I. Determine the Urgency of the Injury
Make an initial evaluation at the dive site. Suspect decompression illness if any of the signs or symptoms previously described occur within 24 hours of surfacing from a dive. The initial state of the affected diver will determine the order and urgency of the actions taken. Based on a classification used by the U.S. Navy, the diver can be placed in one of three case categories:
Category A – Emergency Cases Of DCI
Symptoms are severe and appear rapidly, within an hour or so of surfacing. Unconsciousness may occur. Symptoms may be progressing, and the diver is obviously ill. The diver may be profoundly dizzy, have trouble breathing or have major abnormalities in consciousness. Obvious neurological injury is seen in altered consciousness, abnormal gait or weakness.
These divers are obviously very sick, and a true medical emergency exists. If necessary (e.g., if the diver is unconscious), begin CPR and take immediate action to have the diver evacuated. Check for foreign bodies in the airway. If ventilatory or cardiac resuscitation is required, the injured diver must be supine (lying on the back). Vomiting in this position, however, is extremely dangerous; if it occurs, quickly turn the diver to the side until the airway is cleared and resuscitation can resume in the supine position.
If available, use supplemental oxygen while administering breaths to increase the percentage of oxygen received by the injured diver. Even if CPR is successful and the diver regains consciousness, 100 percent oxygen should be provided and continued until the diver arrives at a medical facility.
If Trained Healthcare Personnel Are Available . . .
… then an intravenous (IV) infusion using isotonic fluids without dextrose should be started. An initial rapid infusion of 1 liter over 30 minutes should begin to correct any dehydration and reduce hemoconcentration. Once this is accomplished, then the rate of administration should be reduced to a 100-175 cc / hour maintenance rate.
Additional 1-liter boluses may be required to further correct dehydration and maintain blood pressure but should only be given by trained healthcare personnel capable of weighing the need for further fluid with possible complications. These would include fluid overload problems and discomfort from urinary retention in divers with abnormal bladder function due to spinal cord decompression sickness. If trained personnel are available, a urinary catheter should be placed in all unconscious divers and in those who cannot urinate.
Category B – Urgent Cases Of DCI
Here, the only obvious symptom is severe pain that is unchanging or has progressed slowly during the past few hours. The diver does not appear to be in distress except for the pain, and the neurological signs and symptoms are not obvious without a careful history and examination.
Immediately place the injured diver on 100 percent oxygen and give fluids by mouth. Do not attempt to treat the pain with analgesics until advised to do so by medical personnel. Continue providing oxygen until arrival at the medical treatment facility.
Contact DAN or the nearest medical facility for advice on what sort of transport is necessary and where the diver should be evacuated to, even if symptoms improve or are relieved with oxygen. Emergency air transport may not be necessary in all cases.
While awaiting evacuation, take as detailed a history as possible and try to evaluate and record the diver’s neurological status. This information will be useful to those at the receiving medical facility. If air evacuation is used, cabin pressure should be maintained near sea level and not exceed 800 feet unless aircraft safety is compromised.
Category C – Timely Cases Of DCI
Symptoms are either not obvious or have progressed slowly for several days. Usually the main signs or symptoms are vague complaints of pain or an abnormality of sensation; the diagnosis of DCI may be in question. Obtain as complete a diving history as possible and do a neurological evaluation. Then call DAN or the nearest medical facility for advice or go to the nearest medical facility, if nearby, for evaluation.
II. Get the Dive History If possible, obtain and document the following information for all suspected cases of DCI:
– For 48 hours preceding the injury, get a description of all dives: depths / times, ascent rates, intervals between dives, breathing gases, problems or symptoms at any time before, during or after the dive;
– Ask for symptom onset times and progression after the diver has surfaced from last dive;
– Get a description of all first aid measures taken (including times and method of 100 percent oxygen delivery) and their effect on symptoms since the injury;
– Record the results of the on-site neurological examination (described below);
– Make a description of all joint or other musculoskeletal pain including: location, intensity and changes with movement or weight-bearing maneuvers;
– Get a description and distribution of any rashes; and
– Provide a description of any traumatic injuries before, during or after the dive.
III. Conduct an On-Site Neurological Examination
Information regarding the injured diver’s neurological status will be useful to medical personnel in not only deciding the initial course of treatment but also in the effectiveness of treatment. Examination of an injured diver’s central nervous system soon after an accident may provide valuable information to the physician responsible for treatment.
The On-Site Neuro Exam is easy to learn and can be done by individuals with no medical experience. Perform as much of the examination as possible, but do not let it interfere with evacuation to a medical treatment facility.
Returning to Diving after DCI
The U.S. Navy has set down rules for returning to diving after treatment. For pain-only DCI where there are no neurological symptoms, divers may begin diving two to seven days after treatment, depending on the treatment table used.
If there are neurological symptoms, the diver may resume diving two to four weeks after treatment, depending on symptom severity. For very severe symptoms, the diver must be reevaluated three months after treatment and cleared by a Diving Medical Officer.
The Navy’s guidelines are for professionals, where time off must be minimized so operations are not compromised.
Guides For Sport Divers
For recreational divers, where diving is not a livelihood, a more conservative approach is called for to further minimize the chance that a diving injury will recur.
After pain-only DCI where there are no neurological symptoms, a minimum of two weeks without diving is recommended.
If there are minor neurological symptoms, six weeks without diving is recommended.
If there are severe neurological symptoms or any residual symptoms, no further diving is recommended.
Even if symptoms were not severe and they resolved completely, a diver who has had multiple bouts of DCI must take special considerations. If DCI is occurring where other divers on the same profile are DCI-free, the diver may have an increased susceptibility to DCI. In these cases, a Diving Medical Specialist must be consulted to determine if diving can be resumed safely.
Remember, your good health needs to last as long as you do
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