LYMPHATIC............................................................................................................ 2 -
M
MALE REPRODUCTIVE SYSTEM (A & P DIAGRAM)..................................... 9 MANAGEMENT OF INMERSIONS PATIENTS................................................... 7 -
N
NERVOUS SYSTEM + AUTOMATIC NERVES (A & P DIAGRAM).................. NERVOUS SYSTEM (A & P DIAGRAM).............................................................. NEUROLOGICAL................................................................................................... NITROGEN NARCOSIS......................................................................................... NON-RECOMPRESSION TREATMENT............................................................... 99243-
O
OBSERVATION RECORD CHART........................................................................ 6 ORGAN POSITIONING-FRONT VIEW (A & P DIAGRAM).............................. 9 ORGAN POSITIONING REAR VIEW (A & P DIAGRAM).............................. 9 OTITIS MEDIA........................................................................................................ 3 OXYGEN TOXICITY............................................................................................... 4 OIL CONTAMINATION.......................................................................................... 7 OXYGEN TOXICITY CHART................................................................................ 4 -
P
PATENT FORAMEN OVALE.................................................................................. PERSONAL AND SATURATION HYGIENE......................................................... PHONETIC ALPHABET.......................................................................................... PULMONARY OXYGEN TOXICITY..................................................................... 2284-
R
RECOMPRESSION TREATMENT.......................................................................... REVERSED EAR...................................................................................................... RN TREATMENT TABLES...................................................................................... ROUND WINDOW RUPTURE................................................................................ 2363-
S
SEA URCHINS.......................................................................................................... 8 SECONDARY DROWNING..................................................................................... 7 SEDATIVES AND SLEEPING TABLETS............................................................... 8 SINUS SQUEEZE...................................................................................................... 3 SIZES OF E.T. TUBES.............................................................................................. 5 SKELETAL SYSTEM-FRONT VIEW (A & P DIAGRAM).................................... 9 SKELETAL SYSTEM-REAR VIEW (A & P DIAGRAM)...................................... 9 SKIN (A & P DIAGRAM)......................................................................................... 9 -
T
TEETH LAYOUT (A & P DIAGRAM).................................................................... 9 -
U
UDERWATER BLAST INJURIES............................................................................ 7 URINARY SYSTEM (A & P DIAGRAM)................................................................ 9 -
V
VACCINATIONS....................................................................................................... VENEPUNCTURE.................................................................................................... VENFLON................................................................................................................. VERTIGO.................................................................................................................. 8553-
Diver Medic Course PARTS OF WORDS, WHICH MAY BE AT THE BEGINNING, IN THE MIDDLE, OR AT THE END OF THE WORD
Dura Loco Derma Stasis Therm CauScope Micro Mega Blast Ortho Pan Tox Neuro Leuco Phobia Morphi -cyst-pneu-mela-lact-hydro-synhard place of skin stand heat burn to view small large build upright whole of poison of nerves white fear from of a cell of respiration black of milk of water going together e.g. Syndrome e.g. Pneumonia e.g. Melaena-black stool, melancholiablack mood e.g. Ploy-morph e.g. Durable, indurated e.g. Locality, locomotor e.g. Dermis, hypodermic e.g. Stat. (give at once), venestasis, static e.g. Thermometer e.g. Cautery e.g. Telescope, cytoscope e.g. Microscope e.g. Mega-ton, acromegaly (disease with overgrowth of bone) e.g. Megaloblastic anaemia (disease with large blood cells) e.g. Orthopaedic, orthopnoeic e.g. Pan-hysterectomy e.g. Toxic e.g. Neuritis e.g. Leucocyte
Patient has a right to refuse treatment. All examinations must be with informed consent, even minor things such as pulse taking. There are a number of situations where the medic is allowed to proceed without consent e.g. An unconscious patient. Is is assumed that the patient would give consent if able. Try to persuade by conversation. Do not argue. If serious condition Interdive's Superintendent may want patient to sign, release form or witness refusal. Privacy Do not talk to others about patient (except Supv/Doctor) may discuss causes/symptoms etc but not PT name. Records Anything written on standard forms become part of patient records may be legal document so, must be complete, accurate and original. Alcohol and Drug Abuse (More later) but know if company wants further action. Is patient danger to self and worksite urine tests, reports to base? Criminal Injury Must be reported to O.I.M. And own Co. Ops. Manager make out report. Doctor Code of conduct guard confidence of patient no info to friends or relatives without permission (nor employer) discretion Nurse Patient entering hospital retains all rights nurse must obtain signed permission for operations may be held negligent or incompetent.
Diver Medic Course SECTION TWO DIVING (General) PERSONAL AND SATURARION HYGIENE
Basic rules of personal hygiene On the surface: Follow the common rules of hygiene based on strict personal cleanliness. Do not however carry out vigorous cleaning of the outer canal with cotton tips. Before going into saturation: Shower, cut fingernails short, do not take cotton-tipped sticks into the chamber. During saturation: Observe strict personal cleanliness (wash with Septivon type bacterial wash). Do not clean ears Maintain for PERSONAL USE only: Your bunk; Stereo Headset; Towel and wash mitt or flannel. For working in the water: Whenever possible the diver should wear a dry helmet (help to keep the ears dry). Otherwise wear a cap and dry the ears when out of the water.
1.2
12 hours
1.3 1.4
* 8 hours applies to short flights. For longer flights, i.e. Intercontinental, the time is extended to 24 hours.
Minimum time from completion of therapy 2000' (600m) 2.1 Inmediate & complete resolution of symptoms 24 hours on first recompression All other flights 48 hours
2.2 A diving medical specialist must decide cases without immediate response or with residual Diving Medical Specialist symptoms on an individual basis. Generally wait as long as possible.
3. DCI in flight Where the diver's symptoms consist only of pain in a limb, he should be treated with analgesics, oral fluids, oxygen if available, and the plane can continue to its destination without diversion or adjustement in altitude. When the diver has any other symptoms, immediate advice should be sought from a diving medical specialist. It may be necessary to reduce the cabin altitude or divert to the nearest airport. In the meantime, the patient should be given oxygen and oral fluids if available.
NEVER 1. Permit any shortening or other alteration of the tables, except under the direction of a Diving Medical Officer. 2. Wait for a bag resuscitator. Use mouth-to-mouth resuscitation immediately if breathing ceases. 3. Break rhythm during resuscitation. 4. Permit the use of 100-percent oxygen below 18 msw. 5. Fail to treat doubtful cases. 6. Allow personnel in the chamber to assume cramped position that might interfere with complete blood circulation.
EMERGENCY SCHEDULES
When conducting shor duration dives, emergency schedules must be available for the dive that runs over time. These schedules may include Oxy/Helium Partial Pressure Tables, Abort Tables, or transfer to saturation.
Diver Medic Course The Diving Medical Advisory Committee Medical Equipment to be Held at the Site of an Offshore Diving Operation
DMAC 15 Rev. 2 May 2009
Supersedes DMAC 15 and DMAC 15 Rev. 1, which are now withdrawn
Commercial diving operations include both surface and saturation diving operations and cover a wide range of work activities. Appropiate medical equipment to be held at any particular site is best determinated by an occupational health service with special knowledge of commercial diving operations. This list is designed to provide guidance on equipment to be held at the site where such advice is not available. It is recognised that in certain circumstances similar or greater facilities may be available from other sources which are sufficiently close and reliable. The list covers equipment suitable for the treatment of diving related disorders on the surface or in a recompression chamber and for other potential problems eg. Trauma which may occur during diving operations. The list takes account of situations where the diving operation may be remote from a vessel or installation sickbay and medical services. It includes equipment for use in an immediate first aid situation, equipment and drugs which may be used by personnel with advanced first aid training as well as equipment which would almost certainly only be used by medical staff. Medical staff who attend a casualty at a dive site may not necessarily be able to bring the appropiate equipment. Some of the drugs mentioned in this note may not be available in some geographical areas and in such cases alternative drugs to those identified should be considered. It is anticipated that except in emergency situations, equipment other than in the bell or chamber first aid kits would be for use by or on the direction of medical staff. There should be an appropriate system for the control and maintenance of the equipment and responsibility for the equipment should be vested in the Diving Superintendent or vessel medic. Equipment should be stored in a locked container and appropriately labelled. The diving supervisor must have access to the equipment at all times. Scheduled drugs should be held in a secure double locked container (with vessel medical supplies or installation sickbay). A logbook should be maintained with the equipment in which all use of equipment and drugs is recorded. The equipment should be inspected regularly (at least every three months) to ensure that all items are in working order (e.g. Batteries) and to exchange drugs and other equipment which is nearing the end of its shelf life. These regular inspections shold be recorded in the logbook. Consideration shold be given to the need for pressure testing mechanical or electrical equipment.
The views expressed in any guidance given are of a general nature and are volunteered without recourse or responsibility upon the part of the DMAC, its members or officers. Any person who considers that such opinions are relevant to his circumstances should immediately consult his own advisers.
2 Intravenous cannulae 14g 1 wide bore needle 2 Urine collection bags 2x20ml sterile water
6 Triangular bandages 12 Safety pins 40 Adhesive bandages 2 Crepe bandages 3in 2 Crepe bandages 6in 2 Dressing bowls 4 Eye pads
Resuscitation Resuscitator to include reservoir and connection for BIBS gas (e.g. Laerdal type)* 3 resuscitation masks (varied sizes) Pocket resuscitator with one way valve (e.g. Laerdal pocket mask) Laryngoscope and batteries and spare bulb Endotracheal tubes (e.g. Sizes 7,8,9). 2 Laryngeal masks or oesofago-laryngeal tubes may replace endotracheal tubes.** 1 ET tube coupling and mount 2 Airways sizes 3+4 (e.g. Guedel type) Foot operated suction device Torniquet 2 Endotracheal suction catheters 2 wide bore suckers Semi-automatic defibrillator *Resuscitators may require modification to gas inlet to ensure adequate filling at pressure. **Endotracheal tubes should be provided for use by doctors only. Drugs Anaesthesia/Analgesia 5 x 10ml Lignoocaine 10mg/ml amps 25 x 500mg Paracetamol tabs 20 x 30mg Dihydrocodeine tabs 20 x 300mg Soluble aspirin tabs 5 x 10mg Morphine sulphate amps (or 100mg pethidine) 2 x 1ml Naloxone 0.4mg/ml amps Various 2 x 10 mg Cholorpheniramine amps 2 x 50mg Chlorpromazine amps 5 x 10mg Diazepam amps 10 x 5mg Diazepam amps 1 Tube Silver Sulphadiazine cream 1% 6 x 500ml Saline 9mg/ml 20 x 250 mg Erythromycin tabs 2 x 10mg Diazepam (rectal) Resuscitation 2 x 40mg Furosemide amps 10 x 1ml Adrenaline 1mg/ml amps 2 x 1.2mg Atropine amps 5 x 100mg Hydrocortisone amps 2 x 25 Prochlorperazine amps 3 x 20ml Glucose 50mg/ml 6 x 150mg Amidarone amps
Diver Medic Course SECTION THREE DIVING (Medical) NON-RECOMPRESSION TREATMENT DIVER INJURIES
The following diagnosis and treatment procedures apply to the most common types of diver injuries, that do not require recompression treatment. Management of traumatic injuries should be accomplished using standard first aid procedures. SQUEEZE Squeeze occurs whenever fixed volume gas spaces within the body or diving gear are not pressure counterbalanced to surrounding depth. Pain is caused by compression and contraction of tissues and, if the pressure difference is allowed to increase, by the haemorrhage and rupture of blood vessels. TYPES AND SYMPTOMS Ear Squeeze Caused by the inability to equalise sinus spaces in the skull as a result of obstruction of passages, wich connect with the nasal cavity. Severe pain in sinus areas around nose and eyes. Swelling of lining tissues and (if the pressure difference is high enough) haemorrhage into the sinus spaces can cause blood and mucus to discharge from nose. Face or Body Squeeze Caused by sudden non-equalisation of facemask, suit, or hardhat resulting from failure of surface gas supply and non-functioning on non-return valve, or rapid increase in depth without compensating gas pressure. Pain caused by local tissue compression and possible haemorrhage of blood vessels in affected tissue. Bleeding into skin, around eyes, or from nose may occur. Thoracic (Lung) Squeeze Caused by compression of lungs to less than their residual volume resulting from an extremely deep skin dive (breath holding) or pronounced body squeeze. May produce significant lung damage due to blood and tissue fluids being forced into the alveoli and uncompensated air passages. Breathing difficult and blood, frothy sputum may be noted. TREATMENT: re-establish pressure balance as quickly as possible. Stop descent and attempt to equalise. If unable to compensate pressure, ascend to the surface do not continue deeper.
BAROTRAUMA
Definition Pressure injury because of differential pressures between body air cavities and the external environment. Classification Barotrauma of descent (squeeze) Barotrauma of ascent Body Spaces Affected Thorax lungs, ears, sinuses, tooth cavities, gut, spaces between body and suit and between mask and face.
TINNITUS or spontaneous noise or ringing in the ear can occur with middle ear disease that causes a conductive hearing loss, but it is usually associated with inner ear or brain disease. TRUE VERTIGO is a disorder of spatial orientation characterised by a sense that either the individual or the surrounding are rotating. Injury to the vestibular system accompanied by vertigo frequently is associated with nausea, vomiting, visual disturbance (frequently nystagmus), fainting, and generalised sweating. Vertigo is the most hazardous ear symptom to occur in diving. When it is caused by inner ear dysfunction, it may be accompanied by ear pain, hearing loss, or tinnitus. Vertigo can result from cold water entering the external ear canal, unequal ear clearing during ascent, inner ear barotrauma, eardrum rupture with cold water entering the middle ear, or injury to the central nervous system. Once dizziness is experienced during diving examination by a specialist is necessary before any further diving is attempted. COMPLICATIONS OF AURAL/OTIC BAROTRAUMA If the eardrum ruptures, cold water may enter the middle ear causing unequal thermal stimulation giving rise to dizziness, nausea, ringing in ears and causes acute or chronic infection with resultant temporary or permanent deafness. Excessive Valsalva manoeuvre may cause damage to the oval window connected to the stapes.
INNER EAR
The inner ear consists of the delicate end organs where the physical stimuli of sound and position changes are converted into nervous impulses for transmission to the brain along the auditory nerve. The cochlea is a coiled tube having a similarity to a snail's shell, wich is adapted to the reception of sound impulses that reach it through the other small bones of the middle ear. The round window, covered by a thin membrane which also opens into the middle ear, allows compensating movements of the perilymph wich is thin fluid bathing the inner ear contents. Hair cells placed on the basement membrane in the organ of Corti excite auditory nerve endings. The mechanism is delicate and excessive sound can cause selective damage at certain frequences, usually centred round 4000 Hz. Other membranes exist at junction zones in the inner ear, notably those separating perilymph from cerebrospinal fluid. All these membranes are subject to rupture under conditions of strain through pressure differentials and sudden hearing loss sometimes occurs, with or without vertigo, as a result of such rupture. Surgical exploration to seek a possible leak in the region of the oval or round windows is sometimes necessary in such cases, and needs to be conducted within a week of injury for best results. Other Causes of Damage in the Inner Ear are: Excessive noise (water is a good conductor of damaging sound waves). Drugs Aspirin and Quinine are examples of simple drugs, which can cause deafness in sufficient amounts and susceptible individuals. Some of the lesser-used antibiotics also have such an ototoxic effect. Injury either by shock waves from underwater explosion, direct blow on the ear forcing incompressible water into the canal and which often also ruptures the eardrum, and skull injury causing fracture of the temporal bone, all may cause irreversible damage. Fractures often injure the facial nerve also, which passes in close relation to the ear to supply the muscles of the face that may be paralysed by injury to that nerve. Decompression sickness may damage the inner ear structures either by direct distortion, or causing labyrinthine window ruptures and perilymph leakage as described earlier. It is possible that when mixed gases are breathed under pressure, differential diffusion rates cause such injuries even when total pressure remain constant (due to changing partial pressures of the various components).
VERTIGO
Whereas the occurrence of deafness in a diver underwater may cause disability even resulting in loss of fitness to continue diving, the occurrence of vertigo underwater is dangerous, being a potential cause of fatal underwater accidents. Normal balance under physiological conditions on dry land is maintained by the inter-action of gravity and a series of sensory organs. Joints and muscles, vision, and the vestibular organs all give complementary information to the brain about position in space, movements etc. Under water a profound change takes place. Buoyancy reduces the value of clues from joints and muscles. Darkness precludes visual clues and a great deal more reliance is placed upon sensations from the semi-circular canals and the vestibular apparatus generally.
ADIABATIC COMPRESSION
Adiabatic compression is the term used to explain how temperature increases in a vessel (decompression chamber or bell), due to the compression of gas into it, as in the bell blow down or chamber pressurisation. It is thus of prime importance that you do not exceed the pressurisation speeds set down by your diving company, for the type of dive being performed. During a pressurisation, you may feel you could go faster (no ear clearing problems etc) but
Some reports have recorded bouts of sleep occurring from which the subject is readily awakened. Difficulty in right left orientation has also been reported. The develpment and severity of High Pressure Nervous Syndrome appears to be related to the rate of compression at great depths being particularly more noticeable at faster rates. Investigations into other possible contributory causes, such as the effects of Oxygen, Carbon Dioxide, Temperature, and fluid shift within the tissues due to gas pressure, have been found to have little, or no part in the incidence of HPNS. It has been found that the inclusion of Nitrogen, or other heavier narcotic gases has significantly reduced the cost of the mixture, alleviated the effects of voice distortion, and reduced the dangers of excess heat loss. For this reason it is common to use a TRI-MIX of Oxygen, Nitrogen and Helium when diving deeper than 200m. The main cause of HPNS would at this stage of investigation, appear to be directly attributable to speed of compression, so prevention can be best served by following the general rule, the deeper the dive, the slower the rate of compression. There has also been report's of a reduction in the HPNS symptoms when incorporating rest stops into the compression schedule. A further method of prevention of HPNS symptoms has been in the use of excursions. This technique involves a slow compression to the saturation depth, deeper levels of 50m, or so may be carried out with fairly rapid compression rates, which would not be tolerable if carried out from the surface. Again, the deeper the excursion from the saturation depth, the slower the rate of compression must be. Various commercial diving companies employing saturarion techniques employ the above-mentioned principles although the particular regime will vary according to the policies, and the particular preferences of each individual company.
COMPRESSION ARTHRALGIA
Hyperbaric arthralgia is pain in the joints due to raised ambient pressure. A diver suffering from hyperbaric arthralgia sometimes hears a creacking and cracking from his joints and feels as if his joints surfaces are dry (no joint fluid). Joints hurt especially on movement. The condition is aggravated by too rapid compression. A compression rate of not more than 1m/min (3.2ft/min) often avoids the painful effects of this condition although the cracking of the joints continues.
UPTD = kp x t
Where kp is a factor derived from the PPO2 using the table below, and t the duration of exposure (in minutes).
PO2 (BA) 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2
PO2 (BA) 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0
PO2 (BA) 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
The appropiate kp value is multiplied by the period of time (in minutes) spent at each oxygen partial pressure. These values are then summed to generate the total UPDT value for the exposure. Standard USN Table 6 or RN 62 Treatment Table without extensions are equivalent to 625 UPDT's. Below is a table, which presents approximate values for expected decrement in vital capacity as a result of various UPDT exposures. It should be recognised that individuals may vary considerably in their response to high partial pressures of oxygen and the UPDT value is useful only as a guide. Generrally, dose of 1425 UPDT is considered to be the upper limit of acceptable exposure.
UPDT UNITS % DECREMENT IN VC 615 825 1035 1230 1425 1815 2190 2 4 6 8 10 15 20
Normally, a complete recovery from the effect of pulmonary O2 toxicity can be expected. The time taken for recovery depends largely on the extent of the exposures and where there is a substantial decrement of vital capacity, this may take days or weeks. d) Treatment. Reduce the concentration of O2 in the breathing mixture, preferably to 0.2 BA/PO2
Treatment: Remove from cause (stop decompression, check for injury, protect airway). PULMONARY (chronic or slow) Cause: Breathing oxygen for long periods with PPO2 > 0.5 bar (500mbar). Symptoms: Dry irritated throat Tight feeling in chest (behind sternum) Dry cough, painful, non-productive Painful fingertips Shortness of breath Treatment: Remove from cause, observ patient, check for neurological symptoms. HYPOXIA When O2 is less than 0.16 bar (160mbar) or 16% SEP (16% on surface). Symptoms: Cyanosis (Blueing of fingers, earlobes) Breathing Increased heart rate Poor co-ordination Note: most symptoms pass unnoticed leading straight to collapse!!! HYPERCAPNIA (CO2 POISONING) 1) Onset 20.000 ppm = 2 SEP = 0.02 BA = 20 mbar Unconscious 150.000 ppm = 15 SEP = 0.15 BA = 150 mbar 2) Should not exceed 5.000 ppm in chamber (0.5 SEP) = 0.005 BA = 5 mbar
Symptoms:
Treatment: change gas supply, jump standby to assit divers ascent, recompression, administrating pure O2 by BIBS (Flushes out CO). NITROGEN NARCOSIS Cause: Increased PP of Nitrogen (nitrogen in air becomes narcotic beyond 30msw) Symptoms: Feeling of euphoria. Treatment: Decrease depth or change mix.
IV CATHETER (VENFLON) RANGE COLOUR IV SIZES & FLOW RATES *Denotes the types that should be in the medical kit. The grey Venflon is mainly used for the rapid transfusions of whole blood or blood components, whereas the green is used for surgical and other patients receiving blood components or large volumes of fluid. Smallest Large COLOUR Purple Yellow Blue Pink * * Green White Grey Brown/Orange GAUGE 26 24 22 20 18 17 16 14 CATHETER DIAMETER Ext. mm INT mm 0.5 0.6 0.8 1.0 1.2 1.4 1.7 2.0 0.4 0.6 0.7 0.8 1.0 1.2 1.4 1.7 25 32 45 45 45 45 31 54 80 125 180 270 Length in mm Flow ml/min
INTRAVENOUS INFUSION This section covers: The decision to use intravenous infusion. Techniques. Issues and complications.
Introduction To maintain circulation you must minimise blood loss. If there has been significant loss of blood you must replace it by intravenous infusion. If you do not, the drop in blood pressure and tissue
IF NOT Minimise blood loss using basic techniques, i.e. Controlling external bleeding by local pressure on the wound and elevation of the part. Raising patient's leg above the level of the heart (controlled blood loss only). Immobilising fractures.
HYPOVOLAEMIC SHOCK This is the most important factor in deciding to use intravenous infusion. Shock is diagnosed by combination of: Pallor Sweating Anxiety Rapid shallow respiration Cold skin Rapid and weak pulse. Low blood pressure
INTERNAL BLEEDING Extreme care must be taken when infusing a patient with suspected internal bleeding. This is due to the very real risk of increasing the blood loss by the mechanism of increased blood pressure leading to clot bursting. Likewise raising the blood pressure by auto-infusion (leg raising, pneumatic anti shock garment PASG) may also be detrimental. HEAVY EXTERNAL BLOOD LOSS You should assess the quantity of blood lost at the scene of the accident, e.g. The degree of
CRYSTALLOIDS Normal saline, Hartmans solution (Ringer's lactate) are normally used. You can also use them for fluid replacement until fully grouped and cross-matched blood is available, provided the blood pressure remains at a satisfactory level. But you must remember that these fluids diffuse out of the circulation within an hour. COLLOIDS Haemanccel and Gelofusine are commonly used. They are better then simple electrolyte solution for patients with a low blood volume because they are retained in the circulation for longer. They do not cause problems with blood cross matching. However, 2% of the population will have an allergy reaction to Haemanccel and it may also cause haemorrhage. Infusion fluids come in three type of container: a soft plastic bag with a port for insertion of the giving-set needle. A semi-stiff plastic container with a snap-off port or ring; when removed this allows for the insertion of the giving-set needle. A glass container, which also needs an air vent.
CHECKING THE INFUSION Before you connect the giving-set to the fluid container you must check: the fluid is of the correct type. it is not beyond its expiry date. the fluid is clear. the container is undamage.
Avoid the legs if you possibly can. INDICATION FOR INFUSION a) Hypovolaemic Shock (established shock from fluid loss). b) Potential Hypovolaemic Shock (possible shock from fluid loss). c) Neurogenic and Cardiogenic Shock (electric shock, cardiac arrest, cares with Cardiogenic). Refer to your training notes and note all the conditions whereby fluid can be lost from the circulation i.e. Burns, vomiting, coughing up blood, etc. DANGERS a) Air Embolus. 20 ml of air is considered large enough to create an air embolus capable of causing problems. Can be caused by the incorrect assembly of the drip, or by air being drawn into the circulation throug the junction of the terminal end of the giving set and the inserted cannula. b) Localised infection at the cannula site of insertion. Could precipitate septicaemia. c) Straight throug puncturing of the venous wall.
Cardiac Overload/Hypertension Stop infusion. Inform A&E Dept. Immediately (wrong fluid could have been administered) Infusion of wrong fluid Delay in the cross -matching of the patient's blood (can be caused by the administration of Dextran solutions). Accidental arterial puncture Stop infusion. Inform A&E Dept. Immediately Obtain a blood sample prior to infusion essential if Dextran solutions are to be given. Withdraw the cannula and apply direct pressure.
IMPORTANT Review IV at least daily (maximun review duration NOT to exceed 72 hours) Victims of heart attacks must not be given fluid resuscitation due to the chances of fluid overload on a weakened heart. CATHETERISATION This is the introduction of sterile rubber tubing into the bladder in order to release retained urine. Urinary retention is caused either by physical blockage, e.g. Enlarged prostate in older men, e.g. Blood clot in the bladder after trauma (D.C.S.). In the former cause retention is painful; in the latter it may cause localised pain, but can contribute to serious distress and should be looked for. Signs of Retention Has not passed water. Lower abdominal swelling and tenderness. Dullness to percussion. Anatomy See cross section diagram (resistance may be felt as prostate is reached). Equipment Sterile catheter, e.g. Foley (gauges 10-24 French). Choose 12 or 14. 2 concentric tubes: a) to drain urine b) to inflate 20-40ml retaining balloon near tip throug non-return valve. Sterile gloves Sterile forceps (2 pairs) Sterile lubricating anaesthetic jelly, e.g. Lignocaine gel Sterile urethrl adapter Sterile drapes Collecting bowl Antiseptic lotion, dish and sterile swabs Spigot or draining bag Sterile water 20ml
Compress to 18m on O2
Yes
No
Yes
Yes
No
Compress to 18m on O 2
Decompress on Table RN 61
No
Yes
Yes No Yes
Yes
No
Is the patient Continuing to Deteriorate?
No
Yes
No
Yes
Consult a Diving medical specialist Consult a Diving medical specialist
Yes
Decompress Using RN 64
No
Complete table RN 62 or USN Table 6 Complete Table RN 61 or USN Table 5
Note 1 R
SPEAK TO CASUALTY (SUPPORT HEAD) SHAKE THE SHOULDERS ENSURE CLEAR AIRWAY LOOSEN TIGHT CLOTHING CHECK CERVICAL SPINE HEAD TILT & CHIN LIFT
USED CAROTID ARTERY FOR ADULTS & OVER ONES. BRACHIAL ARTERY IF UNDER ONES
IS BREATHING?
HELP, RETURN
CHECK PULSE
30 GOOD COMPRESSIONS
NO PULSE
PULSE 2 BREATHS
HELP RETURN
HELP RETURN
CHECK ABC
HELP RETURN
CHECK ABC
IF STARTED PULSE
STARTED
IF BOTH
SWITCH ON LARYNGOSCOPE (CHECK LIGHT) INSERT LARYNG. INTO RIGHT SIDE OF MOUTH USING LEFT HAND DISPLACE TONGUE TO THE LEFT, CHECKING OBSTRUCTIONS LOCATE EPIGLOTTIS EXPOSE VOCAL CORDS - ASPIRATE IF NECESSARY INTRODUCE SELECTED E.T. TUBE (PRE-JELLIED) IF FAILED FOLLOW ARROW CONNECT SWIVEL CONNECTOR CATHETER MOUNT INFLATE CUFF OF E.T. TUBE INFLATE LUNGS 4 INFLATIONS
CHECK E.T. TUBE IN CORRECT POSITION, STETHOSCOPE AND VISUAL CHECKS INFLATE LUNGS TWICE INSERT ORAL PHARYNGEAL AIRWAY SECURE E.T. TUBE WITH ONE INCH TAPE INFLATE LUNGS TWICE CHECK BALLON SECURITY OF E.T. TUBE CONTINUE EAR/ECM AND MONITOR VITAL SIGNS SUPPLEMENT RESPIRATIONS WITH 02 WHEN POSSIBLE
INSERT LARYNGISCOPE
DEFLATE CUFF
SWITCH ON ASPIRATOR
GIVE 02 @ 6 8 l/min REDUCING CHECK MASK (REDUCING 02 FLOW ON SOME MASKS CAN LEAD TO CO2 RETENTION) MONITOR ALL VITAL SIGNS & LOOK OUT FOR LUCID INTERVALS
REMOVE TOURNIQUET
OPEN ADMINISTRATION SET (CHECK INDATE & STRILITY) TURN OFF GIVING SET SELECT/CHECK FLUID DATE, CLARITY, PARTICLES, RIGHT FLUID BREAK FLUID BOTTLE SEALS BREAK GIVING SET SEALS INSERT GIVING SET INTO BOTTLE HALF FILL CHAMBERS SLOWLY RUN FLUID THROUGH TO END OF GIVING SET CHECK FOR AIR BUBBLES RUN DRIP VERY SLOWLY REMOVE CAP PLUG CONNECT GIVING SET TO CANNULA HEAD SET DRIP TO CORRECT RATE FORM LOOP WITH GIVING SET SECURE WITH TAPE SECURE ARM TO SPLINT CHECK TIGHTNESS INTEGRITY OF DRIP MONITOR PATIENTS OVERALL CONDITION
Type of dive (Sat, bounce, etc)___________________ Was excursion involved? If so state range______________________ Medical treatment given?___________________________________________________________ Treatment table followed?___________________________________________________________
If an explosion is near the seabed and the seabed is of a hard material, there is very little absorption and much reflection. This causes pressure waves to inflict increased damage. Pressure waves are reflected from the surface and also thermal layers, corals, walls, shore and large ships. Damage will be influenced by size of charge, depth, and distance of the diver form the explosion. Injuries With air explosions much of the pressure wave is reflected by the body surface, since this represents an interface between mediums of different densities. The density of the body and water are similar. Underwater the pressure wave passes throught the body except at areas capable of compression, i.e. Gas spaces. Therefore damage will be found at these interfaces, e.g. Lungs, sinuses, ear cavities and the abdomen. A SHREDDING EFFECT will take place in the lungs, the tissue will literally be torn apart. INJURY UNDERWATER OCCURS MAINLY AT GAS/TISSUE INTERFACES AS IN BAROTRAUMA Management of injuries The patient must be admited for observation to a hospital or similar medical centre, even thought he may not appear seriously affected, there are often no external signs of injury. Exposure to altitude may aggravate the damage. Until fully assessed, the patient should be maintained on intravenous fluids and gastric suction. MANAGEMENT IS SIMILAR TO THAT OF SEVERE BODY TRAUMA FROM OHTER CAUSES. Care must be taken in the administration of positive pressure ventilation although the administration of 100% oxygen is required whenever there is a degree of hyperaemia. By placing the patient in a hyperbaric environment you could probably de delaying and complicating the cardio-pulmonary support and gastro-intestinal surgery. Dry suits could reduce the damage caused, since they would be the first water-air interface struck. Summary Exposure to an underwater blast will result in damage far in excess of that caused by a simmilar air blast. This is because water is an incompressible substance and transmits the pressure waves with
MOTION SICKNESS
Seasickness can be a distinct hazard to a diver using small craft such as a surface-support platform. Diving should not be attempted when a diver is seasick. Vomiting while submerged can cause suffocation and death. Symptoms and Signs Nausea Dizziness Feelings or withdrawal Pallid or sickly green complexion Sturred speech Vomiting
Prevention There is no effective treatment for seasickness except to return the stricken diver to a stable platform. All efforts are therefore directed at prevention. Some people are more susceptible than others, but repeated exposures tend to decrease sensitivity. Suggestion therapy by a trained mental health specialist has been helpful in some cases. The susceptible person should eat lightly just before exposure and avoid an alcoholic hangover. Seasick individuals should be isolated to avoid affecting others on board adversely. Drug therapy is of questionable value and must be used with caution because most preparations contain antihistamines that make the diver drowsy and could affect judgement. Drugs should be used only under the direction of a physician who understands diving, and the only after a test dose on nondiving days has been shown not to effect the individual adversely.
This information is for guidance only if there is any doubt as to it's accuracy please obtain a copy of Bulletin 19 from the Medical Devices Agency, Hannibal House, Elephant and Castle, London, SE1 6QT. Copies of the European Directive 93/42 EEC are obtainable from HM Stationery Office. This information is intended to help anyone who needs to replace out of date dressings etc, to justify why they are ordering new when they have still got stock which may not even show a date on it. There is a duty of care to the workforce that the companies nedd to address and this area often gets neglected. Author: Rod Urwin RN. REMT (P), DMT, Senior Offshore Medic.
Storing the Serum It should be stored in a refrigerator. It has a validity of one year. It should be transported in an isothermal box. Note: Early ventilatory support has the greatest influence on outcome. The mimimal initial dose of sea snake antivenin is 1-3 vials; as many as 10 vials may be required. Responsibility: each worksite should keep enough antivenin to cover this purpose on board and replenish them from base as necessary. SEA URCHINS Most divers in marine waters are familiar with the sea urchin. The spines, being very brittle, break off at the slightest touch. Symptoms and signs: Immediate sharp burning pain. Redness and swelling. Spines sticking out of skin or black dots where they have been broken off. Purpling of skin around place spines entered.
Treatment: Remove those spines that can be grasped with tweezers. Spines that have broken off flush with the skin are nearly impossible to remove, and probing around with a needle will only break the spines into little pieces. The body will dissolve most of the spines within a week. Others may fester and can then be popped out to the point, where they can be then removed with tweezers. Some forms have small venomous pincers that should be removed, and the wound should then be treated as a poisonous sting. Coral Cuts Coral frequently causes lacerations, and abrasions to inexperienced divers. These injuries may initially appear minor in natyre, but because of foreign material, such as pieces of coral, nematocysts, infected slime, etc, they frequently become inflamed and infected. Clinical Features The laceration, usually on the hand or foot, causes little trouble at the time of injury. Some hours later there may be a smarting sensation, and a mild inflammatory reaction around the cut. This may be due to the presence of discharging nematocyst. In the ensuing 1 to 2 days, local swelling, erythema, and tenderness develop around the site. Usually this abates in 3 to 7 days. Occasionally an abscess, or ulcer will form and discharge pus. This may become chronic, and osteomyelitis of the underlying bone has been reported. Celluitis, and/or lymphadenitis may accompany the accute stage. Fever, chills, arthralgia, malaise, and prostation occur in some cases, probably reflecting the systemic effects of a severe bacterial infection. Healing may take months to years if complications ensue. Treatment This involves early antisepsis, and total removal of foreing material (e.g. With soft brush). The wound should then be dressed with antibiotic powder, or ointment several times daily. Tetanus prophylaxis may be advisable. Cellutitus, lymphangitis, etc, indicates the need for a broad-spectrum systemic antibiotic (e.g. Ampicillin, tetracycline) after a swab is taken for culture, and sensitivity. In such cases, bed rest, elevation of the affected limb, and other general supportive measures will also be required. Prevention Coral cuts can be avoided by the use of protective clothing, gloves, and swim fins with heal cover and active treatment of minor abrasions. VACCINATIONS Certain vaccinations are required by the World Health Organisation (WHO) or by the public health services of some countries. This is the case for: YELLOW FEVER CHOLERA* Cholera vaccinations are indispensable because of the risk of infection on-site in certain countries. TETANUS TYPHOID* Medical treatment however is generally effective for this disease.
Other vaccination may also be required additionally, dependent on the bounty being visited. When several vaccinations are to be made, they should be given according to the following schedules: 1) Yellow fever. 2) A 3) Tetanus/polio 2 weeks later. MALARIA There is no vaccine against malaria, but there is an effective means of prevention, which is IMPERATIVE TO USE before, during and after a visit to an endemic malarial zone. The treatment consists of taking 0.1g of NIVAQUINE every day, starting just prior to departure for the area and continuing for three weeks following departure from the area. A registered doctor must prescribe all malaria chemoprophylaxis. In some countries malaria is resistant to Chloroquine/Nivaquine and should not be used. Recommended anti malaria prophylaxis: Malarone 250mg tablet Dosage i. One tablet 2 days prior to going into a malaria area. ii. One tablet daily whilst in the area. iii. One tablet daily for seven days on leaving that area.
Aeronautical Emergency Frequencies Commercial air traffic keep a listening watch of 121.5MHz. Military air traffic keep a listening watch on 243MHz. SEA KING rescue helicopters can home on all maritime and aeronautical emergency frequencies except of 156.8MHz (channel 16).
48 Telegraphy to 45 Telephony
Telephony 15 to Telegraphy 18
33-30 DISTRESS CALLING Telegraphy: Alarm signal: Distress message: Telephony: Alarm: Distress message: VHF telephony: Alarm: Distress message: 500kHz-8364kHz May-Day 12 x 4 sec. Points + S.O.S. S.O.S. + message. 2182kHz Two-tone alarm signal. May-Day + message. 156.8MHz (channel 16) None. May-Day + message.