DIVING MEDICAL OFFICER HANDBOOK
Compiled by LT Brad Kinney UMO (April 2016)
2
3
TABLE OF CONTENTS
DIVING MEDICINE EMERGENT MANAGEMENT 5
COMMUNICATIONS 5 AIR GAS EMBOLISM 7 DECOMPRESSION SICKNESS 9 CHAMBER OPERATIONS 13
RECOMPRESSION CONSIDERATIONS 13 TREATMENT TABLES 18 AIR TREATMENT TABLES 27 SYMPTOM RECURRENCE 29 POST-TREATMENT CONSIDERATIONS 30 HYPERBARIC OXYGEN THERAPY 32 CHAMBER LIFE SUPPORT CONSIDERATIONS 33
MISCELLANEOUS DIVE MEDICINE 42
DIVE PHYSIOLOGY 42 BASIC DIVE MEDICINE 46 EAR AND SINUS PROBLEMS 48 MARINE POISONING AND ENVENOMATION 50 BAD GAS 53 VERTIGO AND DIVING 54 NEUROLOGICAL EXAM 56 ENVIRONMENTAL PLANNING 67 THERMAL CONSIDERATIONS 70 ALTITUDE CONSIDERATIONS 75
EMERGENCY KITS 78
CHAMBER EMERGENCY KITS 78 DMO MEDICAL BAG 80 BRAD’S DMO BAG 81
DIVING OPERATIONS BASIC DIVING PHYSICS 82 AIR DIVING NO-DECOMPRESSION TABLE 83 AIR DIVING RNT TABLE 84 REPET DIVES 85 DIVER AIR QUALITY 87 DIVE PLANNING 91 UNDERWATER SIGNALING 99
SOURCES 103
4
5
EMERGENT MANAGEMENT
COMMUNICATIONS
Table 1: Important Comms.
1
DIVERS ALERT NETWORK (DAN) Emergency Hotline +1-919-684-9111
Medical Information +1-919-684-2948 Table 2: DAN Contact Info.
2
1 DIVEMAN, Appendix 1C.
2 DAN Dive and Travel Medical Guide.
6
Figure 1: Emergency Checklist.
3
3 DIVEMAN, Figure 6-22.
7
AIR GAS EMBOLISM
Pulmonary Overinflation Syndrome Condition Symptoms Signs
Arterial Gas Embolism
Seizure (focal or general), unconsciousness, confusion, headache, visual disturbances, bloody sputum (rare)
Hemiplegia, monoplegia, altered level of consciousness, blindness, visual motor deficit, focal motor or sensory loss
Mediastinal-subcutaneous emphysema
Substernal pain, “brassy voice,” neck swelling, dyspnea
Subcutaneous crepitus, gas patterns on radiographs of mediastinum and neck
Pneumothorax Chest pain, dyspnea Loss of breath sounds, hyperresonant chest percussion, tracheal shift
Table 3: POIS.4
Figure 2: POIS continued.
5
4 Wilderness Medicine, Table 77-4, page 1534.
5 DIVEMAN, Figure 3-10.
8
Figure 3: AGE and Severe DCS Algorithm.
6
6 DIVEMAN, Figure 20-1.
9
DECOMPRESSION SICKNESS
Common Symptoms and Signs of Decompression Sickness
Condition Symptoms Signs MSK DCS (bends)
Severe joint pain, single or multiple joints involved, paresthesia or dysesthesia about joint, lymphedema (uncommon)
Tenderness, which may be temporarily relieved by local pressure with blood pressure cuff; pain worsened by movement of joint
Neuro DCS (spinal cord)
Back pain, girdling abdominal pain, extremity heaviness or weakness, paralysis, paresthesia of extremities, fecal incontinence, urine retention
Hyperesthesia or hypoesthesia, paresis, anal sphincter weakness, loss of bulbocavernosus reflex, urinary bladder distention
Neuro DCS (brain)
Visual loss, scotomata, headache, dysphasia, confusion
Visual field deficit, spotty motor or sensory deficits, disorientation or mental dullness
Fatigue Profound generalized heaviness or fatigue
May precede signs of other forms
Cutaneous Intense pruritis No visible signs, mottling, local or generalized hyperemia or marbled skin (cutis marmorata)
Chokes Dyspnea, substernal pain that is worsened on deep inhalation, nonproductive cough
Cyanosis, tachypnea, tachycardia
Vasomotor DCS (decompression shock)
Weakness, sweating, unconsciousness
Hypotension, tachycardia, pallor, mottling, hemoconcentration, decreased urine output
Inner Ear (vestibular DCS)
Tinnitus, vertigo, nausea, vomiting Ataxia, possible nystagmus and positive Romberg, acute sensorineural hearing loss
Table 4: DCS Signs and Symptoms.7
7 Wilderness Medicine, Table 77-5, page 1539.
10
Differentiating Features between Disorders of the Spine and Spinal Cord DCS
Favoring Spine Disorder Favoring DCS History -Prior lumbar or cervical
radiculopathy, spine surgery -Documented chronic sensory or motor deficits
-Absence of prior spine involvement -No prior neurologic deficits (before dive)
Symptom onset Prior to or during the dive (before ascent)
Post dive
Diving exposure Benign: shallow depth, short duration, within No-D limits
Provocative: deep depth, long duration, at or beyond No-D limit
Physical Pain Localized to specific dermatome,
usually unilateral, commonly cervical or lumbar
Pain localized to a joint, bilateral, or involving multiple dermatomes, often trunk or abdomen
Paresthesia anesthesia
Dermatomal, usually cervical or lumbar, usually unilateral
Involves multiple cord levels, often bilateral
Cerebral/cerebellar findings
Absent May be present (with accompanying AGE)
Tendon reflexes Depressed or absent at level of involvement, often unilateral
Hyperreflexic, often bilateral
CT/MRI Disc herniation, narrowed neuroforamina, no cord lesions demonstrated
Cord lesion demonstrated
Table 5: Spinal Disorders vs. Spinal Cord DCS.8
8 Bove and Davis, Table 23-1, page 465.
11
Figure 4: Various DCS Considerations.
9
9 DIVEMAN, Section 20-3.
12
Figure 5: Type I DCS Algorithm.10
10
DIVEMAN, Figure 20-2.
13
CHAMBER OPERATIONS
RECOMPRESSION CONSIDERATIONS
Figure 6: Recompression Rules.
11
11
DIVEMAN, Table 20-1.
14
Table 6: Chamber Requirements.
12
Table 7: Chamber Support Levels.
13
12
DIVEMAN, Table 6-1. 13
DIVEMAN, Table 6-2.
15
Figure 7: Chamber Log.
14
14
DIVEMAN, Section 5-5.
16
Table 8: Tender Breathing Requirements.
15
Table 9: Chamber Exposure Times.
16
15
DIVEMAN, Table 20-6. 16
DIVEMAN, Table 20-4.
17
Table 10: Extended Surface Interval and Type I DCS.
17
Table 11: Asymptomatic Omitted Decompression.
18
17
DIVEMAN, Table 9-2. 18
DIVEMAN, Table 9-3.
18
TREATMENT TABLES
Figure 8: TT5.
19
Figure 9: TT5 Indications.
20
19
DIVEMAN, Figure 20-4. 20
DIVEMAN, Section 20-5.2.
19
Figure 10: TT6.
21
Figure 11: TT6 Indications.
22
21
DIVEMAN, Figure 20-5. 22
DIVEMAN, Section 20-5.3.
20
Figure 12: TT6A.
23
Figure 13: TT6A Indications.
24
23
DIVEMAN, Figure 20-6. 24
DIVEMAN, Section 20-5.4.
21
Figure 14: TT4.
25
Figure 15: TT4 Indications.
26
25
DIVEMAN, Figure 20-7. 26
DIVEMAN, Section 20-5.5.
22
Figure 16: TT7.
27
Figure 17: TT7 Indications and Considerations.
28
27
DIVEMAN, Figure 20-8. 28
DIVEMAN, Section 20-5.6 (pages 22-24).
23
24
25
Figure 18: TT8.
29
Figure 19: TT8 Indications.
30
29
DIVEMAN, Figure 20-9. 30
DIVEMAN, Section 20-5.7.
26
Figure 20: TT9.
31
Figure 21: TT9 Indications.
32
31
DIVEMAN, Figure 20-10. 32
DIVEMAN, Section 20-5.8.
27
AIR TREATMENT TABLES
Figure 22: Air TT1A.
33
Figure 23: Air TT1A Indications.
34
33
DIVEMAN, Figure 20-11. 34
DIVEMAN, Section 20-5.1.
28
Figure 24: Air TT2A.
35
Figure 25: Air TT3.
36
35
DIVEMAN, Figure 20-12. 36
DIVEMAN, Figure 20-13.
29
SYMPTOM RECURRENCE
Figure 26: Symptom Recurrence Algorithm.
37
37
DIVEMAN, Figure 20-3.
30
POST-TREATMENT CONSIDERATIONS
Figure 27: Post-Treatment Considerations (pages 30-31).
38
38
DIVEMAN, Section 20-8.
31
32
HYPERBARIC OXYGEN THERAPY
Table 12: HBO Therapy.
39
39
DIVEMAN, Table 20-3.
33
CHAMBER LIFE SUPPORT CONSIDERATIONS
Figure 28: Chamber Life Support Considerations.
40
40
DIVEMAN, Section 20-7 (pages 33-41).
34
35
36
37
38
39
40
41
42
MISCELLANEOUS DIVE MEDICINE
DIVE PHYSIOLOGY
Figure 29: Lung Volumes.
41
41
DIVEMAN, Figure 3-5.
43
Figure 30: Oxygen Consumption Rates.
42
42
DIVEMAN, Figure 3-6.
44
Figure 31: Saturation of Tissues.
43
43
DIVEMAN, Figure 3-16.
45
Figure 32: Desaturation of Tissues.
44
44
DIVEMAN, Figure 3-17.
46
BASIC DIVE MEDICINE
Differential Diagnosis of Conditions Presenting After Surfacing by Time of Onset
<2 min 2-10 min >10 min DCS DCS DCS
Hypothermia Hypothermia Hypothermia IEBT IEBT IEBT CAGE CAGE
Pneumothorax Pneumothorax Pneumomediastinum Pneumomediastinum Alternobaric Vertigo
Hypercapnia Hypoxia
Oxygen Toxicity CO Poisoning
Table 13: Dive Differential Diagnoses.45
Causes of Unconsciousness in Divers Breath-Hold Diving
Underwater hypoxemia after hyperventilation before the dive “shallow-water blackout”
Near drowning
Compressed Gas Equipment
Hypoxic breathing gas
Contaminated breathing gas (such as carbon monoxide)
Equipment failure or exhaustion of breathing gas
Near drowning
Inert gas narcosis
Oxygen toxicity
Pulmonary barotrauma with arterial gas embolism
Rebreathing Equipment
Carbon dioxide toxicity
Oxygen poisoning Table 14: Unconscious Divers.
46
45
Bove and Davis, Table 18-4, page 359. 46
Wilderness Medicine, Box 77-5, page 1538.
47
Potential Medical Problems Associated with Each Phase of a 130-fsw SCUBA Dive on Air
Descent On Bottom Ascent After Surfacing Aural and Sinus Barotrauma
Most likely injury
Impossible except for delayed perilymph fistula
Most likely injury
Impossible, except for delayed perilymph fistula
Hypercapnia Unlikely Unlikely unless: -CO2 is present in air -Regulator resistance is extensive -Skip breathing is used
Unlikely Not possible
CO Poisoning Unlikely -Inadequate time for uptake -Increased PO2 protects
Unlikely -Increased PO2 protects
Most likely time -Adequate time for uptake -Loss of PO2 protection
Unlikely
Alternobaric Vertigo Possible Possible immediately after arrival on bottom
Most likely time
Within 1st 2 minutes only
Nitrogen Narcosis Slight -Aggravated if descent rapid
Slight None None
DCS Not possible Not possible Rare Most likely time Occupational Injury Possible Most likely time Possible Possible CAGE Not possible Not possible Possible in late
stages Possible -Onset of symptoms within 10 minutes of surfacing
Pneumothorax, Pneumomediastinum
Not possible Rare -Usually associated with ditch-and-don exercises
Possible in late stages
Possible -Onset of symptoms within 10 minutes of surfacing
Table 15: Dive Diagnoses Presentations.47
47
Bove and Davis, Table 18-5, page 362.
48
EAR AND SINUS PROBLEMS
Figure 33: Sinuses.
48
Figure 34: Ear Anatomy.
49
48
DIVEMAN, Figure 3-8. 49
DIVEMAN, Figure 3-7.
49
Teed Grading System for Middle Ear Barotrauma Grade Description
0 Symptoms without otologic findings 1 Erythema and mild retraction of the TM 2 Erythema of the TM with mild or spotty hemorrhage within the TM 3 Gross hemorrhage throughout the TM 4 Grade 3 changes plus gross hemorrhage within the middle ear
(hemotympanum) 5 Free blood in middle ear plus perforation of the TM
Table 16: TEED Grading.50
Characteristics of Inner Ear Barotrauma and Inner
Ear DCS IEBT IEDCS Time of symptom onset During compression
(associated with MEBT). During or shortly after decompression.
Dive characteristics -Dives not requiring staged decompression. -Can occur during compression phase of deeper dives. -Dives with rapid descents. -Reported cases associated with air diving – can probably occur with helium diving.
-Dives requiring staged decompression. -Dives without proper, staged ascents. -More common during decompression from helium dives – can occur with air diving.
Possible associated symptoms
-Difficulty with ear clearing and/or ear pain or drainage – frequent. -May have a history of preexisting nasal, sinus, or middle ear disease.
-None or other symptoms of decompression sickness.
Possible associated physical findings
Signs of middle ear barotrauma – frequent.
None or other symptoms of decompression sickness.
Table 17: IEBT vs. IEDCS.51
50
Wilderness Medicine, Table 77-3, page 1529. 51
Bove and Davis, Table 22-5, page 452.
50
MARINE POISONING AND ENVENOMATION
Marine Toxin Diseases Disease Ciguatera
poisoning Scombroid poisoning
Puffer fish poisoning
PSP paralytic shellfish poisoning
DSP diarrheic shellfish poisoning
ASP amnesic shellfish poisoning
NSP neurotoxic shellfish poisoning
Vector Carnivorous reef fish (barracuda, grouper, moray eel, parrot fish, red snapper, surgeon fish, trigger fish, amberjack, wrass, mullet)
Scombroid fish (tuna, mackerel, skipjack, bonito)
Puffer fish (served as Fugu in Japanese restaurants)
Shellfish Shellfish Shellfish Shellfish
Organism Dinoflagellate Surface bacteria ? bacteria Red tide dinoflagellate
Red tide dinoflagellate
Red tide dinoflagellate
Red tide dinoflagellate
Distribution Worldwide tropical and subtropical
Worldwide Worldwide Worldwide temperate
Worldwide temperate
North America Gulf of Mexico, New Zealand
Incubation Hours Minutes-hours 5-30 minutes Hours Hours Days Duration Months-years <24 hours Days Days Days Years Days Symptoms GI, neuro Cutaneous Neuro
(respiratory paralysis)
Neuro (respiratory paralysis)
GI Neuro GI, Neuro
Mortality <1% 0% 60% 1-14% 0% 3% 0% Treatment Supportive,
mannitol Antihistamines, H2-blockers
Supportive (respiratory)
Supportive (respiratory)
Supportive Supportive Supportive
Prevention (Avoid)
Avoid large carnivorous fish
Poorly preserved fish
Puffer fish Shellfish Shellfish Shellfish Shellfish
Table 18: Marine Toxin Diseases.52
52
http://www.the-travel-doctor.com/seafoodpoisoning.htm.
51
Figure 35: Marine Envenomation Algorithm.53
53
Wilderness Medicine, Figure 80-104, page 1627.
52
Algorithmic approach to marine envenomation. *A gaping laceration, particularly of the lower extremity, with cyanotic edges suggests a stingray wound. Multiple punctures in an erratic pattern with or without purple discoloration or retained fragments are typical of a sea urchin sting. One to eight (usually two) fang marks are usually present after a sea snake bite. A single ischemic puncture wound with an erythematous halo and rapid swelling suggests scorpionfish envenomation. Blisters often accompany a lionfish sting. Painless punctures with paralysis suggest the bite of a blue-ringed octopus; the site of a cone snail sting is punctate, painful, and ischemic in appearance. †Wheal and flare reactions are nonspecific. Rapid (within 24 hours) onset of skin necrosis suggests an anemone sting. “Tentacle prints” with cross-hatching or a frosted appearance after application of aluminum-based salts suggest box-jellyfish (Chironex fleckeri) envenomation. Ocular or intraoral lesions may be caused by fragmented hydroids or coelenterate tentacles. An allergic reaction must be treated promptly. ‡Sea snake venom causes weakness, respiratory paralysis, myoglobinuria, myalgias, blurred vision, vomiting, and dysphagia. The blue-ringed octopus injects tetrodotoxin, which causes rapid neuromuscular paralysis. §As soon as possible, venom should be sequestered locally with a proximal venous-lymphatic occlusive band of constriction, or (preferably) by the pressure-immobilization technique, in which a cloth pad is compressed directly over the wound by an elastic wrap that should encompass the entire extremity at a pressure of 9.33 kPa (70 mmHg) or less. Incision and suction are not recommended. ¶Early ventilatory support has the greatest influence on outcome. The minimal initial dose of sea snake antivenom is one to three vials; up to 10 vials may be required. ǁThe wounds range from large lacerations (stingrays) to minute punctures (stonefish). Persistent pain after immersion in hot water suggests a scorpionfish or stonefish sting or a retained fragment of a spine. The puncture site can sometimes be identified by forcefully injecting 1% to 2% lidocaine or another local anesthetic agent without epinephrine near the wound and observing the egress of fluid. Do not attempt to crush the spines of sea urchins if they are present in the wound. Spine dye from already-extracted sea urchin spines will disappear (be absorbed) in 24 to 36 hours. **The initial dose of stonefish antivenom is one vial per two puncture wounds. ††The antibiotics chosen should cover Staphylococcus, Streptococcus, and microbes of marine origin, such as Vibrio. ‡‡Acetic acid (5%; i.e., vinegar) is a good all-purpose decontaminant and is mandated for the sting from a box-jellyfish. Alternatives, depending on the geographic region and indigenous jellyfish species, include isopropryl alcohol, bicarbonate (baking soda), ammonia, papain, and preparations containing these agents. Hot (45° C or 113° C; usually, heated water) application may be effective for relieving pain. §§The initial dose of box-jellyfish antivenom is one ampule IV or three ampules IM. ¶¶If inflammation is severe, steroids should be given systematically (beginning with at least 60 to 100mg of prednisone or its equivalent), and the dose should be tapered over a period of 10 to 14 days. ǁǁAn alternative is to apply and remove commercial facial peel materials. ***An alternative is to apply and remove commercial facial peel materials, followed by topical soaks of 30mL of 5% acetic acid (vinegar) diluted in 1 L of water for 15 to 30 minutes several times a day until the lesions begin to resolve. Anticipate surface desquamation in 3 to 6 weeks.54
54
Wilderness Medicine, Figure 80-104, page 1627.
53
BAD GAS
Table 19: Common Problems with Breathing Gas Under Pressure.
55
55
http://books.publications.chestnet.org/data/Books/PULM/chapter41-t02.png.
54
VERTIGO AND DIVING
Causes of Vertigo in Divers Decompression Sickness Hypoxia Hypercarbia Nitrogen Narcosis Seasickness Alcoholic Hangovers Sensory Deprivation Hyperventilation Impure Breathing Gas Unequal Caloric Stimulation Difficulties with middle ear pressure equalization
Table 20: Vertigo in Divers.56
Differential Diagnosis of Central and Peripheral Vertigo in Diving
Peripheral Central Symptoms Generally intense with nausea and
vomiting. Generally affected by head movement; one head position may be critical
Only slightly responsive to head movement
Spontaneous Nystagmus
Horizontal or rotatory, never vertical. Suppresses with visual fixation. Gaze direction dependent. Always conjugate.
All forms possible. Unchanged or enhanced by visual fixation. May depend on gaze direction. May be disconjugate.
Positional Nystagmus 2-10 sec latency period. Short-lived. Positive when affected ear is positioned downward. Direction fixed. Response fatigues on repeat testing.
No latency. Generally persists. Positive when either ear is positioned downward. Direction changing. Response does not fatigue.
Saccadic and smooth eye pursuit
Normal Very infrequent
Associated Auditory findings
Frequent Very Infrequent
Neuro Exam Results Normal* Abnormal *Peripheral labyrinthine lesion in DCS and CAGE may be associated with an abnormal result on neuro exam
Table 21: Central vs. Peripheral Vertigo.57
56
Bove and Davis, Table 22-1, page 438. 57
Bove and Davis, Table 18-6, page 372.
55
Differential Diagnosis of Vertigo after Surfacing ABV IEBT DCS CAGE Onset Within 2 min Anytime Anytime Within 10 min Duration Usually
short, <10 min
Persistent Persistent Persistent
Associated Neuro Findings
Absent* Absent Possible Common
Decompression Stress Required+
No No Yes No
Difficulty Clearing/evidence of MEBT
Not required Generally present
Not required Not required
Coexisting Auditory Signs
Unusual Very common (88%)
Common (38%) Less common
Nystagmus Peripheral Peripheral Central or peripheral
Central or peripheral
Fistula Test Unknown May be positive Unknown Unknown *Except for alternobaric facial palsy +Sufficient time has elapsed on the bottom to allow for inert gas absorption. For sensitive individuals, this may be inside the no-decompression limits. ABV, alternobaric vertigo; CAGE, cerebral arterial gas embolism; DCS, decompression sickness; IEBT, inner-ear barotrauma; MEBT, middle ear barotrauma.
Table 22: Vertigo after Surfacing.58
58
Bove and Davis, Table 18-7, page 373.
56
NEUROLOGICAL EXAMINATION
Figure 36: Neuro Exam Checklist.
59
59
DIVEMAN, Figure 5A-1a.
57
Figure 37: Neuro Exam Checklist continued.
60
60
DIVEMAN, Figure 5A-1b.
58
Figure 38: Neuro Exam.
61
61
DIVEMAN, Section 5A-3 (pages 58-63).
59
60
61
62
63
Table 23: Reflexes.
62
62
DIVEMAN, Table 5A-2.
64
Table 24: Strength Tests.
63
63
DIVEMAN, Table 5A-1.
65
Figure 39: Dermatomes and Spinal Cord Segments.
64
64
DIVEMAN, Figure 5A-2a.
66
Figure 40: Dermatomes and Spinal Cord Segments continued.
65
65
DIVEMAN, Figure 5A-2b.
67
ENVIRONMENTAL PLANNING
Figure 41: Environmental Checklist.
66
66
DIVEMAN, Figure 6-6.
68
Figure 42: Sea States.
67
67
DIVEMAN, Figure 6-7.
69
Figure 43: Wind/Temperature.
68
68
DIVEMAN, Figure 6-8.
70
THERMAL CONSIDERATIONS
Table 25: Signs and Symptoms of Hypothermia.
69
Expected Survival Time in Cold Water Water Temperature Exhaustion or Unconsciousness in: Expected Survival Time 70–80° F (21–27° C) 3–12 hours 3 hours – indefinitely 60–70° F (16–21° C) 2–7 hours 2–40 hours 50–60° F (10–16° C) 1–2 hours 1–6 hours 40–50° F (4–10° C) 30–60 minutes 1–3 hours 32.5–40° F (0–4° C) 15–30 minutes 30–90 minutes
<32° F (<0° C) Under 15 minutes Under 15–45 minutes Table 26: Expected Survival Times.
70
69
DIVEMAN, Table 3-1. 70 http://www.ussartf.org/cold_water_survival.htm.
71
Figure 44: Water Temperature Protection.
71
71
DIVEMAN, Figure 6-11.
72
Table 27: Heat Stress Signs.
72
72
DIVEMAN, Table 3-2.
73
Figure 45: Thermal Considerations.
73
73
DIVEMAN, Section 6-5 (pages 73-74).
74
75
ALTITUDE CONSIDERATIONS
Table 28: Repet Groups at Altitude.
74
Figure 46: Treatment at Altitude.
75
74
DIVEMAN, Table 9-5. 75
DIVEMAN, Section 20-7.13.
76
Table 29: Surface Intervals before Ascent to Altitude.
76
76
DIVEMAN, Table 9-6.
77
Table 30: SLED Chart.
77
77
DIVEMAN, Table 9-4.
78
EMERGENCY KITS
CHAMBER EMERGENCY KITS
Table 31: Chamber Primary Emergency Kit.
78
78
DIVEMAN, Table 20-7.
79
Table 32: Chamber Secondary Emergency Kit.
79
79
DIVEMAN, Table 20-8.
80
DMO MEDICAL BAG
Diving Medicine Physician’s Kit for Remote Locations
EQUIPMENT DRUGS AND FLUIDS Sphygmomanometer NS and LR solution
Stethoscope Injectable Dexamethasone Otoophthalmoscope Sodium Bicarbonate Ampules
Oropharyngeal Airway Local anesthetic solution Endotracheal tubes, scope, blade Aspirin Tablets
Foley Catheter, 18-22 gauge Otic Domeboro Solution Syringes and Needles Cortisporin Otic Solution
Venous Cannula Ophthalmic Antibiotic Solution Tourniquet Afrin Nasal Spray
IV Infusion Sets Benadryl Injection and Capsules Scissors, disposable scalpels Topical Steroid Cream
Bandage Materials Topical Antibiotic Ointment Ace Bandages Hibiclens Surgical Soap Sterile Gloves Antacid Tablets
Ciprofloxacin 500mg Tabs Diazepam Injection Baby Ear Syringe White Vinegar
Table 33: Dive Medicine Kit.80
80
Bove and Davis, Appendix 3, page 579.
81
82
BASIC DIVING PHYSICS
Gas Laws Boyle’s Law At a constant temperature, the absolute pressure and the
volume of a gas are inversely proportional P1V1=P2V2
Charles’ Law At constant pressure, the absolute temperature and the volume of a gas are directly proportional
𝑉1
𝑇1 =
𝑉2
𝑇2
Gay-Lussac’s Law
At constant volume, the absolute temperature and the pressure of a gas are directly proportional
𝑃1
𝑇1 =
𝑃2
𝑇2
General Gas Law
The general gas law is a combination of Boyle’s law, Charles’ law, and Gay-Lussac’s law, and is used to predict the behavior of a given quantity of gas when pressure, volume, and temperature changes
𝑃1𝑉1
𝑇1 =
𝑃2𝑉2
𝑇2
Dalton’s Law The total pressure exerted by a mixture of gases is equal to the sum of the pressures of the different gases making up the mixture, with each gas acting as if it alone occupied the total volume
Ptotal=p1+p2+p3+…
Henry’s Law The amount of gas that will dissolve in a liquid at a given temperature is almost directly proportional to the partial pressure of that gas
Ideal Gas Law Used to predict the behavior of ideal gases PV=nRT Table 34: Gas Laws.
81
Commonly Used Units of Pressure in the Underwater Environment FSW MSW PSIG PSIA ATA mmHg Gas
Bubble Volume
Gas Bubble Diameter
Sea Level Sea Level 0.0 14.7 1 760 100% 100% 33 10 14.7 29.4 2 1520 50% 79% 66 20 29.4 44.1 3 2280 33% 69% 99 30 44.1 58.8 4 3040 25% 63%
132 40 58.8 73.5 5 3800 20% 58% 165 50 73.5 88.2 6 4560 17% 54% 198 60 88.2 102.9 7 5320 231 70 102.9 117.6 8 6080 264 81 117.6 132.2 9 6840 297 91 132.2 147.0 10 7600
Table 35: Units of Pressure.82
81
Bove and Davis, pages 26-32; DIVEMAN, Chapter 12. 82
Wilderness Medicine, Table 77-2, page 1527.
83
AIR DIVING NO-DECOMPRESSION LIMITS
Table 36: No-D Limits and Repet Group Designators.
83
83
DIVEMAN, Table 9-7.
84
AIR DIVING RESIDUAL NITROGEN TIME TABLE
Table 37: RNT Table.
84
84
DIVEMAN, Table 9-8.
85
REPET DIVES
Figure 47: Repet Dive Worksheet.
85
85
DIVEMAN, Figure 9-9.
86
Figure 48: Repet Dive Flow Chart.
86
86
DIVEMAN, Figure 9-8.
87
DIVER AIR QUALITY
Table 38: Dry Atmospheric Air.
87
Table 39: Diver Air Purity Standards.
88
87
DIVEMAN, Table 2-2. 88
DIVEMAN, Table 4-1.
88
Tables 40 and 41: Diver Quality Air Standards.89
89
DIVEMAN, Table 4-2 and 4-3.
89
Tables 42 and 43: Diver Quality Air Standards continued.90
90
DIVEMAN, Table 4-3 and 4-4.
90
Table 44: Diver Quality Air Standards continued.91
91
DIVEMAN, Table 4-5.
91
DIVE PLANNING
Figure 49: Dive Abbreviations.
92
Figure 50: Air Diving Techniques with Limits.
93
92
DIVEMAN, Figure 9-2. 93
DIVEMAN, Figure 6-13.
92
Figure 51: Decompression Selection.
94
94
DIVEMAN, Figure 9-7.
93
Figure 52: Limits for Air Diving.
95
95
DIVEMAN, Figure 6-14.
94
Figure 53: Diving Safety.
96
96
DIVEMAN, Figure 6-19 (pages 94-97).
95
96
97
98
Table 45: SCUBA Cylinder Data.
97
97
DIVEMAN, Table 7-1.
99
UNDERWATER SIGNALING
Table 46: Line-Pull Signals.
98
98
DIVEMAN, Table 8-3.
100
Figure 54: SCUBA Hand Signals.
99
99
DIVEMAN, Figure 7-9.
101
102
103
DMO HANDBOOK SOURCES
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