VOLUME 5 Diving Medicine & Recompression Chamber Operations 20 Diagnosis and Treatment of Decompression Sickness and Arterial Gas Embolism 21 Recompression Chamber Operation Appendix 5A Neurological Examination Appendix 5B First Aid Appendix 5C Dangerous Marine Animals U.S. NAVY DIVING MANUAL PAGE LEFT BLANK INTENTIONALLY Volume 5 - Table of Contents Chap/Para Page 20 DIAGNOSIS AND TREATMENT OF DECOMPRESSION SICKNESS AND ARTERIAL GAS EMBOLISM 20-1 INTRODUCTION .............................................................20-1 20-1.1 Purpose .............................................................20-1 20-1.2 Scope . .............................................................20-1 20-1.3 Diving Supervisor’s Responsibilities .......................................20-1 20-1.4 Prescribing and Modifying Treatments . ....................................20-2 20-1.5 When Treatment is Not Necessary ........................................20-2 20-1.6 Emergency Consultation ................................................20-2 20-2 ARTERIAL GAS EMBOLISM ...................................................20-2 20-2.1 Diagnosis of Arterial Gas Embolism . ......................................20-3 20-2.1.1 Symptoms of AGE . ...........................................20-3 20-2.2 Treating Arterial Gas Embolism . .........................................20-4 20-2.3 Resuscitation of a Pulseless Diver . .......................................20-4 20-3 DECOMPRESSION SICKNESS .................................................20-4 20-3.1 Diagnosis of Decompression Sickness .....................................20-5 20-3.2 Symptoms of Type I Decompression Sickness ...............................20-5 20-3.2.1 Musculoskeletal Pain-Only Symptoms .............................20-5 20-3.2.2 Cutaneous (Skin) Symptoms . ...................................20-6 20-3.2.3 Lymphatic Symptoms ..........................................20-6 20-3.3 Treatment of Type I Decompression Sickness . ..............................20-6 20-3.4 Symptoms of Type II Decompression Sickness . .............................20-6 20-3.4.1 Neurological Symptoms ........................................20-7 20-3.4.2 Inner Ear Symptoms (“Staggers”) . ...............................20-7 20-3.4.3 Cardiopulmonary Symptoms (“Chokes”) . ..........................20-7 20-3.4.4 Differentiating Between Type II DCS and AGE . .....................20-7 20-3.5 Treatment of Type II Decompression Sickness ...............................20-8 20-3.6 Decompression Sickness in the Water .....................................20-8 20-3.7 Symptomatic Omitted Decompression . ....................................20-8 20-3.8 Altitude Decompression Sickness .........................................20-8 20-3.8.1 Joint Pain Treatment . .........................................20-9 20-3.8.2 Other Symptoms and Persistent Symptoms . .......................20-9 20-4 RECOMPRESSION TREATMENT FOR DIVING DISORDERS .........................20-9 20-4.1 Primary Objectives .................................................... 20-9 20-4.2 Guidance on Recompression Treatment. 20-9 Table of Contents—Volume 5 5–i Chap/Para Page 20-4.3 Recompression Treatment When Chamber Is Available ........................20-9 20-4.3.1 Recompression Treatment With Oxygen . .........................20-10 20-4.3.2 Recompression Treatments When Oxygen Is Not Available . ..........20-10 20-4.4 Recompression Treatment When No Recompression Chamber is Available .......20-11 20-4.4.1 Transporting the Patient .......................................20-11 20-4.4.2 In-Water Recompression . .....................................20-11 20-5 TREATMENT TABLES .......................................................20-13 20-5.1 Air Treatment Tables ..................................................20-13 20-5.2 Treatment Table 5 .....................................................20-13 20-5.3 Treatment Table 6 ....................................................20-13 20-5.4 Treatment Table 6A ...................................................20-14 20-5.5 Treatment Table 4 . ..................................................20-14 20-5.6 Treatment Table 7 ....................................................20-15 20-5.6.1 Decompression . ............................................20-15 20-5.6.2 Tenders. ..................................................20-16 20-5.6.3 Preventing Inadvertent Early Surfacing . ..........................20-16 20-5.6.4 Oxygen Breathing. 20-16 20-5.6.5 Sleeping, Resting, and Eating . .................................20-16 20-5.6.6 Ancillary Care ...............................................20-16 20-5.6.7 Life Support . ...............................................20-17 20-5.7 Treatment Table 8 ....................................................20-17 20-5.8 Treatment Table 9 ....................................................20-17 20-6 RECOMPRESSION TREATMENT FOR NON-DIVING DISORDERS ...................20-17 20-7 RECOMPRESSION CHAMBER LIFE-SUPPORT CONSIDERATIONS .................20-18 20-7.1 Minimum Manning Requirements ........................................20-18 20-7.2 Optimum Manning Requirements ........................................20-19 20-7.2.1 Additional Personnel . ........................................20-19 20-7.2.2 Required Consultation by a Diving Medical Officer . .................20-19 20-7.3 Oxygen Control ......................................................20-19 20-7.4 Carbon Dioxide Control ................................................20-19 20-7.4.1 Carbon Dioxide Monitoring .....................................20-20 20-7.4.2 Carbon Dioxide Scrubbing ...................................... 20-20 20-7.4.3 Carbon Dioxide Absorbent .....................................20-20 20-7.5 Temperature Control ..................................................20-20 20-7.5.1 Patient Hydration . ...........................................20-21 20-7.6 Chamber Ventilation . .................................................20-21 20-7.7 Access to Chamber Occupants. 20-22 20-7.8 Inside Tenders .......................................................20-22 20-7.8.1 Inside Tender Responsibilities . .................................20-22 20-7.8.2 DMO or DMT Inside Tender ....................................20-22 20-7.8.3 Use of Diving Medical Officer as Inside Tender . ....................20-22 5–ii U.S. Navy Diving Manual—Volume 5 Chap/Para Page 20-7.8.4 Non-Diver Inside Tender - Medical ...............................20-23 20-7.8.5 Specialized Medical Care ......................................20-23 20-7.8.6 Inside Tender Oxygen Breathing . ...............................20-23 20-7.8.7 Tending Frequency ...........................................20-23 20-7.9 Equalizing During Descent . ............................................20-23 20-7.10 Use of High Oxygen Mixes . ............................................20-23 20-7.11 Oxygen Toxicity During Treatment . ......................................20-24 20-7.11.1 Central Nervous System Oxygen Toxicity . ........................20-24 20-7.11.2 Pulmonary Oxygen Toxicity . ...................................20-25 20-7.12 Loss of Oxygen During Treatment . ......................................20-25 20-7.12.1 Compensation . .............................................20-25 20-7.12.2 Switching to Air Treatment Table . ...............................20-26 20-7.13 Treatment at Altitude ..................................................20-26 20-8 POST-TREATMENT CONSIDERATIONS ........................................20-26 20-8.1 Post-Treatment Observation Period . .....................................20-26 20-8.2 Post-Treatment Transfer ...............................................20-27 20-8.3 Flying After Treatments ................................................20-27 20-8.3.1 Emergency Air Evacuation .....................................20-27 20-8.4 Treatment of Residual Symptoms ........................................20-28 20-8.5 Returning to Diving after Recompression Treatment . ........................20-28 20-9 NON-STANDARD TREATMENTS ..............................................20-29 20-10 RECOMPRESSION TREATMENT ABORT PROCEDURES ..........................20-29 20-10.1 Death During Treatment . ..............................................20-29 20-10.2 Impending Natural Disasters or Mechanical Failures . ........................20-30 20-11 ANCILLARY CARE AND ADJUNCTIVE TREATMENTS .............................20-30 20-11.1 Decompression Sickness. ..............................................20-31 20-11.1.1 Surface Oxygen . ............................................20-31 20-11.1.2 Fluids . ....................................................20-31 20-11.1.3 Anticoagulants . .............................................20-32 20-11.1.4 Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs .............20-32 20-11.1.5 Steroids . ..................................................20-32 20-11.1.6 Lidocaine . .................................................20-32 20-11.1.7 Environmental Temperature ....................................20-32 20-11.2 Arterial Gas Embolism . ...............................................20-32 20-11.2.1 Surface Oxygen . ............................................20-32 20-11.2.2 Lidocaine . .................................................20-32 20-11.2.3 Fluids . ....................................................20-32 20-11.2.4 Anticoagulants . .............................................20-33 20-11.2.5 Aspirin and Other Non-Steroidal Anti-Inflammatory