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INDEX

Chapter 1 - Introduction p. 5Chapter 2 - First Aid Kit p. 14Chapter 3 - Anatomy, Diagnostic Signs & Symptoms p. 21Chapter 4 - First Aid p. 35Chapter 5 - Diving Accidents p. 77Chapter 6 - Quick Reference Guide p. 87

©IDEA EuropeDive Medic ManualJune 2001

Via Mulino di Pile 3 - 67100 L’Aquila (Italy)Phone +39 0862 318499 - Fax +39 0862 318542

Internet IDEA Europe:www.idea-europe.comwww.idea-europe.org

Duplication and reproduction, even partially,of this manual is prohibited unless with written authorization.

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SCOPE AND PURPOSE OF THE IDEA DIVE MEDIC SPECIALTY TRAINING

Beginning in 1980, IDEA initiated the first IDEA Dive Medic courses. The first IDEA Dive Medic specialty courses were Dive Medic I and Dive Medic II. These courses were taught by IDEA Scuba Instructors who were also certified as Emergency Medical Technicians and Para-medics. There have been many changes to both the Emergency Med-ical System and First Aid since these first Instructors started teaching the IDEA Dive Medic courses. The American Heart Association and American Red Cross have updated and simplified CPR (Cardio Pulmonary Resuscitation) for the lay person. Both the American Heart Association and The American Red Cross have programs that include the use of Automatic External Defibrillators (AED). These programs may be incorporated into each agency’s CPR program. For more information on training in the use of Automatic Defibrillators ask your IDEA Instructor or contact the local branch of the American Heart or American Red Cross. The Ameri-can Red Cross has for many years offered excellent training in Basic First Aid. There are also industrial First Aid courses available to the general public. In the past there was a gap between the First Aid provider and the EMS system. The EMS system consists of certified Emergency Medical Technicians and Paramedics of various levels. To address this GAP, a new level of care was introduced, “The First Responder” program. The First Responder program has been a great success and many lives have been saved with its advent. How-ever, the First Responder program is generally used by the fire ser-vice and has a minimum training program of over forty hours. The First Responder program is generally beyond the interest of the aver-age individual or scuba diver. There may also be legal implications involved that may influence the scuba diver or individual to not pursue certification as a First Responder. IDEA developed the revised Dive Medic Specialty to bridge the gap between the basic First Aid pro-vider and First Responder. The Dive Medic course offers an intermediate level of basic life sup-port and First Aid to assist in the care of sick or injured persons. The new IDEA Dive Medic specialty is a combination of the DAN Oxygen Provider, basic CPR certification and First Aid. Dive Medic offers two

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levels of training. The first level (Dive Medic I) consist of first aid, CPR, primary survey, secondary survey and training individual to adminis-ter blood pressure checks. With the addition of DAN Oxygen provider training the student will qualify for the Dive Medic II rating. With the addition of blood pressure training and DAN Oxygen Provider training IDEA Dive Medics will be able to provide a higher level of care for the sick or injured.

The four most important factors of the IDEA Dive Medic program are:

1. The ability of the IDEA Dive Medic I & II to conduct a primary and secondary survey of the victim to determine the best course of action and treatment. 2. The ability of the IDEA Dive Medic I & II to perform Mouth to Mouth Resuscitation and CPR on a victim. 3. The ability of the IDEA Dive Medic I & II to administer Basic Life Support and First Aid to the victim of illness or accident. 4. The ability of the IDEA Dive Medic II to administer the DAN Oxygen Provider Program to the victim if necessary.

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Chapter 1

INTRODUCTION

1. Prerequisites2. Capabilities3. Emotional Reactions of the Victim4. Legal Responsibilities

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INTRODUCTIONThe IDEA Dive Medic is required to possess certain capabilities and skills. The IDEA Dive Medic is required to complete the prescribed course of study required by IDEA. The basic First Aid required for the IDEA Dive Medic course may be conducted by the IDEA Dive Medic Instructor or an individual designated by the Dive Medic Instructor. ndividuals designated must be certified in basic First Aid. CPR instruc-tion may be conducted by a instructors certified by either the Ameri-can Heart Association or Red Cross organization. The IDEA Dive Medic must be able to handle a variety of medical emergencies. These emergencies may vary from a simple applica-tion of a band aid to the administration of oxygen during CPR. We will divide these skills into three main categories during our course of instruction.

CAPABILITIES OF THE IDEA DIVE MEDICThere are certain skills, procedures and capabilities that must be pro-vided to a victim of accident, injury or illness. Properly trained and motivated individuals can make a major difference in the comfort and care of the victims of accident, injury or illness. Your efforts to obtain a higher level of skills and knowledge are commendable. Feel free to ask questions of your IDEA Dive Medic Instructor during your course. IDEA Dive Medic Instructor is limited to the materials contained in the Dive Medic text. Many IDEA Dive Medic Instructors are also MDs, Nurses, EMTs, and Paramedics.

I. The IDEA Dive Medic must be able to:- Conduct a primary survey (A) Establish and maintain a patent airway (B) Control accessible bleeding (C) Administer Cardio - Pulmonary Resuscitation (CPR)- Administer the DAN Oxygen Provider program (Dive Medic II requirement)- Take a blood pressure and recognize abnormal blood pressures- Take a pulse to determine victim’s heart rate and function- Recognize breathing rates and patterns- Recognize and treat for shock

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- Immobilize and stabilize victims with suspected Cervical and Spinal injuries- Treat for ingested or inhale poisons and toxic fumes- Treat for animal and snake bites

There are other conditions which are not life threatening but must be treated prior to the arrival of EMS personnel. In these cases, early treatment may be required so that the problem does not escalate or turn into a life threatening situation or create irreversible damage to the victim.

II. The IDEA Dive Medic must be able to:

- Clean, dress and bandage wounds- Clean, dress and cover burns- Splint fractures- Splint or immobilize sprains

There are some important non medical skills the IDEA Dive Medic will need. These non medical skills will assist the Dive Medic with all the necessary skills needed to care for victims of accident, injury or ill-ness.

III. The IDEA Dive Medic must also be able to:

- Assemble a properly equipped Dive Medic Kit- Maintain the Dive Medic Kit and supplies- Give verbal and written communication- Evaluate your personal safety and the safety of others in hostile or hazardous situations- Plan and execute proper rescue and extrication procedures in the water and on land- Direct less qualified persons to assist you

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EMOTIONAL REACTIONS OF THE VICTIMIn most cases a victim of an accident or illness will cooperate with the care giver. The Dive Medic should identify himself to the victim and any family or persons assisting the victim. Always reassure the victim and explain to them what you plan of action is to assist him. At times a victim may appear to be over reacting to what appears to be a minor accident or injury. At other times when there is an obvious problem they may not show any signs of pain, illness or injury. What ever the circumstance is never question a victim’s complaints. Take the com-plaints at face value and let the arriving EMS personel determine the next step in the care of the victim. Your job is to assist the victim to the best of your training and ability until a higher level of care is available. Calmly appraise the situation and the victim’s condition. Be courte-ous, use the proper tone of voice and show confidence in your ability to administer First Aid to the victim. Victims, such as children, elderly or mentally handicapped persons, may be confused or terrified of the situation. Always show compas-sion and sincerity in your care of these special persons. Your reas-surance and kind words will help in the administration of the care you are giving the victim. Your actions will also reassure bystanders and family members of your abilities and the quality of care you are pro-viding the victim.There may be the possibility that you may be called upon to assist in a situation that involves a fatality.We hope that you never have to face this type of situation. In the event of fatality, it is extremely important that the deceased be handled with respect and dignity. It is generally an accepted practice to cover the body and minimize exposure. It is advisable not to move a body. Wait for law enforcement and EMS to arrive. Also keep in mind that only a medical doctor can pronounce a death. What may appear to be an apparent death may be decep-tive. Unless there is obvious death from a traumatic injury such as decapitation or sever trauma to the body never assume a victim is deceased. Always continue basic life support until EMS arrives. If you are in the process of administering CPR, follow the recommen-dations of your CPR certification agency. Most agencies recommend that you continue CPR until you are relieved by another CPR pro-vider, EMS arrives or you are no longer physically able to continue.

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There may be possibilities of charges of abandonment if you stop CPR before arrival of EMS. The physician at the emergency facility will determine when to cease life support actions.

Legal responsibilities of the Dive MedicEveryone is concerned about the legal implications involved in ren-dering emergency First Aid to victims of accidents or illness. State laws differ widely but most offer some protection to the individual who assists a sick or injured person. Generally speaking a “Good Samari-tan” has little to fear if he or she has acted in his capacity in a reason-able manner and followed accepted First Aid procedures. In some states, persons having been trained in First Aid may have a duty to act. In most cases this duty to act only applies to profes-sional persons such as EMT’s, Paramedics, Nurses or Doctors. The passerby or lay person with First Aid training usually is not held to the “duty to act” or standards of a professional. Remember that the “Good Samaritan Laws” differ state by state. These laws are intended to offer protection to the volunteer who ren-ders First Aid to a victim of an accident or sudden illness. They do not offer protection in the case of gross negligence or misconduct that results in exacerbating the injury or illness. The best protection you can have is by giving proper and prudent care to the victim. It is advis-able to check with your local or state standards on the “Good Samari-tan Laws” for your area.

Implied consentThe following are a few examples of implied consent. A person who is at risk of death from an action on his part or the part of others. A victim that is unconscious or is unable to make a verbal consent for care would be considered implied consent. Situations in which a person cannot make a rational decision concerning his health or safety would be covered under implied consent.

Informed consentInformed consent may be given by the victim or next of kin if the victim is unconscious. It is always a good idea to ask a conscious victim if

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you may care for him. It is not very often that your assistance will be rejected.

Minors consent Generally speaking, minors do not have the knowledge or maturity to recognize the seriousness of an injury or illness. If a parent or guard-ian is not present to give informed consent, the consent is implied. Not all minors’ consent is implied. If you are dealing with a conscious and alert teenager, the consent can also be informed consent. When a minor is at risk and no parent or guardian is present to give informed consent, care should be rendered under implied consent.

The right to refuse treatment or careAdults have the right to refuse treatment. If a situation occurs where a victim is in need of treatment or care and he refuses, you must comply with his wishes. However, if a law enforcement officer is pres-ent or is summoned, he may at his discretion place the victim under the Baker Act. The Baker Act may be used by law enforcement offi-cers if a person is in need of care and the officer determines that the person is not competent to make a logical decision. Care may then be given. If a law enforcement officer is not available, continue to reason with the victim. If the victim loses consciousness, you may assume that the consent is now implied.The information that is provided on consent varies from state to state you should check with your state emergency medical services divi-sion for up to date and current rules and regulations.

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Chapter 2

FIRST AID KIT

1. Components2. Container3. Oxygen

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FIRST AID KITMany of the best dive locations are not easily accessed by the general public. Many times the best dive sites are in remote areas or are only accessible by boat or a four wheel drive vehicle. For this reason, each diver should carry a First Aid kit con-sisting not only of the basic First Aid sup-plies, but also oxygen and items for specific injuries.

The following supplies should be considered when putting together a kit:- DAN Oxygen Kit- List of emergency telephone numbers- Cold packs and Hot packs- Decongestant, Non drowsy (Sudafed or Actifed)- Extra strength pain reliever - Non aspirin- Extra strength pain reliever - aspirin- Extra strength pain reliever - coated or buffered aspirin- Antibacterial ointment- Antipruritic (anti itch) cream- Sterile gauze pads of varying sizes- Benzalkonium chloride pads (antiseptic towelettes)- Bottle of isopropyl alcohol- Elastic bandage- Triangular bandages- Single edged razor blades or razor knife with extra blades- Adhesive bandages of varying sizes and types- Adhesive tape- Needle nose tweezers- Small pair of scissors- Stainless steel multi tool - Emergency blanket (Foil, thermal)- Seasickness medication- Cotton swabs- Tongue depressors

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- Dental temporary repair kit - Padded bite stick (tongue depressor)- Roll bandages- Feminine hygiene pads (for large wounds)- Pocket mask with non return valve- Benadryl (for Anaphylactic (allergic) reactions)- Stethoscope and blood pressure cuff (adult and children’s)- 1 quart of home brew sting kill (5% Isopropyl Alcohol, 5% Ammonia and 90% bottled water)- 1 quart of home brew disinfectant (5% to 10% chlorine bleach (Clorox©) 95% to 90% bottled water) Note: Home brew should be discarded and re-brewed every couple of months so that you will always have a fresh and potent supply in your kit.- 1 quart of clean bottled water - Disposable latex gloves - large size (fits all)- Disposable medical face masks- Disposable red plastic hazardous materials bags- Disposable plastic garbage bags- Disposable face shield- Disposable long sleeve medical scrub top- Zip lock bags of assorted sizes

Your kit may consist of a variety of over the counter drugs. The deci-sion to use these drugs must be left up to the individual. Many per-sons may not be able to take certain over the counter drugs. Many people may have an adverse reaction to an over the counter drug. Remember the choice to use the over the counter drug must be the decision of the indi-vidual and not the Dive Medic. Like the home brew, you should regularly check your supply and the expiration dates. Replace any out of date products with a fresh supply.The above list may seem large but is merely a starting point for a First Aid

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kit. You may think of more items that will enhance your First Aid Kit by the time your course is completed. The components that are listed will meet most needs of the Dive Medic in the field. During your class, discuss with your instructor and classmates any items that you feel should also be included.

First aid kit containersNow that we have listed a wide variety of items for a first aid kit, we will need a container to carry them in. The most popular style of car-rier used is a medium sized heavy duty nylon gear bag. Most fire and rescue person-nel prefer this type of soft nylon bag. The term used for this style bag is “jump bag”. he second most popular carrier is a large fishing tackle box. The larger size with the fold out trays is the most popular. Fishing tackle boxes can be quite expensive and are not as popular as the nylon jump bags. Generally when packing the box or bag the larger items such as a BP cuff, stethoscope, and liquid containers are placed in the bottom of the box along with a large supply of 4 in. x 4 in. gauze pads. The 4x4s take up any extra room and hold the heavier items in place. The items we have mention for your first aid kit may seem like a lot to carry but they are the basics for a good kit. As you put your own first aid kit together you will soon find a place for everything and still have room left for extras.

OXYGEN EQUIPMENTThe use of oxygen in an emergency may mean the difference between life and death of the victim. You should make every effort possible to complete the DAN oxygen provider course required to be certified as an IDEA Dive Medic II. Oxygen administration is vital in the care of victims of asthma and respiratory distress. Drowning and other serious diving problems (air embolism, decompression sick-

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ness, mediastinal emphysema, subcu-taneous emphysema, pneumothorax) should be treated with oxygen admin-istration. There are several units avail-able, the continuous flow unit, the positive pressure unit, and the demand unit. Of these mentioned, only the demand unit is suitable for use in appli-cations where oxygen must be admin-istered by non emergency medical trained personnel. The positive pres-sure units are for use only by trained

emergency personnel, while the continuous flow units are wasteful of the oxygen supply.The demand unit has a demand regulator much like the one used in diving regulators. They only supply oxygen when the victim inhales. The units supply 100% oxygen, and can be switched over to continu-ous flow if needed. At this time, Diver’s Alert Network (DAN) markets a demand unit that is in wide use throughout the diving community.

Pocket mask (non return valve)A very handy device for providing mouth to mouth resuscitation is the pocket mask. Pocket masks are available from IDEA, the Red Cross, or medical supply businesses. The pocket mask allows a rescuer to provide ventilation’s to a victim without direct contact with that person. Make sure that the pocket mask is equipped with a one way, non return, valve. This will provide the user with a barrier between the victim and the care giver. The non return valve will stop body fluids or contami-nation from being exchanged between the victim and the care giver. A pocket mask can easily be carried in a buoyancy compensator pocket for use in the event of an in water emergency. A separate mask should be carried in your first aid kit. If you do carry a mask in your BC pocket, check it on a regular basis. The mask should be

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cleaned and rinsed after each dive. Pay special attention to the non return valve. Be sure that it seals properly and is not ruffled on the edges or torn. Make sure that it is still in the pocket and in good work-ing condition prior to each dive. There are several position techniques that can be applied when using the pocket masks in the water. The pocket mask allows the rescuer to work from either side of the victim. The other method is employed when the rescuer is positioned above the victim’s head while towing the victim. The technique employed will best be decided by the res-cuer, one style may be preferred over the other.

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Chapter 3

ANATOMY, DIAGNOSTIC SIGNS & SYMPTOMS

1. General and Topographic Anatomy2. Interpretation of Diagnostic Signs & Symptoms3. Primary Survey4. Secondary Survey a. Pulse b. Blood Pressure c. Respiration d. Temperature e. Skin Color f. Pupils of the Eyes g. State of Consciousness

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ANATOMY, DIAGNOSTIC SIGNS & SYMPTOMS

General and Topographic AnatomyThe surface of the body has many definite landmarks. These features serve as guides to structures that lie beneath them. This is called Topographic Anatomy. General anatomy would be the head, neck, chest, abdomen, buttocks, arms, hands, legs, and feet.Inspection is the simplest part of the primary and secondary survey conducted on a victim. These surveys cause little or no pain or fur-ther discomfort to the victim. They do, however, give the care provider information that will assist the provider with the correct diagnosis and treatment of the victim. These topographic landmarks are needed to make a correct diagnosis. They are also necessary to communicate the victim’s condition and other information to EMS personnel on/or before EMS arrival. Picture the human body standing, face forward, arms at the sides with palms facing forward. The terms right and left refer to the victim’s right or left. The main regions of the body are the head, neck, chest, abdo-men and the extremities - the arms and legs. The surface of the front is called the anterior surface and the back side is called the posterior surface. Now picture an imaginary vertical line from the top of the head to the floor. This is called the mid line. If you wanted to describe a wound above the left nipple of a victim you would describe it as: The victim has an anterior, two inch laceration, four inches superior to the left nipple. If the wound was located below the landmark we would describe it as inferior to the left nipple. If the wound was to the left of the nipple we would call it lateral, if it were to the right we would call it medial. Proximal and distal are terms used in describing locations of wounds or marks on the extremities (arms and legs). A wound located on the leg that is close to the knee would be proximal to the knee. A cut on the mid to lower arm would be described as distal to the elbow or proximal to the wrist. These landmarks and terms are simple and useful. If, however, you find it difficult to use these terms, don’t worry. Plain talk is acceptable. If you use plain talk be sure to keep your description and explanations short and to the point. It’s perfectly all right to say for example: “The victim has a deep cut about four inches above the knee

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cap on his left leg”. With a little study and application you can easily learn the cor-rect medical terms also.Another important part of the anatomy are the underlying arteries that pass between the skin and a bony prominence. It is important to the first aid provider to know the exact locations of these pres-sure points. Generally, bleeding may be stopped at the site of the wound by using direct pressure on the wound itself. In some cases the bleeding is so severe that it must be stopped at the nearest pressure point. If this fails, you must try using a combination of direct pressure on the wound and a pressure point. If the wound is located on an extremity, ele-vation of the wound may also help stop the blood flow. If these methods fail you may have to resort to the least desired method, using a restrictive band. The

absolute last resort is a tourniquet. We will discuss stopping blood loss in more detail later in the text.Generally most of the arteries that are close to the surface of the skin and over a bony prominence is a good place to take a pulse. As noted in the diagram you will see the pressure points that a pulse may be obtained.

The easiest to find and most important pulses are:1. Temporal (temples) 2. Carotid (neck) 3. Brachial (upper & lower inside arm) 4. Radial (wrist) 5. Femoral (groin) 6. Popliteal (located behind knee) 7. Dorsalis Pedis (starting at top of foot at ankle down to big toe)

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INTERPRETATION OF DIAGNOSTIC SIGNS AND SYMPTOMS

The Primary and Secondary SurveyAs a first aid provider it is important to quickly conduct a survey of the victim’s condition. This first inspection of the sick or injured person is called a Primary Survey. The most important factors of the primary survey are the A,B,C’s: Air way, Bleeding And Circulation. Each of these are required to support life. All three are to be given equal importance. It will do the victim no good, if one or more of the life sustaining factors are not attended to. When conducting a primary survey, it must be done very rapidly; usually in less than one minute. If any one or more life sustaining factors is not functioning, it must be corrected immediately. (A) Make sure that the victim has a patent (clear and open) airway and is breathing (B) Stop any serious bleeding (C) Make sure the victim has a heartbeat

During the Primary Survey, make sure you talk with the victim. Ask questions about the current medical problem. Ask the victim if he has any prior or existing medical problems. If the victim is unconscious, check for medical alert necklaces, bracelets or cards. After this quick survey has been conducted, the Secondary Survey may begin. The basic diagnostic signs can be observed quickly. Try and determine what happened to cause the current situation of the victim.

1. Ask if anyone was present and saw what happened to thevic-tim? 2. How was he noticed? 3. How was he found?4. Is the victim conscious?5. Was the victim conscious earlier? 6. If so, did he give any verbal information concerning his illness or injury?7. If the victim was injured, what were the mechanics of the injury.

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Any and all information obtained should be acknowledged and recorded for later use. This information is important to the immediate care of the victim. It will also play an important role in the care given on arrival of EMS personnel.

The Secondary Survey diagnostic signs are: 1. Pulse 2. Respiration 3. Blood pressure 4. Body temperature 5. Skin color 6. Status of the pupils of the eyes 7. State of consciousness; ability to communicate 8. Ability to move 9. Reaction to pain or stimuli

All of these diagnostic signs can be obtained in less than five min-utes with minimal equipment. Together with the observations of the victim’s injuries and condition we can make a basic diagnosis. With the information we have gathered, we may then attend to the immedi-ate medical care of the victim. It is important that the information we have obtained be passed on to the EMS Professionals on their arrival. It will save them time in their formulation of a plan of action for the care of the victim.

PulseThe pulse is the pressure that is created by the beating of the heart and is propagated through the arteries. The standard pulse rate for adults is between 60 and 80 beats per minute at rest, with no physical activity. The pulse rate for children is normally between 80 and 100 beats per minute at rest, with no physical activ-ity. Individuals that are emotionally upset may have a much more rapid pulse rate due to their emotional status at any given time. In most cir-cumstances a pulse can be felt in most of the

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pressure points of the body where the artery passes over a bony prominence or lies close to the skin. Usually the pulse is taken at the base of the thumb over the wrist. The radial artery is quite super-ficial. In an emergency situation it may be difficult to find the radial pulse. The best place to check for a pulse is at the carotid arter-ies located on either side of the neck. It is best to palpate (feel) the carotid pulse with the victim sitting or laying down. This pulse will be stronger and easier to pal-pate and record. If you are unable to palpate a pulse you must either place your ear against the chest over the heart or use a stetho-scope to hear the actual heartbeat. For a pulse to be audible or to palpate it, a certain blood pressure (systolic) must be present. To be present, a Radial pulse requires a systolic pressure of at least 90 mm, and a Carotid pulse of 60 mm.The normal pulse has a strong regular beat and usually reflects a full blood volume. Changes in the rate or volume may be an indicator of the appropriate treatment needed. A rapid and weak pulse is usually an indicator of shock from blood loss. A rapid and pounding pulse can indicate hypertension or fright. The complete absence of a pulse means that a specific artery is blocked or that the heart has stopped beating. The pulse should be taken immediately in the primary survey and checked periodically during treatment of the victim. Always record the findings and note if the pulse is weak or strong, regular or irregu-lar.

Blood pressure As the heart pumps blood through the arteries it creates pressure on the walls of the arteries. This is called blood pressure. Blood pressure is determined by a diagnostic tool known as a sphygmomanometer (sometimes referred to as a blood pressure cuff) and a stethoscope. The blood pressure cuff is wrapped around either arm above the elbow. It is then inflated with a rubber bulb. There is a dial indicator

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attached to the cuff. As the bulb is pumped, the needle will rise. The taker is watching the needle rise. He is also listening with the stethoscope that has been placed over the brachial artery which lies medially at the front of the elbow in an area know as the antecubital fossa. As the needle rises it will pulsate with the heart-beat. You will also be able to hear the heartbeat through the stethoscope. Somewhere between 150 to 200 millimeters of mercury the needle will stop pulsating with the heartbeat. When this point is reached, stop pumping the bulb and slowly release the air from the blood pressure cuff. You will also note that you no longer hear the heartbeat through the stethoscope. As the needle falls, note the read-ing when the first sound of the pulse is heard. This is the systolic

blood pressure. Continue monitoring the needle and note the reading when the sound of the pulse stops. This is called the diastolic blood pressure. Again, the reading are in millimeters of mercury. Blood pres-sures vary with the age and sex of the individual. A good rule of thumb for normal systolic blood pres-sures for an adult male is 100 mm hg. plus their age. This is usually close up to a level of 140 - 150 mm hg. The normal diastolic pressure for an adult male is between 60 - 90 mm hg. For the adult female you will find that the normal pressures are 8 - 10 mm hg. less for both systolic and diastolic.

RespirationThe normal rate of breathing is between 12 and 20 times per minute for teenagers and adults. Shallow or unusually deep breathing may indicate a medical problem. Make note of the breathing rate and check it periodically for any change. Rapid, shallow respiration’s may be an indicator of shock. Deep, gasping or labored breathing may indi-

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cate an airway obstruction, heart dis-ease or pulmonary problems such as emphysema. The lack of any respi-ration may indicate a blocked airway and require the standard procedures for a blocked airway or for treating a victim of choking. The lack of respi-ration’s requires immediate attention. Always check for breath sounds by listening with your ear close to the mouth of the victim and also listen with the stethoscope for both breath

sounds and a heart beat. If the heart is beating normally, CPR is not needed. Pulmonary ventilation should be given to victims that have a heart beat but are not breathing. Don’t give heart compression’s if the heart is still beating. Unneeded heart compression’s may cause damage to the heart and create more problems.

TemperatureThe normal body temperature is 36,5 degrees Celsius. Change from the normal body heat may occur in the event of injury or illness. The temperature of a victim is a useful tool in diagnosing the medical problem. Most temperatures are taken orally if the victim is conscious and awake. If the victim is unconscious an axillary tem-perature may be taken under the arm pit. Axillary temperatures are not as accurate but will give you an indication if a high temperature is present. If a victim is sweating and the skin is cold and clammy you may suspect shock. The body can lose heat rapidly by the process of sweating. The victim should be covered and treated for shock. Exposure to cold usually produces cool dry skin. The expo-sure can not only reduce skin temperature but reduce the body’s core temperature (heart & lung area) creating a dangerous situation. This condition is called Hypothermia. Hypothermia is a very serious condi-

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tion and must be treated immediately. The victim should be covered and warmed as soon as possible. Hot dry skin may be caused from illness or by exposure to excess heat. Our concerns here would be heat exhaustion and heat stroke. Both of these conditions are dangerous and present themselves dif-ferently. We will discuss both later in the text.

Skin ColorSkin color can provide the care giver with a great deal of information about the victim. Persons with light colored skin are more easily observed for changes. Color changes in dark skinned people are more easily observed by examining the fingernail beds, sclera of the eyes (whites) and under the tongue. The color changes that are impor-tant in the observation of victims are red, blue and white. A cherry red color may indicate the first stages of carbon monoxide poisoning, high blood pressure or sunstroke. Persons in advanced stages of carbon monoxide poisoning may appear blue. Lack of oxygen causes a blue or ashen color is called cyanosis. Cyanosis is seen in victims with heart failure, airway obstruction, shock and drowning. Victims that are cyanotic require immediate oxygen administration. Since we are dis-cussing skin color you may come across a someone that have a yel-lowish tint to their skin. This person most likely suffers from a chronic liver disease. The only care the Dive Medic can offer a person with liver disease is DAN oxygen protocol, treat for shock and make them as comfortable as possible until EMS personnel arrive.

Pupils of the EyeNormally the pupils of the eyes are regular in shape and equal in size. When checking the pupils, be aware of contact lens and prostheses (false eyes). Variations in the size of one or both pupils are signs to watch for. Dilated pupils indicate an unconscious or relaxed state. Constricted pupils may be an

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indication of drug use or a disease of the central nervous system. Pupils that are uneven are an indication of head injuries or strokes. The pupils should be monitored every few minutes while the victim is under your care. Should a change occur because of underlying head injury it is imperative that the EMS providers be notified as soon as possible. Provide a patent airway; administer oxygen as directed by the DAN protocol.

State of ConsciousnessIt is important to observe the state of consciousness of an ill or injured victim. Normally people are alert and oriented. Normal consciousness is observed when people know where they are, know the date, day and year and can answer questions. Per-sons that are unable to answer you or acknowledge their surroundings may be ill or injured. There is also the possibility that the person may actually be asleep, hard of hearing or deaf. Make sure that this is not the case when you are determining if the person is alert and oriented. Always try to alert the person of your presence. You don’t want to startle or scare them. If it appears that your communication efforts are not working you may try other means. The level of consciousness may sometimes be determined by a slight pain stimulus. A light and gentle sternum rub or an object like a pen or pencil stroked on the bottom of the bare foot often will get a response. Persons that have rapid loss of consciousness may have a head injury, may have ingested a large overdose of drugs or may suffer from diabetes or seizures. In any of these cases make the victim comfortable, maintain a patent airway, treat for shock and administer oxygen.

Common FaintThe exact cause of the common faint is not clearly understood. Appar-ently it is relative to a slowing of the pulse without an increase in blood flow per heartbeat. The result is diminished cerebral function.

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Persons that experience a lightheadedness or near faint can usually avoided unconsciousness by laying down quickly and elevating the legs. This will increase the return of the blood to the heart, which in turn counteracts the effect of the slowing of the pulse; and cerebral blood flow then becomes adequate to sustain consciousness. Most of us have had the experience of standing quickly and becoming light-headed or faint. n many cases we can simply sit back down and lower our head for a few minutes to overcome the problem.

SeizuresSeizures may be cause by numerous problems. Seizures may be induced by alcohol, drugs, head injuries, toxic fumes or medical prob-lems such as Epilepsy or Diabetes. Except in the case of seizures caused by Diabetes the care giver is limited in the help they may render. Seizures caused by Diabetes will be discussed later.Epilepsy is a common condition that is normally controlled by medica-tion. Epilepsy can be caused from an injury to the brain, birth defects, brain tumors, cerebral embolus or illegal drug use that has caused damage to the brain. There are two types of seizures or convulsions. Grand Mal and Petite Mal. The petite mal seizure does not normally cause convulsions and many times may go unnoticed. Any convul-sions that present as body movement are considered grand mal. Grand mal seizures are the concern of the care giver. The grand mal seizure is caused by a burst of brain cell activity leading to uncontrollable contractions of the muscles throughout the entire body. The victim will lose consciousness and flail about uncontrollably. The grand mal can cause the victim to lose bladder and bowel con-

trol. There is also the possibility of the victim having contractions of the jaw muscles that can cause biting to his lips or tongue. After the seizure is over, the victim will be extremely dis-oriented and exhausted. The proper care to the victim of a grand mal seizure is to assure an open airway and proper respirations during the unconscious state. Protect the victim

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from injury but don’t try to restrain the victim unnecessarily. Protect the vic-tim’s head, arms and legs but do not rigidly restrain them. Move any objects the victim may come in contact with that can cause injury. A padded bite stick may help avoid injury to the vic-tim’s mouth, lips and tongue if the mus-cles of the jaw are effected. Never place your fingers in the victim’s mouth. You may receive a severe injury from the teeth of the victim. Do not place

any unpadded or hard object in the victim’s mouth. This will increase damage from the biting and jaw movement. Standard BLS procedures should be followed for the seizure victim. Activate the EMS by calling emergency as soon as possible.

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CHAP

TER

4

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Chapter 4

FIRST AID

1. Bleeding a. Control b. External c. Direct Pressure d. Pressure Points e. Restrictive Bands and Tourniquets f. Epistaxis g. Bleeding or Fluid from the Ears h. Internal Bleeding i. Universal Precautions2. Shock a. Types b. Signs and Symptoms c. Treatment3. Insulin Shock and Diabetic Coma 4. Fractures5. Splinting6. Neck and Spinal Injuries7. Poisons, Stings and Bites8. Injuries and Illnesses from Marine & Aquatic Fish and Animals9. Dyspnea10. Unconscious Victim, Unknown Reasons11. Communicable Diseases

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FIRST AID

Scene SurveysBefore any care is given, it is important that the care giver conduct a scene survey. scene survey is very important to the safety of the care giver and the victim. The survey is done quickly and is an audio visual task. The scene survey was developed by the fire service as a safety measure for fire rescue personnel. The term used by the fire service is “circle size up”. The term is almost self explanatory. Any scene is viewed with the accident or victim as the center with an outer circular boundary. The boundary is determined by the type of accident. The more hazardous the situation the larger the boundary. Providing there are no extenuating scene mechanics, in the case of illness or an acci-dent the boundary is usually not large. If the accident or injury or ill-ness was caused by a downed power line, a gas leak ect. special care must be used and the boundary extended. If there is a possibil-ity of a gas leak or toxic chemicals always approach up wind. Never enter an area that is toxic. You will also become a victim. In the case of a contaminated area of toxic fumes, leave the rescue and the vic-tim’s care to the professionals. Call 911. Explain the perceived emer-gency. Remain up wind in a safe area. Warn others of the situation and dangers. To conduct a scene survey, start with a slow approach. The victim or accident area should be physically circled, quickly looking for any signs of potential hazards. Hazards to look for are downed power lines, fuel leaks from auto accidents, gas leaks from broken gas lines of damaged tanks, chemical spills, suspicious by standers, animals etc. The scene survey is an important tool and will provide a level of protection for both the victim and the care giver.

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ABC’sAs we mentioned previously, the basics of all first aid ren-dered to a victim are the ABC’s. The ABC’s are the first things that we check in the Primary Survey. Make sure that the ABC’s are properly established before providing other care. A - Check for, establish or maintain an open airway B - Control visible blood loss C - CirculationAfter following the ABC’s, basic first aid care may be rendered.

BleedingBleeding and hemorrhage mean the same thing. Most people will use the word hemorrhage when bleeding is profuse. Bleeding may be internal or external and is caused by a break in the vascular system from either an artery or a vein. The average adult has about six liters of blood in his body. Loss of one liter of blood in an adult or 500 mil-liliters in a child or 25 milliliters in an infant can lead to shock. This is known as hemorrhagic shock. This is a true emergency and immedi-ate first aid is needed. Blood from an artery spurts with each heart beat and is usually bright red. Blood from a vein is slow with a steady flow, its color is much darker. Blood flow from the upper areas of the skin may be from capillaries and usually is a slow steady ooze. The rapidity of blood flow is very important. Rapid blood loss must be addressed immediately.

External BleedingExternal bleeding is obvious and is easily detected by the care giver. The different types of wounds are: Lacera-tions, Abrasions, Avulsions and Puncture wounds. Small or minor wounds will usually stop bleeding within 6 to 10 minutes. leeding is stopped by the normal body func-tion provided by different protection mechanisms of the

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circulatory system. The cut vessel will react by constricting at the cut ends. Under normal con-ditions the wound will clot and stop the blood flow. If the wound is large or does not stop flow-ing there are several methods that can be used to slow or stop the blood flow.

Direct PressureDirect pressure will stop most blood flow and is the most effective method. Direct pressure may be applied by exerting pressure directly over the wound by a finger, hand or pressure bandage. ressure is exerted until the blood flow is stopped. Periodic checks will be neces-sary to determine when the blood flow has stopped.

Pressure PointsFor bleeding that cannot be stopped with direct pressure a pressure point may be used. Pressure points are located where an artery is close to the skin’s surface and the artery passes over a bone. Rarely can blood flow be stopped completely by using a pressure point. The blood flow can be reduced significantly when the pressure point is used along with direct pressure. The major pressure points are: Axil-lary, Brachial, Radial, Ulnar, Femoral, and Popliteal.

Elevation of the WoundDon’t overlook the possibility that simple elevation of the wound or cut will also help stop or slow the blood. Obviously this will work best if the wound or cut is located on an extremity. If the victim is not show-ing any signs of shock he may be placed in a sitting position. Victims with minor cuts or wounds to the head may benefit from the sitting position.

Restrictive Bands and TourniquetsRestrictive bands and tourniquets are used only as a last resort. If a restrictive band or tourniquet is used it should be a minimum of four inches wide and should not be overly tight. The band should only

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be tight enough to stop or slow the blood flow as much as possible. When used, it is important that the victim receive EMS care as soon as possible. Do not loosen a restrictive band or tourniquet once it has been applied. Only EMS or a Medical doctor should loosen the band or tourniquet. In most cases the band or tourniquet will not be released until the victim is under a doctor’s care in the emergency room.

Tourniquets and amputations In the case of a boating accident there is the possibility of an ampu-tation caused by the propeller. Propellers can cause severe cuts, broken bones and traumatic amputations. You may be surprise that there is not always a large blood loss from an amputation. When an traumatic amputation occurs the muscle and tissues usually draw up and cut off a considerable amount of blood flow. Even so it is impor-tant to use a tourniquet close to the wound and bandage the exposed wound. Watch for a renewed blood flow, treat for shock and activate the EMS system.

Epistaxis Epistaxis is commonly know as “nosebleeds”. In most cases nosebleeds are not serious. However, when a person experiences a nosebleed from an accident or injury, a nosebleed may be a sign of a more serious medical problem. A nosebleed could possibly be a sign of: 1. A fractured skull 2. Facial injuries 3. Barotrauma injuries to the sinuses 4. Sinusitis or infections 5. High blood pressure 6. Bleeding diseases

Care and treatment of nosebleeds Most common nosebleeds can be treated by tilting the head back and applying direct pressure to the nostrils. Ice may also help to stop the bleeding. For severe bleeding treat for shock and seek EMS care as soon as possible.

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Bleeding or Fluid from the EarsAny bleeding or fluid from the ears should be treated as an emer-gency. Bleeding or fluid from the ears may indicate a severe head injury or fractured skull. Protect the head, neck and spine by immo-bilization, treat for shock and activate the EMS system. Seek EMS assistance as soon as possible.

Internal BleedingInternal bleeding is a very serious situation demanding immediate medical care. Bleeding internally from injuries to soft tissues, closed fractures or lacerated liver, spleen or lungs is difficult to detect. The victim’s blood pressure will be an important factor in recognizing inter-nal bleeding. A low blood pressure is an indication of loss of blood or shock. Internal bleeding should be considered a serious condition which can quickly lead to death if not treated. Treat for shock and acti-vate the EMS system quickly. Time is important if the victim is to survive.

Universal PrecautionsWhen assisting a victim of accident or injury, the possibility of coming in contact with blood or body fluid is likely. Any time that you have the possibility of exposure to blood borne pathogens or body fluids you should take precautions not to expose yourself. Special disposable equipment is available that can be used to decrease your exposure to blood and body fluids. Plastic face shields, coated long sleeve disposable (medical scrub tops) shirts, latex gloves and nose and mouth protective shields are available. These throw away items are not expensive and are available from medical supply stores and phar-macies. You should also have a few red hazardous materials plastic trash bags for soiled protective gear. You may ask EMS personnel or the medical facility to dispose of the hazardous material bags prop-erly for you. These items should be part of your first aid kit also. If you are exposed to any blood or body fluids report it to the EMS per-

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sonnel and have them record it in their written report of the incident. Follow the recommendations covered in the communicable disease section. Make sure that you follow through with a visit to a medical doctor immediately.

SHOCKTypes and causes of Shock

- Hemorrhagic shock (blood loss) - Respiratory shock (inadequate oxygen supply) - Neurogenic shock (loss of vascular control by the nervous - system) - Psychogenic shock (fainting) - Cardiogenic shock (inadequate function of the heart) - Septic shock (severe infection) - Metabolic shock (loss of body fluid) - Anaphylactic shock (allergic reaction) - Insulin Shock (too much insulin)

Signs and Symptoms of ShockThe signs and symptoms are similar in all types of shock. 1. Restlessness and anxiety 2. Weak and rapid pulse 3. Cold and clammy skin 4. Profuse sweating 5. Pale or cyanotic skin 6. Shallow, labored, rapid breathing 7. Dull eyes, dilated pupils 8. Nauseated 9. Low or falling blood pressure 10. Victim faints

Treatment of ShockVictims that exhibit any of the signs or symptoms should be aggres-sively treated for shock immediately. It is important to recognize the possible cause of shock so that the treatment can be administered accordingly. Many of the principles of shock treatment can be applied to all victims in shock. If in doubt, always treat for shock. The treat-

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ment for shock is unlikely to cause any further problems and could possibly save the victim’s life.

The proper treatment for shock is:1. Maintain a clear and patent airway - administer oxygen if needed. Do this first before anything else.2. Control all obvious bleeding.3. Elevate the lower extremities about twelve inches, providing the victim’s injuries do not make it impossible.4. Splint any fractures. In doing so, bleeding is lessened, pain and discomfort is reduced and will not continue to aggravate the shock condition of the victim.5. Avoid any rough or excessive handling and moving of the victim.6. Prevent the loss of body heat by covering the victim. If the victim is a diver remove the victim’s wet suit. Wet suits do not hold body warmth and will cause possible hypothermia in the victim. Cover the victim with dry warm blankets to conserve their body heat.7. Keep victim supine (laying flat on their back) if possible. Victims in shock after a heart attack or with lung disease such as emphysema can’t breathe as well while laying flat. You may have to accommodate the victim by placing them in a sitting position if this is a problem.8. Record the victim’s initial pulse, blood pressure and breathing rate. Keep checking and recording these every five minutes until EMS arrives.9. Do not let the victim eat or drink.

TREATMENT OF SPECIFIC TYPES OF SHOCK While the treatment of shock in general will apply to all types of shock, there are two types of shock that the Dive Medic can address with additional care.

Hemorrhagic ShockThe emergency treatment for hemorrhagic shock caused by external bleeding is, of course, to stop or decrease the bleeding as much as possible. After making sure that the victim is breathing properly, use

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the direct pressure or a combination of methods to stop the bleeding. If there is a fracture, splint it if possible. Hemorrhagic shock is caused from the loss of blood. The vascular system needs the proper amount of fluid to function correctly. If the victim was in the care of a hospital or EMS professional the victim would receive intravenous fluid or a blood transfusion. By replacing the lost fluid the shock will be elimi-nated. As a Dive Medic we can increase blood flow to the brain and vital organs by elevating the victim’s lower extremities. Summon EMS as soon as possible - the victim is in an extremely dangerous condi-tion. For victims that may have internal bleeding, elevate the lower extremities and keep the airway clear. Make sure that the victim does not aspirate any vomitus into his lungs. If he should vomit, roll the victim to his side and clear the airway. Again the victim is in extreme danger - summon EMS as soon as possible. If there is no local EMS Rescue Unit, the victim must be transported to the nearest medical facility as soon as possible. Call 911 and notify the local law enforce-ment agency of the situation. Law enforcement will assist you in coor-dinating transportation of the victim.

Anaphylactic Shock Anaphylactic shock presents special signs, and treatment is more involved for the care giver. Anaphylactic shock may be caused from a reaction to drugs, insect bites, marine life stings and bites or food aller-gies. Anaphylactic shock is a true emergency and can be extremely dangerous. Respiratory and cardiac arrest may occur and is common to Anaphylactic shock. Victims that are not allergic to the over the counter drug Benadryl may take the prescribed dose. Benadryl is helpful in relieving the symptoms in many cases. Make sure you have a supply of Benadryl in your first aid kit. Individuals who are allergic to foods, insect bites and stings may carry a personal injection for emergencies. These devices are simple to use and come with com-plete instructions. Look for medic alerts and question the victim if conscious. Treat the victim for shock and summon EMS immediately. Anaphylactic shock is very dangerous. Follow the same protocol as you would for Hemorrhagic shock. If there is no local EMS Rescue Unit, the victim must be transported to the nearest medical facility as soon as possible. Call 911 and notify the local law enforcement

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agency of the situation. Law enforcement will assist you in coordinat-ing transportation of the victim.More information on Anaphylactic shock is located in the dangerous marine life section of this text.

Insulin Shock and Diabetic ComaA normal person will have a certain amount of sugar present in his blood stream. The cells of the human body require an energy source to function properly. Sugar is the source of fuel. Normally the body controls the level of glucose (sugar) naturally. ndividuals that are dia-betic are no longer able to produce natural insulin. Persons with dia-betes must control their blood glucose (sugar) levels by taking man made insulin in the form of tablets or injection. Persons with diabetes must walk a thin line in control of the diabetes. Blood glucose that is too high or too low causes premature failure of the vital organs of the body. There are two conditions to be concerned with when dealing with Insulin Shock and Diabetic Coma. Generally speaking the most dangerous is Insulin Shock. Insulin Shock has a rapid onset which could be in a few minutes or a few hours after receiving insulin. Insu-lin Shock is caused by too much insulin. On the other hand Diabetic Coma has a slow onset that may take days or weeks. The high level of insulin may be caused from actually taking too much insulin or by not eating the proper amount or enough carbohydrates prior to taking the insulin. Excessive exercise can also cause an imbalance to occur. Persons with the onset of Insulin Shock will feel weak and rapidly lose consciousness. Insulin Shock may also occur while the person is sleeping. The brain requires a constant supply of glucose just as it requires a constant supply of oxygen. If there is a lack of blood glucose to the brain, unconsciousness and permanent brain damage can quickly occur. The loss of consciousness is especially critical in scuba diving or swimming. It is quite obvious that an unconscious person would surely drown. Diabetics are required to obtain written approval from a medical doctor before participation in scuba training. Diabetics should only participate in water sports with a buddy or a partner who is aware of their condition and can act appropriately to assist in case of a problem.

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Signs and Symptoms of Insulin Shock 1. Normal respiration’s 2. Pale, moist skin, profuse sweating 3. Dizziness, headache 4. Rapid pulse 5. Normal blood pressure 6. Varying degrees of unresponsiveness. Unable to answer simple questions (day, date, year, etc.) 7. Fainting, seizures, coma

Treatment of Insulin ShockIn most cases diabetics can feel an insulin reaction coming on. By acting quickly they can eat a sugar cube or sugar packet. The sugar will be absorbed into the blood stream faster by letting it dissolve in the mouth rather than swallowing it. It is important that the victim immedi-ately eat food that is high in carbohydrates. The sugar may offset the insulin reaction but the results of the sugar are short termed.If a person is found unconscious check for any medical alert brace-lets, chains or cards. You may also look for glucose tablets or a Glu-cose Emergency Kit. The emergency kit contains a small syringe and a bottle with a single tablet of high concentrate glucose. The kit has instructions for mixing the solution and administering the contents with the syringe. Some kits will have the liquid already in the syringe. You take the cap of the bottle with the tablet and inject the solution into the bottle. The liquid will dissolve the tablet immediately. You then draw out the mixed solution and inject it into the victim. You may also find a Glucose Kit that has an empty syringe with the liquid in one bottle and the tablet in another. If this is the case you would draw out the liquid and then inject it into the bottle with the tablet. The next step would be to draw the solution out and inject it into the victim. The Glucose Emergency Kit is simple and easy to use. Do not hesitate to use the kit if it is available. If you have never given an injection before, don’t worry, it is really not difficult. The needle in the kit is very small and sharp. It will take a minimal amount of pressure to puncture the skin and tissue. Press it in firmly and push the plunger to inject the solution. The fatty area of the victim’s arm is a good injection site. Remember to follow the instructions in the kit.

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If in doubt between Diabetic Coma and Insulin Shock always give sugar to the conscious victim. If a victim is actually suffering from Dia-betic Coma the added sugar will not cause any additional problems. However, if it is Insulin Shock, it may save the victim’s life. If the victim is semi conscious, granular or powered sugar under the tongue will help revive them enough to administer a sugar solution. Orange juice is often used, but any drink with sugar will help offset the insulin. You may add a couple of extra spoonfuls or packets of sugar to enhance the victim’s recovery. If you do not have any soft drinks or orange juice you may add four or five sugar packets or teaspoonfuls to plain water. If the victim is unconscious do not attempt to administer any sugar or solution. Prompt medical attention by EMS is required.

Diabetic ComaDiabetic Coma is considerably different from Insulin Shock. Diabetic Coma has a slow onset and is not usually associated with emergency treatment. Diabetic Coma is a result of the lack of proper insulin man-agement or the victim is unaware that they have Diabetes. Diabetic Coma is caused by high levels of blood glucose. Many adults become ill with Type II (Adult onset Diabetes) later in life. They may not have any idea that they have diabetes. The classic signs of Type II Diabe-tes is an excessive thirst and rapidly failing vision. Diabetic Coma will not suddenly manifest itself and is not usually a medical emergency. It is rare that a first aid provider would see this medical problem.

Signs and Symptoms of Diabetic Coma 1. Rapid, deep, sighing respiration’s 2. Dehydration, dry warm skin 3. Sweet, fruity acetone odor of the breath 4. Rapid weak pulse 5. Normal or slightly low blood pressure 6. Varying degrees of unresponsiveness

Treatment for Diabetic ComaThe proper emergency treatment for Diabetic Coma is to guard the victim’s airway and call EMS support quickly. If in doubt between Dia-betic Coma and Insulin Shock always give sugar to the conscious

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victim. As a matter of priority the victim in insulin shock is far more critical and likely to have brain damage than the victim in Diabetic Coma. The additional sugar will not harm a victim in Diabetic Coma but will help the victim in Insulin Shock. Both Diabetic Coma and Insu-lin Shock are dangerous to the victim; call for EMS as soon as pos-sible or transport the victim to the nearest Emergency Care facility.

FRACTURES, DISLOCATIONS, & SPRAINSInjuries of the bones, joints, muscles and tendons are common. The first aid provider should check for theses types of injuries. Injuries of these types may not always be apparent. A close inspection of the body by sight, feel and questions to the conscious victim will play a major part in recognition of these type injuries. Immediate care by the care provider will decrease the pain and possibility of shock or further injury occurring to the victim.A fracture is a break in the continuity of a bone. Some fractures may be only a crack. In others the bone may be broken completely and separated. Some fractures may be angulated or actually protrude from the skin. here may be swelling and discoloration along with the pain caused from a fracture. These types of fractures are obvious while others are not. Fractures that are not obvious to the eye are detected by X-Rays.

Signs of fracturesDeformity - An arm or leg that is lying in an unnatural position or is angulated where there is no joint is a sign of a fracture.Tenderness - Tenderness localized at the site of the injury is a sign of a possible break. By gently pressing along the bone with the finger tips, the care provider can often locate the fracture.Grating - A grating sensation under the skin can be felt when the broken ends of the bone rub together.Swelling and discoloration - Generally swelling to some degree is always present with fractures. The swelling is caused by injury to the soft tissues or from bleeding.Inability to move extremity - In some cases the complete or partial loss of movement of the extremity is present. It is best not to move a fracture any more that necessary to prevent further injury.

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Major classes of fractures There are two major classes of fractures - Closed (simple) Fractures with no bone protrusion and Open (compound) Fractures with bone protrusion. he Open Fracture may have only a small cut where the bone has protruded and returned or the bone may actually extend out from the skin. Open Fractures are much more serious than a Closed Fracture. The possibility of blood loss and contamination is much more likely. Care must be given to stop any bleeding with a direct pressure bandage. Cover the Open Fracture and prevent any further contamination. The possibility of infection is great when there is an open fracture. Make sure that the EMS personnel are aware of any contamination of the wound. The victim is in need of immediate care from an emergency medical facility. Be aware that there can be a large blood loss from both open and closed fractures. When a bone breaks there is bleeding from inside the bone and from surrounding tissues. Because there can be a large blood loss, care should be taken to check the victim’s blood pressure and pulse. The possibility of hypovolemic shock should not be overlooked. It is best to immobi-lize any injury to prevent further trauma to the area and discomfort to the victim.

Types of FracturesFractures are also classified according to the type of break in the bone.Greenstick fracture - This fracture is an incomplete break which passes only part of the way through a bone. It usually only occurs in children because of the flexibility of the growing bone. Adult bones have less flexibility and usually break completely.Transverse fracture - A transverse fracture is a break line that is straight across the bone at a right angle to the bone’s long axis.Spiral fracture - The spiral fracture line twists around and through the bone.Oblique fracture - This fracture line crosses the bone at an oblique angle.Comminuted fracture - The Comminuted fracture is a bone that is broken in more than two pieces.

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Impacted fracture - The broken ends of the bone are jammed into each other with a impacted fracture.

Fractures of the Clavicle (collarbone)Fractures of the clavicle are most common in children. The injury usually occurs when the person falls on the outstretched hand. This break is an indirect injury and can cause a lot of pain in both children and adults. A person with a broken clavicle usually holds his arm on the injured side with the other arm pulled close to the chest. There is swelling, tenderness, deformity in the area and inability to move the arm due to the pain. The best first aid treatment for a broken clavicle is a sling to support the arm and a swath to immobilize the arm close to the chest.

Dislocations Dislocations are displacements of the bone ends that form joints. Bones that are not in proper contact are considered dislocated and may cause extreme pain and possible shock. Immediate care should be given to dislocations to make the victim more comfortable and reduce the pain that may come with a dislocation. Splinting a dislocation will prevent motion of the bone or joint that can further damage the joint, bone or soft tissue.

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SprainsSprains are a partial tearing or over stretching of the ligaments around a joint. Sprains generally occur from twisting or stretching a joint beyond its normal range of motion. Sprains can vary in severity. The most common sprains are to the ankle or the knee. Sprains are best treated by immobilizing the joint and using a cold pack on the injured area.

SPLINTINGRendering proper emergency care to a victim with a fracture or dislocation will decrease the possibilities of causing further injury and compli-cations. Splints can be made from any material or appliance which will prevent the movement of a fractured or dislocated extremity. Splints can be fashioned from rolled up newspaper, sticks, boards and metal. Commercial splints are readily available and are not expensive. The use of splints can alleviate pain by mini-mizing movement at the injury site. It can also prevent damage to muscles, nerves and blood vessels. Remember to check for a pulse below the suspected injury. Don’t wrap the to tightly when splinting you don’t want to slow or cut of the blood supply to the extremity.

The General Rules of Splinting are:1. Clothing must be removed or cut away from the suspected frac-ture or dislocation.2. The fracture or dislocation must be immobilized above and below the injury.3. Check and record the pulse and neurological (feeling) status distal to the injury. Don’t wrap the area to tightly. Make sure there is a blood supply to the effected extremity.4. Dislocation or fracture with a deformity near a joint can be a serious injury. Damage to the adjacent nerves and blood vessels is possible. Summon EMS as soon as possible.

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5. Cover all wounds with a sterile dressing. Do not wrap the wound, EMS will need to see the injury to treat it on their arrival.6. Pad the splint to prevent discomfort and excessive pressure.8. Neck and spinal injuries should not be moved except to clear the airway.9. When in doubt, splint.10. Splint in the position of the break. If the break needs to be straighten EMS personnel are qualified to realign the break if nec-essary.

Most of the time when splinting an arm you will also need to fashion a sling to support the extremity. Commercial slings are available and are inexpensive. You may of course use any type of cloth that is wide enough to support the full length of the arm.

Types of splintsMany different types of materials are used for splints. plints may be purchased from medical supply houses or fashioned from almost any type of material that is close at hand. There are several type of splints available - rigid splints, soft splints (air splint, pillow splint or sling splints). Splints may be made of newspaper, cardboard, wood dowels, etc. The main object is to immobilize the area of concern.

Neck and Spinal InjuriesThe spine is a column of thirty three fused and separate bones. The spine extends from the base of the skull to the tip of the coccyx. Each segment surrounds and protects the spinal cord and nerve roots. Damage to these bones can cause associated damage to the spinal cord or nerve roots. This damage can cause paralysis or death. With-out X-ray studies, damage cannot be determined. It is very important to stabilize and immobilize anyone in which possible damage to the spine is suspected. The only treatment that can be rendered is to keep the victim completely still or on a backboard until EMS arrives to take over the care of the victim. Never ever move a victim that has a possibility of a spinal injury. In some cases,

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such as in water or an auto accident, it may be necessary to move the victim if imminent danger is present. If you must move a victim, make sure that the victim is moved on a backboard and the spinal integrity is in alignment. Traction must be held on the head with no movement as the victim is being moved to a safe area. If the victim is not breathing and mouth to mouth resuscitation is necessary, do not hyperextend the neck. Under no circumstance should the victim be allowed to move. Even the smallest amount of movement may sever or damage the spinal cord. Damage to the spinal cord may cause paralysis or death. Keep the victim immobilize until EMS arrives.

POISONS, STINGS, AND BITESThere are many different poisons, stings, and bites that the unlucky victim may come in contact with both on land and in the water. In all cases, the best treatment for any of these is avoidance. No sane indi-vidual seeks to become poisoned, stung or bitten. In most cases the problem can be simply being in the wrong place at the wrong time. The best way to prevent these problems and accidents is edu-cation and using common sense. If you are educated and cognizant of your surrounding, these accidents are less likely to happen. Many of the same type of accidents related to poisoning, stings or bites can happen in a business area, a remote dive site or in the water. Always be aware of your surroundings, your personal actions and conduct. Many times the cause of poisoning, stings and bites is simple care-lessness. The first aid provider is limited to the care they can provide in the case of poisons, stings and bites. Prompt action is required in the care and activation of the EMS system.

Poison The basic definition of a poison is any substance that produces a harmful effect on the body processes and functions. Poison may modify the normal metabolic functions of cells or directly destroy them. Poison can be inhaled, ingested, injected or absorbed through the

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skin. Common symptoms of poisoning are nausea, vomiting, abdomi-nal pain, pupil dilation or constriction, diarrhea, excessive sweating , salivation, abnormal respiration’s or inadequate breathing and cyano-sis (bluish color of lips and skin)

Ingested Poison Poisons that are most likely ingested are foods, drinks, drugs and household products. Most of these types of poisonings are related to children. The possibility of an adult ingesting poison is less but it still happens. A great deal of poisonings each year are due to the inges-tion of poisons that are not marked and are in food containers. The unsuspecting victim may assume a glass or cup may hold a soft drink and take a drink before realizing that they have just gulped down a cup of bleach or some other toxic substance. These type of accidents occur every day and are quite common. Treatment for ingested poi-soning should begin as soon as possible. A great majority of people think that there is a medical antidote for most poisonous substances. This is not true, in fact there are very few antidotes for the thousands of different poisons. After calling 911 the first step in treatment should be to call your state poison control center. They can guide you in the correct first aid treatment of a poisoned victim. In most cases the dilu-tion or removal of the poison is important. Removal requires the care of a medical professional to pump the victim’s stomach to remove the stomach contents and the poison. The first aid provider’s only option is to dilute the poison by having the conscious victim drink one or two glasses of milk or water. If the victim is conscious and alert the next step would be to consider inducing vomiting. In some cases inducing vomiting will cause more harm than good. If there is any doubt, seek advice from EMS, a physician or from the Poison Control Center.

Do not induce vomiting under the following circumstances1. If the victim is unconscious or convulsing.2. If the ingested poison is a corrosive such as acid, lye, drain cleaner or if it has caused burns on the lips and throat.3. If the poison contains kerosene, lighter fluid, gasoline, furniture polish or other petroleum products.

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If vomiting is the appropriate treatment, the most effective way for victims one year of age or older is to use syrup of ipecac. Use one tablespoonful of the syrup of ipecac followed by a glass of water. Most victims will vomit within fifteen to twenty minutes. If no vomiting has occurred in twenty minutes of the first dose you may repeat the dose only once. Do not attempt to administer any additional doses. If vomiting is induced, the victim must be closely observed at all times. It is very important that the victim does not aspirate the vomitus into their lungs. If vomiting is induced, have a receptacle handy. Vomiting is an unpleasant experience for both the victim and the care giver. Be prepared and the experience will not be as unpleasant.

Absorbents Activated charcoal has long been used as an effective absorbent of many toxic substances. The first aid provider should check with an EMS, a physician or the poison Control Center to see if it’s use is indi-cated. If ipecac has been administered, the activated charcoal should be used only after the victim has vomited. The activated charcoal inhibits the vomiting action of the ipecac. Make sure the victim has fin-ished the vomiting episode completely before administering the acti-vated charcoal. Activated charcoal is administered by the mouth. Mix one or two tablespoonfuls in eight ounces of water immediately prior to giving it to the victim. Stir it briefly immediately before giving it to the victim. Make sure that the charcoal is suspended in the water. If you let the water sit too long it will settle to the bottom of the glass making it difficult to swallow. Both syrup of ipecac and activated char-coal are available without a prescription from your local pharmacy. n some cases soothing agents are useful in relieving some of the irri-tation and discomfort to the stomach and gastrointestinal tract. The most common soothing agents are Milk of Magnesia type antacids and milk. These agents have both a soothing and demulcents effect.

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Inhaled Poisons Poisons that are inhaled offer a special problem for not only the victim but also the first aid provider and rescue person. Due to the possibil-ity of the first aid and rescue person also becoming a victim, special precautions must be used. The first rule in aiding the victim is not to become a victim also. Make sure that you have someone to back you up that is upwind from any possible toxic fumes or gases. Do not enter the area unless you are sure you will not be overcome by toxic fumes or gases. In many cases your only choice is to wait for professional and properly equipped help to arrive. If you are able to evacuate the victim to a safe area, the administration of oxygen and standard care is given. Remember don’t add to the problem by becoming a victim yourself.

Injected Poisons Injected poisons are usually related to the use of illegal drug use. There is little a first aid provider can do for the victim. The correct care would be to activate the EMS system. Care should be given to the respiratory system and to guarding the victim’s airway. Make sure that the victim does not aspirate any vomitus and keep the airway open. In some cases the victim may require Mouth to Mouth resuscitation and/or CPR. Closely monitor the victim until assistance has arrived.

Contact Poisons Some poisons that come in direct contact with the skin or other body parts may cause irritation or poisoning. The substances include acids, alkalies and other corrosive chemicals. These substances can cause chemical burns or poisoning of the body from contact with them. The proper emergency treatment for this type of exposure is to quickly flush all body parts the skin and eyes with large volumes of water. It is best not to attempt to neutralize acids and alkalies. The best treat-ment is to flush with plenty of water until help arrives.

Poison Plants Each year there is a high incident rate for people coming in contact with poisonous plants. Because there is such a high incident rate, the indications are that most children and adults are not aware of the dan-

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gers that arise from eating or nibbling innocent looking plants. There are many plants worldwide that can cause illness or death. Poison-ous plants can affect the central nervous system, circulatory system, and gastrointestinal system. Plants that have an affect on the circula-tory system usually start within thirty to fifty minutes following contact or ingestion. The classic signs of circulatory collapse are rapid heart rate, falling blood pressure, cyanosis, sweating and weakness. Like other types of poisoning there is no antidote for most plant poison-ings. The treatment for circulatory collapse is the same as any other cause of shock. Place the victim in a supine position with the legs elevated, keep them warm, activate the EMS system immediately or transport to the nearest emergency facility. If the victim is conscious and alert you may induce vomiting with syrup of ipecac. Collect a sample of the vomitus and take a sample of it and the ingested plant to the hospital if possible.

Plants that may cause circulatory collapse are: - Autumn crocus - Baneberry - False hellebore - Foxglove - Green hellebore - Indian poke - Lantana - Lily of the valley - Mistletoe - Monkshood - Mountain laurel - Oleander - Poison hemlock - Potato (sprounts) - Rhododendron - Rosary pea - Snakeberry - Yew

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Some plants can produce reactions to the central nervous system. The symptoms are depression, hyperactivity, hyperexcitement, stupor, mental confusion, or coma. The primary treatment and concern should be with basic life support. If the victim is unconscious or stu-porous do not induce vomiting. There is the possibility of the victim aspirating the vomitus into his lungs. Monitor the victim and activate the EMS system.

Plants that may cause Central Nervous System disturbances - Apple (seeds) - Apricot (pits) - Autumn crocus - Baneberry - Indian poke - Poison hemlock - Bleeding heart - Jimson weed - Rhubarb (blade) - Cherry (pits) - Larkspur - Rhododendron - Daffodil - Monkshood - Rosary pea - Fly mushroom - Green hellebore - Hemp - Peach (pits) - Potato (sprouts) - Precatory bean - False hellebore - Water hemlock - Morning glory - Narcissus - Oleander - Yellow jessamine

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Everyone is familiar woth some of the notes poisonous plants such as Oleander, Poison ivy, Poison oak and Poison sumac. Simple skin contact can cause irritation from some plants. The contact can cause severe itching, burning and cause blisters and rashes to form.

Plants that cause skin irritation - Buttercup - Christmas rose - Dumbcane - Four o’clock - Iris - Mayapple - Oleander - Poinsettia - Poison ivy - Poison oak - Poison sumac - Yew

There is one plant that most people are not familiar with and may not recognize as a potential danger. This plant is called Dieffenbachia or Dumbcane. This plant is used extensively as a house plant and is seen daily as a decorative plant for both homes and offices. This plant, if ingested even in a small amount, can cause severe swelling of the airway. In some cases the airway may be completely closed and can cause the victim to suffocate. The treatment is basic life sup-port and the administration of oxygen until EMS arrives or the victim is transported to the nearest medical facility.

Insect Stings Stings are common and most present no major danger to humans. There are, however, many individuals that do have allergic reactions to insect stings. It is estimated that between five and ten percent of the population of the United States are hypersensitive to

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insect bites from scorpions, wasps, hornets and bees. In the case of a sting from a scorpion there is an antivenin available only for the sting of the scor-pion found in the southwestern United States. The antivenin must be administered by a physician. It is imperative to get the victim to a medical facility as soon as possible. When dealing with wasps, hor-nets and bees, it does not take multiple stings to cause serious illness or death. The allergic reac-

tions vary among individuals. The reaction can range from simple swelling of the affected area to a complete shutdown of the victim’s cardio-vascular and respiratory systems. Anaphylac-tic shock is possible and is a very dangerous condition. Immediate care must be given to these victims. Most individuals that are allergic to insect stings carry an emergency kit that consists of an injection to counteract the poison of the sting. The kits are simple to use and should be used as soon as possible. The kit syringe is pre filled and will have complete instruc-tions on the proper use. Be prepared to provide mouth to mouth resuscitation and CPR if necessary. If the stinger is still in the skin, you may remove it. Clean the area with soap and water. Apply a cold pack to slow down the poison. If the victim is conscious have him take two Benadryl tablets or capsules to help counteract the poison. Keep the victim calm and provide basic life support if needed. Continue monitoring the victim until EMS arrives or a medical facility is reached.

Insect Bites Spider bites can also be dangerous should the spider be a poisonous variety. In the United States the two poisonous spiders that we may encounter are the Black Widow and the Brown Recluse. Both the Black Widow and the Brown Recluse are small spiders with a bad bite.

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While not usually fatal, a bite from either one is to be taken seriously. Treatment for both of these spider bites are the same - clean the area with soap and water. Apply a cold pack to slow down the poison. If the victim is conscious and not allergic to Benadryl, have them take two Benadryl tablets or capsules to help counteract the poison. Children and the elderly may have a more serious reaction to stings or bites. Keep the victim calm and activate the EMS system. Continue to moni-tor the victim until EMS arrives or the victim reaches a medical facil-ity.

Snake bites Because of the nature of our sport, some of best dive sites are in remote areas. any of the dive sites are in wooded or swampy areas. These areas are habitats for many species of wild-life including snakes. A great deal of scuba diving in the United States is in fresh water areas . The possibility of running across a poisonous snake, such as a water moccasin, is always there. There is also a chance of finding other snakes, both poisonous and non poisonous. Mammals are drawn to these areas by the water, and, in turn, snakes are drawn to the area by the smaller mammals. Although it rarely happens, underwater snake bite to a human is possible. It is more likely that the human will be bitten on dry land. Imagine that you are at a remote dive site, possibly in a swampy area with a minimal amount of clothing and protection for your feet. You’re excited about the dive and you’re not watching where you put your hands or feet. Bang! You just met a snake and you’re back stepping. Your chances of being bitten have just gone up. Over fifty thousand snake bites are reported in the United States each year. Very few of these have anything to do with dive sites. Of the fifty thousand reported bites, between seven and eight thou-sand are from venomous snakes. While these figures seem high it should be noted that approximately only thirty percent of the bites by venomous snakes show evidence of envenomation. In the major-

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ity of these snake bites, there is no injection of poison. The average death rate from poi-sonous snake bite is less than twelve each year. There are approximately 120 species of snakes in the United States, only twenty of these are poisonous. Because of the many different kinds of poisonous snakes, it is important to identify the snake as accurately as possible. The best sce-nario would be to bring the snake (preferable dead) for positive identifica-tion at the hospital. With accurate identifica-tion the correct antivenin can be used. If the snake can be identified in the field, let the hospital know in advance of the arrival of the victim. Antivenin is available, but may not be on hand, and may have to be ordered from a central location. The majority of poisonous snakes in the United States are pit vipers. Pit vipers have two hollow fangs attached to the poison glands of the snake. There is a pit between the snake’s eyes and nose. The pit is a heat sensing organ and is capable of detecting heat changes. The pit is used to locate warm blooded mammals which make up the major part of the pit viper’s diet. Another characteristic that is found in pit vipers is the snake’s head is triangular in shape. Variations of Rattle Snakes, Copper Heads, and Water Moccasins make up the pit vipers in the United States.

Signs and Symptoms A bite from a pit viper will have a severe burning pain and immediate swell-ing around the fang marks. Swelling and pain will usually happen within five to ten minutes and spread slowly over the next eight to thirty six hours. If no signs have occurred within a few hours, there was most likely no injection of poison. Although it may be slow in taking effect, the poison is quick to cause systemic problems. Weakness, sweating, fainting, nausea, vomiting, tachycardia (rapid heart beat) and hypotension (low blood

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pressure) may set in quickly. Generally speaking, if the victim says that the bite stings like a bee sting or wasp sting, there was little or no venom injected with the bite. If the victim is in excruciating pain and says it feels like a hot poker or extreme burning, the snake has injected venom. n the case of injected venom, quick administration of the antivenin is of the utmost importance. Keep in mind just the fact that a person has been bitten by any kind of snake is going to be quite a traumatic experience. Treat all snake bites as an emergency. Never assume that venom was not injected.

Treatment Reassure the victim. Have them remain as calm as possible. Explain that many times a snake does not inject venom, the poison is slow acting and there is antivenin for the bite. In the last few years the treatment for poisonous snake bite has changed. The old methods of cutting the bite, sucking the wound, restrictive bands, cold packs and ice are no longer used. These old methods can actually create more problems for the victim. The latest method calls for treating the victim for shock and activating the EMS system immediately. Identify the snake to EMS as soon as possible so that the correct antivenin can be located and ready for immediate use on the victim. Keep the victim quiet and reassure the victim. Explain that in most cases, snakes do not inject venom. This could be a major factor in calming the victim. Reassure the victim that you can help him. Check the vic-tim’s vital signs and continue to monitor them. Treat for shock. Admin-ister artificial ventilation with oxygen if needed. If there is a delay with the arrival of EMS, the victim should be safely transported to the near-est medical facility as soon as possible. If you have a cell phone, stay in contact with the 911 operator. Follow their instructions and informa-tion they provide.

Coral Snake The other poisonous snake that is native to the United States is the Coral Snake. The Coral Snake is generally docile and shy. It will, how-ever, bite if provoked. A Coral Snake is very colorful with bright red, yellow and black rings circling its body. Coral Snakes have a color sequence of Red on Yellow and then Black. Coral Snakes are small

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snakes usually less than two feet in length. They do not have the large fangs of the pit vipers. The fangs are small and grooved. The Coral Snake because of its size would usually bite the victim on a small part of their body. In the case of a human, most bites are to the hands, feet or a fleshy part of the body. Because of the small size of the mouth and short fangs the snake must chew to inject the venom. A bite from the Coral Snake will only be one or more tiny punctures or scratches in the area of the bite. Remember if the snake has Red and Yellow bands that touch it is a Coral Snake. There is a non poisonous snake that has similar colors and is harmless. The Scarlet King snake looks a lot like the Coral Snake but the adjoining bands are not in the same sequence. Remember Red and Yellow Kill a Fellow.

Signs and Symptoms The bite of a Coral Snake is a great concern if venom is injected. Coral Snakes belong to the same group of poisonous snakes as the Cobra, Mamba and Krait. The venom of a Coral Snake is the most toxic venom of the poisonous snakes in the United States. The venom of the Coral Snake is a neurotoxin. Because of this the signs and symptoms of the bite are completely different from a pit viper’s bite. The neurotoxin will attack the central nervous system. Victims may complain of depression, apprehension or even euphoria. Neurotoxins will affect the cranial nerves resulting in paralysis of the respiratory system.

Treatment Immediate care is needed because of the quick effect of the neu-rotoxin. Activate the EMS system. Advise them the victim has been bitten by a Coral Snake. Keep the victim quiet and reassure the victim. Explain that in most cases snakes do not inject venom. This could be a major factor in calming the victim. Reassure the victim that you can help him. Flush off the area of the bite with plenty of water. The flush-ing will wash away any venom left on the skin. The most important factor is getting the victim to a medical facility for administration of the anti venom as quickly as possible. Check the victim’s vital signs and continue to monitor them. Treat for shock. Administer artificial ventila-tion with oxygen if needed. If there is a delay with the arrival of EMS,

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the victim should be safely transported to the nearest medical facility as soon as possible. If you have a cell phone, stay in contact with the 911 operator. Follow their instructions and information they provide.

Other poisonous snakes Consideration should also be given to the possibility of an

imported poisonous snake from other parts of the world. There are many captive poisonous snakes that are not

indige- nous to the United States being kept and displayed. It would be unlikely that we would come in contact with an exotic poi- sonous snake, but it could happen. Remember that a good accurate description of the snake is very impor- tant. If you can bring the snake in (again prefer- ably dead) for positive identification it will help in the treatment and administration of the cor-rect antivenin. Be very cautious with the snake. Whether the snake is dead or alive the venom is still toxic. The cap-ture of live poisonous snake should not be con-sidered or attempted. Dealing with live poisonous snakes is best left to the experts. Having another victim of snake bite presents additional prob-lems. In the case of a human life being at risk, dispatch the snake and place it in a con-tainer for identification. Extreme care should be taken in not getting close enough to the snake to be bitten.

Summary Needless to say, all snake bites should be treated aggressively and quickly. When you have a victim of a poisonous snake bite, call 911 and explain the situation and condition of the victim. Nine one one operators have a protocol for different types of emergency care. The operator can direct you and also start an emergency response team to your location. In many areas of the United States, special centers are established to stock antivenin and direct EMS and hospital phy-sicians in the proper care for venomous snake bite. The best bet to

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find the proper antivenin is to call the nearest Zoo. Most Zoos keep a stock of different antivenins. The Herpetology section of the Okla-homa City Zoo has for many years maintained an Antivenin index. They can provide Physicians or Hospitals with information of available supplies of antivenin and information on patient care. The day time phone number is 1-405-424-3344. During the night or weekends it is 1-405-271-5454. The director of the Herpetology section is Mr. David Grow, ext. 283. Also a noted expert on snake bite is Maynard Cox of Orange Park Florida. In the event of a poisonous snakebite, Mr. Cox is available on a 24 hour a day basis to Medical facilities and Physicians for consultation on emergency snake bite treatment. Mr. Cox may be reached by contacting the Clay County (Florida) Sherriffs office at (904) 264-6512 (24 hour number).

Animal bites Animal bites from both domestic and wild mammals such as dogs, cats, raccoons are not uncommon. There is a possibility that you will encounter a victim of animal bite in just about any area. If the animal is still present, care must be used so that you or someone else does not become an additional victim. The first course of action you should take is to have a bystander call for EMS and local Law Enforcement.

Treatment of animal bitesThe general treatment for an animal bite depends on the severity of the wound. In most cases, an animal bite will consist of a simple punc-ture wound. Generally, there will not be a large amount of bleeding from a puncture wound unless the bite has punctured a vein or an artery. If a vein or an artery has been punctured, use direct pressure to stop the bleeding. If direct pressure fails to stop the bleeding, then use the pressure point method. If the wound is on an extremity, raise the extremity. This may have an effect on slowing or stopping the blood flow. If both these methods fail, use a restrictive band. Apply a restrictive band lightly. Do not cut off any arterial or deep venous blood flow. Next, clean the wound thoroughly with soap and water. If you have an anti bacterial cleanser such as betadene or physohex

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soap, use it. Hydrogen peroxide will also help in cleaning the outer area of the wound. Because most of the trauma and damage of puncture wounds occurs beneath the skin, the cleaning is strictly superficial. Puncture wounds are notorious for infections and must be treated immediately by a phy-sician with antibiotics. Even though we can’t do a great deal of clean-ing, it is important that we make the effort and clean the exterior of the wound and surrounding area as much as possible. lso look for additional scratches that may have been made by the animal’s teeth or claws. These wounds should receive the same care and cleansing as the primary wound or wounds.Animal bites that are tears or lacerations should also be cleaned with soap and water or an anti bacterial soap. o not use hydrogen peroxide for deep open wounds. The hydrogen peroxide may cause damage to the tissue cells and actually kill the cells and cause irreparable damage. Hydrogen peroxide should only be used on shallow wounds or scratches. In some instances, a bite may cause a tear that creates a flap of skin or scalp. This type of tear is called an avulsion. Avulsions may be shallow or deep tears. The same treatment should be used on this type of wound. In the case where an animal bite is especially vicious or severe, the wound should be treated as a trauma. Remem-ber that an animal attack can be very traumatizing to the victim. Some animal attacks can be very vicious and pose immediate life threaten-ing wounds. Pay special attention to the victim and look for signs of shock. If the signs of shock are present or you think the possibility of shock is present always treat for shock.

SummaryThere are some special considerations concerning animal bites. arlier I mentioned the possibility that the animal responsible for the bite may still be around. If this is the case, the animal may be docile or it could present a danger to anyone else in the area. Caution must be used by the first aid provider and any other persons in the immediate area. Law enforcement must be notified. In most states, it is required by law that any animal bites be reported and investigated by local law enforcement officers. If the police, fire/rescue, sheriff’s deputy or game warden is present, let him handle the problem with the animal

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or its owner. If at all possible, the animal should be detained. The animal should be examined by the health department to determine if there is the possibility of Rabies. Rabies is a very serious disease and can be fatal to humans if not treated immediately. Do not place yourself or others in danger of being bitten by the animal by trying to detain or capture it. If it is a pet, you may end up in a dangerous situ-ation with the pet owner. Let the authorities handle the animal and its owner. The priority of the first aid provider is to the victim of the bite or attack. Care for the victim until EMS arrives or the victim is trans-ported to the nearest medical facility.

INJURIES AND ILLNESSES FROM MARINE AND AQUATIC ANIMALS AND FISHES

Divers have little to fear from marine and aquatic animals and fishes. Provided they are left alone, most marine and aquatic animals and fishes are of little concern to the diver. There are over one thousand species and types of marine animals that are poisonous to eat, or that are capable of injuring humans. hese may divided into two catego-ries.

1. Things that Sting, Stick, Bite or are Poison. 2. Major types of injury mechanisms.

Both categories are listed in the following chart. Whether they stick, sting, bite or are poisonous, each type of injury has its own treatment procedure as outlined in the chart. The exception would be in the case of consuming poisonous fish or shellfish. The care needed for ingesting poison fish or shellfish requires hospitalization and the care of a physician as soon as possible. Standard BLS protocol is to be followed until arrival of EMS or transportation to the nearest medi-cal facility. The most noted fish poisoning by ingestion is Ciguatera. Ciguatera occurs from eating fish that have acquired the disease from eating small reef fish that feed off the corals of the reef. The most notable carrier is the Barracuda. It seems that Barracuda have acquired a reputa-tion for carrying the Ciguatera microbe. Usually Ciguatera is only found in

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older and larger fish. Ciguatera may sometime be found in snapper, grouper and pelagic fish in tropical waters. Each type of injury has it own first aid treatment. The first aid treat-ment usually results in a definitive cure. In most cases the injury is more of a short term discomfort that has no lasting effects. Caution should still be used no matter how slight the wound. Even though first aid is administered and the main complaint or problem has subsided, an examination by a physician is still required if the skin has been broken, lacerated or punctured. In the last few years there have been numerous cases of the extremely dangerous “Flesh Eating Bacteria”.

This bacteria is usually associ-ated with cuts and wounds that have been caused by marine life such as crabs, oysters and barna-cles. The bacteria has also been found and contracted miles from any water, marine or aquatic life. There seems to be more of a chance of encountering the bac-

teria when associated with marine and aquatic life wounds. Two of the signs and symptoms of this dangerous bacteria are immediate infec-tion of the wound with pain to the touch within a few hours after con-tact. Because of the difficulty of treating this drug resistant strain of bacteria, any injury even a scratch should be followed up with a medi-cal examination by a physician.In terms of occurrence, injuries from marine, aquatic animals and fish are not common place. Most of the injuries are self-inflicted or caused by the swimmer or diver. Its really uncom-mon for a jellyfish or spiny sea urchin to crash into an unsuspecting human. hink about it for a minute. Ice melts a hun-dred thousand times faster than a sea

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urchin moves in a month. But with the tremendous draw the ocean has to humans, we still manage to get stung, stuck or bitten by this gentle, slow moving marine creature.

Their are three common injuries that occur when diving in the ocean. Number one is stepping on a stingray or sea urchin. Two is swimming into the tentacles of a jellyfish or Portuguese man of war. Three is sticking our hand into a hole to grab a lobster and finding his roommate the Moray

Eel. As far as the dangers of aquatic life, the main problems would be snakes and turtles. Both of these are pretty easily avoided. There are many streams and rivers that flow into the sea that also host a vari-ety of marine life in the brack-ish waters. Crabs and many saltwater fishes and jellyfish can often be found in waters thought to only contain fresh water species. Sharks and other salt water fish and ani-mals have been found in rivers many miles from the ocean. Divers who are in areas that may present a hazard should make sure they have added a few extra first aid items to their kit. ome of

the items may seem a little out of the ordinary, but all have a special purpose or use in the field. Three of the items are a solution of alcohol and ammonia, meat tenderizer and talcum or baby powder.Stings seem to be the occur-rence most often needing first aid.

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TreatmentThe three items mentioned will be used as the first aid treatment. Have a quart bottle filled with a mixture of 25% ammonia 75% rubbing alcohol. This solution will kill the thousands of stinging cells known as nematocysts. Thousands of these single cell nematocysts make up the tentacles of the jellyfish, Portuguese man of war, and fire corals. Pour this solution over the affected area, then sprinkle meat tender-izer over the area. Meat tenderizer breaks down protein based stings (jellyfish, Portuguese man of war, fire coral, etc.) Make sure the meat tenderizer has a high percentage of Papaya in it. he Papaya is a natu-ral fruit that will break down proteins. Next use talcum or baby powder to dry the area. The powder will not only dry the area but will make it possible to scrape or wipe the area clear of the nematocysts caus-ing the discomfort and pain. You may then make a paste of the meat tenderizer and spread it over the area to further ease the discomfort. There are a couple of other items that may be added to the first aid kit if you have room. One is a lightweight aluminum pan that is large enough to soak a diver’s foot or hand in. The other is a Sterno stove and a can of Sterno gel. A person that is unlucky enough to step on a sea urchin or a stingray will most likely be in excruciating pain. The poison toxin that is introduced into the wound is highly sensitive to heat. Soaking the wound in hot water or hot water with Epsom salts will work quickly to ease the pain. The heat from the hot water works to destroy the toxins in the poison. Care must be given not to get the water too hot. The possibility of scalding or burning the victim should be taken into consideration. The pain from the wound may mask the victim’s sensitivity to the hot water.

RESPIRATORY PROBLEMS

DyspneaThe definition of dyspnea is the “sensation of shortness of breath”. Difficulty breathing may be caused by a variety of medical reasons or may be caused from a trauma. Dyspnea caused by trauma generally limits the action a first aid provider can render. As an DAN Oxygen Provider, you will be able administer oxygen. We will also monitor the victim’s blood pressure. These two skills and procedures should

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be used until arrival of EMS. We will direct our information toward dyspnea from non traumatic causes. Care for traumatic dyspnea is treated the same as non traumatic and is used in conjunction with basic life support procedures. Medical problems that cause dyspnea are:

1. Acute pulmonary edema2. Airway obstruction3. Emphysema or chronic bronchitis4. Asthma or allergic reactions (Anaphylactic shock) 5. Dyspnea without lung abnormalities (hyperventilation)

Acute pulmonary edema Acute pulmonary edema is quite a complicated pulmonary illness. We don’t want to make our explanation of the illness too complicated. Our main goal will be more concerned with sup-porting the dyspneic victim. Basically, the prob-lem with most lung disorders is the restriction of the pulmonary blood flow. Slowing of the blood flow in the lungs will prevent exchange of gases in the lungs. Without the gas exchange the dyspnea will increase rapidly.

Treatment Proper care would be to establish a patent airway, maintain the airway and administer oxygen. BLS support may be required with artificial respiration. Follow the standard protocol for BLS and oxygen adminis-tration.

Emphysema and chronic bronchitis Emphysema and chronic bronchitis are usually found in middle aged to elderly persons. Emphysema is almost always caused by smoking or chemical exposure to the lungs. Chronic bronchitis is similar in that both emphysema and chronic bronchitis are reductions in function of the alveoli (air sacs of the lungs). Both of these diseases of the lungs will cause dyspnea to the victim.

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TreatmentThe proper first aid for the victim would be administration of oxygen and monitoring of the respiration rate. Encourage the victim to breathe deeply. It is very important to note that the stimulus for breathing is changed because of the nature of the disease. In normal individuals, the stimulus to breathe is the build up of carbon dioxide in the blood. The stimulus for the person with an obstructive lung disease is low oxygen content. If the victim receives too much oxygen, his breath-ing rate may slow. Monitor the victim closely. If the breathing rate falls below twelve times per minute you may have to assist the victim’s breathing. Use a non return pocket mask and continue oxygen admin-istration. Activate the EMS system and continue to monitor the victim until EMS arrives or victim is transported to nearest medical facility. Dyspnea may occur in unconscious and semi conscious individuals as a result of the position of the head. Simple repositioning of the neck may relieve the problem. Remember, caution must be used and manipulation should only be done after it has been determined there is no cervical injury present. If opening of the airway does not cor-rect the breathing problem, look for an upper airway obstruction. Any individual, adult or child who has been eating just prior to the dyspnea should be a prime suspect for an upper airway obstruction. Use the standard protocol for obstructed airway.

AsthmaAsthma is a direct contraindication to scuba diving. There are some major dangers of having asthma and scuba diving. One would be the possibility of having an asthma attack while diving. The air in the lungs cannot be exhaled normally and will almost cer-tainly cause a barotrauma that can range the entire spectrum of pressure related injuries. There is an extremely high probability that the diver will have a severe barotrauma. Divers who are already certified and develop asthma should definitely recon-sider diving as an activity. These individuals should seek expert medi-

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cal advice from a physician specializing in respiratory problems. In most cases, potential student divers are eliminated by their own phy-sician after filling out the medical form required to participate in scuba instruction.There is always a possibility a first aid provider may encounter a person experiencing an asthmatic episode. The correct term for asthma is bronchial asthma. Bronchial asthma may occur at any age. The disease is caused by abnormal spasms of the airway passages. The classic signs of asthma are wheezing and obvious respiratory distress. The whines and wheezes may be heard without the use of a stethoscope. The problem is caused by the constriction of the air-ways known as bronchi. The victim is able to draw air in without too much difficulty, but is not able to expel the air normally. Being unable to expel the inspired air that is heavy with carbon dioxide is a major problem. The asthmatic victim is truly in distress and care should be started immediately.

TreatmentFirst determine if the victim is choking or having an asthmatic epi-sode. The first thing you should do is ask the victim if he is having an asthmatic attack. He may not be able to speak but may indicate by shaking his head yes or no. If he indicates no and you still hear the sounds of whines and wheezes you may assume a couple of pos-sibilities. He may be having his first asthmatic episode or he may have a partially obstructed airway. If he says yes, ask if he has an asthma inhaler (puffer). If he indicates that he has an inhaler, have him use it several times. The victim may also have other medications for his condition. If he has other medications have the victim use them also. If oxygen is available, then place him on oxygen. Make him as com-fortable as possible until EMS arrives or he has been transported to the nearest medical facility. Asthma is a true medical emergency. It should never be taken lightly. A victim of asthma will soon lose con-sciousness and may need artificial respiration until EMS arrives.

UNCONSCIOUS VICTIM FROM UNKNOWN REASONS There are times when you may find a person that is not conscious. Normally we would ask any friends, relatives or bystanders if they

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have any knowledge of the victim or his condition. If no one knows what caused the unconsciousness or there is know one present, the treatment is limited to BLS. There are many causes for an individual to lose consciousness. The common faint, epilepsy, head injury or drug overdose are just a few of the many possibilities.

TreatmentWhatever the cause may be, start with the ABC’s, check the vital signs, treat for shock, establish an open airway and monitor the victim closely until EMS arrives.

COMMUNICABLE DISEASECommunicable disease has always been a concern of all individuals involved with the care of the sick or injured. The first aid provider should be just as concerned as the medical professionals. Disease may be transferred to the unprotected care givers of all levels. First aid providers are no exception. A communicable disease is a dis-ease that is contagious and may be transmitted from one person to another. Disease transmission may be from direct or indirect contact. It may be transmitted by body fluids or by airborne particles from an infected individual. Other means of contact may be from soiled dress-ings, clothing, bedding, food, coughs or sneezes. Some diseases are spread by intravenous needle sharing by drug users or accidental sticks received by the unsuspecting care giver. The two main con-cerns over the last ten years have been the HIV Virus and Hepatitis. Both of these diseases are very dangerous. They have no cures and may be fatal. Even though communicable diseases are dangerous they can be avoided if proper measures to protect the care giver are used. Remember we are care givers of first aid. We are not professional EMT or Paramedics. They deal with victims daily as a professional and are well equipped to handle medical emergencies and situations. As first aid care givers we must protect ourselves from exposure to communicable diseases. There are some basic precautions that we may take to protect ourselves.

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Prevention and Precautionsif we are working around body fluid or blood, every effort should be made to not come in contact with these body fluids. Protective latex gloves are readily avail-able at local pharmacies and drug stores. The same is true for surgical type face masks used by EMS when they suspect an airborne disease such as Tuberculo-sis. If a victim is coughing excessively use a face mask. Some face masks have a clear shield that covers your eyes. If the victim is not having trouble breathing you may request that he also wear a face mask. If you are exposed to body fluids or blood you may disinfect yourself with a mixture of 5 % to 10% percent household chlorine bleach and water. This mixture will kill most all communicable diseases, including the HIV virus. A quart of this homemade disinfec-tant should also be part of your first aid kit. Make sure to mark the disinfectant properly. After rinsing the contaminated area with the dis-infectant solution, wash the exposed area thoroughly with soap and water. When dealing with communicable disease the adage. “A ounce of prevention is worth a pound of cure” is definitely true. If any part of your body comes in contact with blood, mucus or any body fluids you are considered contaminated. If you are exposed to a communi-cable disease you will need to tell the EMS personnel at the scene, have them record the your contamination in their written report of the incident. You must seek the advice of a medical doctor immedi-

ately. You do not know if the person you assisted was a carrier of an infec-tious disease or not. Your doctor will advise you on the proper precautions and any testing you will need. Take the proper precautions not to expose family or friends until you are checked out by your doctor. Remember it is a communicable disease and you don’t want to continue the spread.

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Chapter 5

DIVING ACCIDENTS

1. Air Embolism2. Pneumothorax3. Mediastinal Emphysema4. Subcutaneous Emphysema5. Decompression Sickness6. Drowning7. Near Drowning

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DIVING ACCIDENTSThe first concern of the diver performing rescue and victim care must be with victim retrieval and resuscitation. In so far as diving is con-cerned, most first aid courses are general in nature. They simply do not cover all the possibilities that can be present when diving acci-dents occur. The IDEA Dive Medic course will cover as many of these possibilities as possible.

DIVING SPECIFIC PROBLEMSThe following problems are potentially life threatening. All Dive Medics must be able to recognize the signs and symptoms of each diving injury or illness. Dive Medics must also understand the various causes of diving accidents and the proper first aid.

Air Embolism An air embolism is caused by expanding air within the lungs when a diver ascends without breathing properly. The expanding air within the air sacs (Alveoli) of the lungs may pierce or leak through the sac wall. The leak may allow air to enter the blood stream. The danger is, air in the blood stream may block small capillaries sup-plying oxygen enriched blood to tissues. The most serious blockage could occur to an area supplying the brain. (Cerebral air embolism). The brain can be deprived of oxygenated blood for only a matter of min-utes before permanent damage can occur. An air embolism may also occur in divers who make normal ascents but have lung prob-lems which can trap air. Among these problems are: asthma, mucous plugs, scar tissue, tumors, etc. A diver may be unaware of his risk. Some conditions may go undetected even with a medical exam. It is a good idea for every diver to have a chest x-ray each year with his annual physical. Smokers may have an increase in risk even during normal ascents.

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Symptoms The symptoms that cannot be seen, but are felt by the victim of air embolism are: dizziness, visual problems, chest pain, weakness, and paralysis. The signs (can be seen) are bright bloody froth from mouth or nose, convulsions, and unconsciousness. Most often the onset of signs and symptoms occur very shortly after a diver surfaces.

Treatment The first aid is treat for shock, with oxygen administration. Activate the EMS system as soon as possible. Prompt recompression in a hyperbaric chamber is mandatory. In addition to air embolism there are other problems which are associated with non vented air during ascent. The conditions listed may or may not be associated with air embolism. The occurrence of any of these disorders means that the lung has been injured and an air embolism should be suspected. All first aid should be aimed at treatment of air embolism, even if signs and symptoms do not seem to indicate so. In all cases, immediate first aid, BLS and activation of the EMS system is necessary. Be pre-pared to administer resuscitation and CPR if necessary. Transporta-tion to a hyperbaric chamber is required for proper treatment for all barotrauma.

Pneumothorax A pneumothorax is caused by air being forced through the lung itself. The air then enters a potential space between the lung and the chest wall. This air then creates a positive pressure that overrides the pres-sure reduction within the lung and the lung collapses. Fortunately, people can survive on one lung. A pneumothorax is not usually life threatening. In fact, prior to the days of “wonder” drugs, tuberculosis was treated by the affected lung being deflated in this manner so it could “rest”.

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SymptomsLook for signs of difficulty breathing, and pain in the chest area. Other signs are rapid, shallow breathing, and possible discoloration of the skin (blue). Recompression is not mandated for this problem. A physi-cian may insert a chest tube, withdraw air from the chest cavity, and reinflate the lung. Pneumothorax is a very serious condition if it is in both lungs. The victim will be straining to breath and it will be difficult to ventilate the victim. You will notice possible expansion in the chest and a hardness. In this case the victim is in extreme danger EMS must be summoned quickly.

TreatmentEven though a minor case of Pnemothorax is not necessarily a life threatening injury, the extent of the injury can only be diagnosed in a medical facility with the proper care and equipment. In the field we can’t always see signs of other barotrauma that could also be present. Proper first aid would include BLS, immediate activation of the EMS system, administration of oxygen and treat for shock. Be prepared to administer resuscitation and CPR if necessary. Monitor victim closely until EMS arrives or victim is transported to the nearest medical facil-ity.

Mediastinal Emphysema Mediastinal emphysema is caused by air escaping from a damaged lung into the space between the two lungs, the medi-astinum. This area contains the heart and large blood vessels.

Symptoms Pain in the middle of the chest, under the breastbone (Sternum), shortness of breath, and possible feeling of faintness. Signs are difficulty in breathing and possible hoarse-ness in the victim’s voice.

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Treatment The person is not necessarily recompressed, unless signs of air embolism or decompression sickness are present. Proper care would include BLS, immediate activation of the EMS system, administration of oxygen and treat for shock. Be prepared to administer resuscita-tion and CPR if necessary. Monitor victim closely until EMS arrives or victim is transported to the nearest medical facility.

Subcutaneous Emphysema Subcutaneous emphysema is caused by air escaping from a lung injury. Subcutane-ous emphysema is most often caused by a mediastinal emphysema injury. The escap-ing air is trapped just under the skin in the area of the neck.

Symptoms The symptoms are tightness in the area of the neck. Signs are a change in the victim’s voice, due to air pressure on the voice box (larynx), swelling or a bulge in the neck area, and crepitation (crackling) of the skin when the area is touched.

Treatment This condition is not normally serious; however, the person should be monitored for possible air embolism. The person should be examined by a physician. First aid is to treat for shock. In most cases there is no need for oxygen administration. If the victim complains of shortness of breath there may be other underlying problems. Oxygen adminis-tration should always be used if the victim is in any respiratory dis-tress. Proper care would include BLS, immediate activation of the EMS system, administration of oxygen and treat for shock. Monitor victim closely until EMS arrives or victim is transported to the nearest medical facility.

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Decompression Sickness Decompression sickness is normally caused by inadequate decom-pression following an exposure to increased pressure. While most cases reported are not life threatening, all should be treated by recompression to prevent long term tissue damage. Decompression sickness can cause death or permanent paralysis. Decompression sickness should never be taken lightly.

Symptoms The skin may show red rash (skin bends), pain in the joints, stagger-ing, coughing spasms, and unconsciousness. Signs and symptoms usually appear anywhere from 15 minutes to 12 hours after surfacing. In severe cases, signs and symptoms may appear before surfacing or immediately thereafter.

Treatment Proper treatment for decompression sickness is prompt recompression. In water recompression should never be attempted. Proper treatment in a hyperbaric chamber by qualified medical personnel is required. The first aid provider should ask a bystander to activate the EMS system. Aggressively treat the victim with BLS procedures and administer oxygen. Be prepared to administer resuscitation and CPR if neces-sary. Have a bystander call DAN and arrange for transportation to the nearest medical facility with a hyperbaric chamber. The mode of transportation is also an important factor in the victim’s treatment. If a medical helicopter is available, by all means use it. The local EMS system will make the arrangements for air transportation and direc-tions of the EMS crew to the injury site. Make sure the EMS dis-patcher knows exactly what your problem is and your exact location. Have your bystander helper stay in contact with the EMS dispatcher. Give periodic reports of the victim’s condition and vital signs to the dispatcher for relay to the responding EMS units.

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Drowning (Near Drowning) This problem is fairly rare in scuba diving. At many dive sites we will also encounter swimmers. For this reason it is quite possible that you find yourself present at a drowning of a swimmer or a diver. If the victim is a diver, drowning is usually associated with inade-quate positive buoyancy after the diver surfaces. Drowning (where death occurs), does not occur instantly. When res-cues can be started within a short period of time, the probability of recovery greatly increases. This is why it is important for a rescue effort to be generated in a short period of time. Usually, a person that is drowning holds his breath for a period of time after he submerges. It is only after unconsciousness occurs that the breathing reflex is trig-gered. Drowning victims, even though unconscious, will tend to swal-low water rather than to breathe water. This explains why drowning victims have large amounts of water in their stomachs. It is during this ‘swallowing’ period where the chance of recovery from drowning is still high. At some point, the victim will cease the reflex swallowing and take a deep breath. It is estimated that after a victim submerges, underwater breathing will begin in 3 to 4 minutes. If recovery is made prior to this breathing, chances of recovery are very good. There are certain circumstances that may account for variations in the time that a rescue and successful resuscitation may be successfully com-pleted. One of these is the factor of cold water. The colder the water, the better the chance of recovery is, even after periods of long sub-mersion.

Treatment The proper treatment for a near drowning would be to administer oxygen, treat for shock, activate the EMS system and monitor the victim closely until EMS arrives. The victim must be transported to the nearest medical facility. Near drowning victims may seem to recovery quickly but minutes or hours later have a major medical problem. This

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is due to swallowing water. Swallowing fresh and salt water cause dif-ferent problems. Fresh water is absorbed readily from the lungs into the bloodstream. The fresh water dilutes the normal body salts found in the body. The dilution directly damages blood cells of the pulmo-nary membranes (alveoli) and may cause them to rupture. Salt water attacks the body differently. The salt water is two or three times more concentrated in salt than the normal body fluids. Because of this difference, it tends to pull water out of the body tissues and into the lungs. This condition is known as pulmonary edema. Pulmonary edema causes difficulty in transporting oxygen across the membranes (alveoli) into the blood. There is also the possibility of contaminates found in the water also causing medical problems. Drowning victims should be treated with artificial respiration’s and CPR if needed. In both near drowning and drowning, the victim may sometimes quickly respond to artificial respiration. Spontaneous breathing may result after administration of artificial respiration. In all cases drowning and near drowning must be ultimately treated in a hospital. Standard BLS protocol for CPR and BLS should be followed.

Oxygen Toxicity Due to the increase in the use of Nitrox, Tri-mix and Rebreathers, consideration must be given to the pos-sibility of encountering a victim suffering from oxygen toxicity. In the past, the possibility of a diver suffering from oxygen toxicity was virtually nonexistent in sport diving. With more training and equipment available to the sport diver, the possibility of an oxygen toxicity victim is more likely. Oxygen toxicity occurs when a mixture of pure or enriched oxygen is used instead of normoxic air. The partial pressure of oxygen is increased as a diver descends. Sport divers using normal (normoxic) air in scuba tanks are not in danger of oxygen poisoning (oxygen toxicity). Diving within the sport diving range of five atmospheres does not increase the partial pressure of oxygen to a danger-ous level. When diving with mixtures that contain higher levels of oxygen, the maximum safe depth is decreased. A diver that is not

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trained and certified to use Nitrox or Tri-mix should never attempt to dive with these special mixtures. The possibility of a fatal accident is high. The problem with oxygen toxicity is that in most cases there may be no warning signs or symptoms. The first symptom will most likely be an uncontrollable convulsion. Needless to say, if this occurs, a diver will have little or no chance of survival unless his buddy is close at hand. Even with a buddy close at hand, would they be able to control the victim having a convulsion? It would be very difficult to control a victim having a convulsion, while attempting to keep the victim’s regulator in place. Adding to this scenario, consider the difficulties in trying to compensate for both the victim’s and rescuer’s buoyancy while making a safe controlled accent. Oxygen toxicity is best to avoid in the first place. Divers should not place themselves or their dive companion in a situation that would require a rescue. The decision to use Nitrox or a Tri-mix requires strict adherence to special rules and strict regulations. The use of these special breathing gases also require that the users demonstrate a high level of maturity and responsibility. There is absolutely no room for error when using Nitrox or Tri-mix. If an accident does happen, the most important concern of the rescuer is to assist the victim in a safe and controlled ascent to the surface. The victim’s regulator should be held in his mouth to help prevent water from entering the airway. Tilt the victim’s head upwards slightly to keep the airway open. Use the standard rescue ascent procedures from your Rescue Diver train-ing. Once the victim is at the surface, check for an open airway and breathing. When the victim reaches land or is on the boat conduct a primary survey. Follow the ABC’s and then conduct the secondary survey. Take into consideration the possibility of air embolism or other barotrauma. Administer oxygen and activate the EMS system. Moni-tor the victim’s vital signs until help arrives.

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Chapter 6

QUICK REFERENCE GUIDE

1. General First Aid2. First Aid for Choking3. Mouth to Mouth Resuscitation4. CPR5. Basic Life Support and the Trauma Victim

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QUICK REFERENCE

Basic Life Support & General First AidInformation found in the Quick Reference section follows general first aid procedures. Artificial resuscitation and cardiopulmonary resus-citation in this text follow recommendations and procedures of the American Heart Association and the American Red Cross. IDEA Dive Medic I and II are required to complete a certification program by the American Heart Association, American Red Cross or other nationally recognized CPR program.

1. (A) Restore normal breathing. Open airway, start mouth to mouth resuscitation if necessary. Use of pocket mask recom-mended for better ventilation’s and communicable disease control.2. (B) Stop severe bleeding. Use these methods in this order, direct pressure on wound, pressure points, if these fail to stop bleeding of an extremity use a restrictive band or tourniquet as a last resort.3. (C) Check for pulse and heart beat and administer CPR if absent.4. Keep victim lying down.5. Send for assistance, call 911.6. Reassure victim.7. Check for other injuries.8. Remove restricting clothing or gear if the victim is a diver. Make sure that the head, neck and spine are protected in case of pos-sible cervical or back injury.9. Do not leave victim unattended.10. Give the maximum first aid or medical care you can provide.11. Be able to recognize symptoms of diving accidents.

TREAT FOR SHOCKElevate the victim’s feet with the body turned on it’s left side. If air embolism is suspected, use the modified shock position with the entire body elevated 30 degrees with victim on his left side (Breathing Victims Only).CALL 911

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After calling 911 if the victim is a diver also call DAN (Divers Alert Network)(919) 684-8111 (CALL COLLECT IF NECESSARY) State that you have an emergency, and ask for the diving physician.

FIRST AID FOR CHOKING

Conscious victim1. Ask the victim:” Are you choking?”2. If the victim can speak, cough or breath, do not interfere.3. If the victim cannot speak, cough, or breath, apply the Heimlich maneuver. Use a sub dia-phragmatic abdominal thrust. Repeat the maneuver numerous times until the foreign body is expelled or the victim loses consciousness.

Victim becomes unconscious1. Open victim’s mouth and perform a finger sweep. Visually observe for foreign objects. Remove any food, foreign objects or dentures.2. Open airway and try to venti-late victim.3. If unsuccessful, with victim laying flat on his back, straddle the victim and apply 6 to 10 sub diaphragmatic abdominal thrusts.4. Be Persistent. Don’t give up. It may take numerous attempts to free the foreign object. Remem-ber to activate the EMS system as soon as possible. Call 911 !

Mouth to mouth resuscitationThe human heart will usually beat for several minutes after breathing has stopped. These first few minutes are vital for the victim’s survival. Many times simply opening the victim’s airway will allow for spontane-

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ous respiration’s by the victim. If this fails, resuscitation is necessary. Mouth to mouth resuscitation is a skill. Like any skill mouth to mouth resuscitation must be practiced for the user to be proficient. IDEA rec-ommends that all persons obtain mouth to mouth resuscitation train-ing from either the American Heart Association or the American Red Cross. Both of these organizations have excellent training programs in the administration of mouth to mouth resuscitation. After certifica-tion and training in mouth to mouth resuscitation, you should renew your certification at least every two years. In between renewal of your certification, a refresher course is a good idea. It is important to keep these vital skills sharp and be able to act quickly without hesi-tation. Practicing on a mannequin is an excellent way to keep your skill level up. Never practice mouth to mouth resuscitation skills on another person. Prac-ticing on a person that is not in need of actual mouth to mouth resusci-tation may cause injury or even death. Never practice on another person. The techniques presented in this mate-rial are used by the American Heart Asso-ciation and the Ameri-can Red Cross.

1. Determine if the victim has simply fainted. Shake the victim and shout “ARE YOU OK?”. If there is no response, ask bystand-ers for assistance, and have someone call 911.2. Place victim on his back, gently tilt the head back to open the airway, Place your ear close to the victim’s mouth and nose, look to see if the victim’s chest is rising and falling from breathing. Listen and feel for the noise or movement of air from the victim’s nose and mouth.3. If not breathing, start mouth to mouth resuscitation (the use of a pocket mask is recommended for better ventilation’s and protec-

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tion from communicable disease). Make sure that the head, neck and spine are protected in case of possible cervical or back injury. Tilt the head back gently, pinch the victim’s nostrils closed with your thumb and forefinger, place your palm on the forehead. With your other hand pull down on the chin to hold open the victim’s mouth. Place your mouth over the victim’s and give two full venti-lation’s. These breaths are slow, full ventilation’s lasting 1 1/2 to 2 seconds each. Watch for the victim’s chest to rise. If the chest doesn’t rise, check for obstructions in the mouth and/or reposi-tion the head making sure the airway is open.4. Check for a heart beat by placing two finger on the carotid artery located next to the trachea. If you feel a pulse the heart is still beating. If the victim is still not breathing ventilate at the rate of 1 breath every 5 seconds. Recheck the pulse every few minutes for a heart beat. 5. If the heart is not beating then CPR must be started. CPR requires specialized training. If you know CPR, start immediately. If not, continue ventilation’s until help arrives. Ask the bystanders “ DO YOU KNOW CPR?”. If someone knows CPR, let them assist you or take over. Do not exhaust yourself or your helper. Pace your-self and your helper, making sure the victim receives the proper amount of ventilation’s and compression’s.

Cardio Pulmonary ResuscitationCardio Pulmonary Resuscitation (CPR) is a skill. Like any skill CPR must be learned and prac-ticed for the user to be proficient. IDEA recom-mends that all persons obtain CPR training from either the American Heart Association or

the American Red Cross. Both of these organizations have excellent training pro-grams in the administration of Cardio Pulmonary Resuscitation. After certi-fication and training in CPR, you should renew your certification at least every two years. In between renewal of your certification, a refresher

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course is a good idea. It is important to keep these vital skills sharp and be able to act quickly without hesitation. Practicing on a mannequin is a excellent way to keep your skill level up. Never practice CPR skills on another person. Practic-ing on a person that is not in need of actual CPR may cause injury or even death. Never practice on another person. The techniques

presented in this material are used by the Amer-ican Heart Association and the American Red Cross.

Basic One Person CPR1. Assessment: Determine if the victim is in need of CPR.Shake the victim, Shout “ Are You Ok?”

2. Call 911: If no response, Activate the Emergency Medi-cal Services system.

3. Airway: Position the victim then open the airway by using tilting the head and lift-ing the chin.

4. Breathing: Check for breathing. Look at chest for move-ment, listen for the sounds of breathing. If victim is breathing and there is no evidenceof trauma, place the victim on his side in the recovery position. Make sure the airway is still open. This will also help if the victim vomits. Monitor the victim until EMS arrives.

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5. Not Breathing:If victim is not breathing, pinch nostrils closed, make a tight seal around victim’s mouth, give 2 slow breaths of 11/2 to 2 seconds per breath. Watch for victim’s chest to rise. Allow thelungs to deflate between breaths.

6. Circulation: Place two fingers on the Adam’s apple.Slide the fingers into the groove between the Adam’s apple and neck muscle. Feel for the carotid pulse.

7. Pulse: If the victim has a pulse, perform rescue breathing. 12 breaths per minute (1 breath every 5 seconds).

8. No Pulse: If no pulse, start first cycle of CPR. Find the lower third of the sternum (breastbone). Place heal of your hand two fingers below sternum. Place other hand on top of hand and com-press straight down 11/2 to 2 inches. Establish a rhythm by counting “one and, two and, three and, four and, five etc.

The compression rate for adults is between 80 and 100 times per minute. After every 15 compression’s give 2 slow rescue breaths.

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9. Check Pulse: At the end of 4 complete compression and breathing cycles, check for return of pulse. If pulse returns but there is no breath-ing, give one breath every 5 seconds. If there is still no pulse continue cycle of 15 compression’s and 2 ventila-tion’s. Continue to monitor for pulse or breathing every 4 cycles.

10. 2nd Rescuer: If another rescuer arrives, switch places and assess the adequacy of the second rescuer’s performance. Watch for the victim’s chest rise during rescue breaths. Check pulse during chest compres-sion’s. When the rescuer tires take back over the rescue efforts. Rescuers should alternate until EMS arrives.

One Rescuer CPR for child 1-8 years oldCPR for children has four major differences from adult CPR

1. If you have no help, administer about 1 minute of CPR before activating the EMS system.2. The heel of one hand is used for chest compression’s not both hands as with an adult.3. Depress the sternum one third to one half the depth of chest, about 1 to 11/2 inches only.4. Give 100 compression’s per minute, with 1 rescue breath for every 5 chest compression’s.

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Airway1. Determine unresponsiveness. Tap or gently shake the shoulder and shout “ Are you OK?”2. Call out “Help!”3. Position the victim on his back. Take time to support the head and neck in case of injury.4. Open the airway. Use the head tilt - chin lift method.

Breathing1. Determine if the victim is breath-ing. Listen with your ear over the child’s mouth, look for chest rise and feel for breath while keeping the airway open. If the victim is breath-ing and there is no evidence of injury or trauma, place him in the recovery position.2. If the victim is not breathing, give 2 rescue breaths mouth to mouth. Each breath should be 1 to 11/2 sec-onds per breath. Look for the chest to rise with each breath.

Circulation1. Determine if the victim has a pulse. Use two fingers to feel for the carotid pulse with one hand while maintain-ing the head tilt with the other. Guard against head or neck injury or hyper-tension of the neck of children.2. Start chest compression. Find the sternum using the same techniques as for an adult. Remember to only use the heel of one hand. Compress the chest 100 times per minute. Give 1 rescue breath for every 5 compres-sion’s.

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3. Complete 20 cycles of compression’s and rescue breaths.4. Activate the EMS system, Call 911.5. Check pulse.6. If no pulse, continue CPR.7. Check pulse every few minutes.8. If pulse returns, check for spontaneous breathing. If there is not breathing, give 1 breath every 3 seconds and monitor the pulse. If the victim is breathing, place him in the recovery position, maintain an open airway, monitor breathing and pulse.

2nd RescuerIf another rescuer arrives, have them check for a pulse, if no pulse the second rescuer takes over CPR. First rescuer assesses the ade-quacy of the second rescuer’s performance. Watch for the victim’s chest rise during rescue breaths. Check pulse during chest compres-sion’s. When second rescuer tires take back over the rescue efforts. Rescuers should alternate until EMS arrives.

OBSTRUCTED AIRWAY FOR CHILD 1 TO 8 YEARS OLD

First aid for choking in children 1 to 8 years old is the same as adults and older children. There is one change however. Instead of using the blind finger sweep use the tongue - jaw lift. Look down into the airway and use your finger to sweep the foreign body out only if you can actually see it.

ONE RESCUER CPR FOR INFANT LESS THAN 1 YEAR OLD

Special considerations must be used when perform-ing CPR on infants. Because of their size and vul-nerabilities there are several differences for CPR and choking.

Airway1. Determine if the infant is unresponsive. Gently tap or shake the shoulder.

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2. If no response call for “Help”3. Position the infant on his back on a firm surface. Make sure to support the head and neck.4. Open the airway by using the head tilt - chin lift. Do not hyper-extend the head too far back.

Breathing1. Determine if the victim is breathing. Listen with your ear over the child’s mouth, look for chest rise and feel for breath while keep-ing the airway open. If the victim is breathing and there is no evi-dence of injury or trauma place him in the recovery position.2. If infant is not breathing, cover the infant’s mouth and nose, maintain on open airway and give 2 gentle rescue breaths. Watch for the rise and fall of the chest. Each breath should be 1 to 11/2 seconds in length.

Circulation 1. Check for a pulse. Use the brachial pulse located on the inside of the upper arm. Use two fingers of one hand while maintaining the head tilt with the other hand.2. Start compression’s. Trace an imaginary line between the nip-ples, in the exact center of the chest. Place your index finger slightly below the imaginary line. Next place middle and your ring finger (third and fourth fingers) next to the index finger. Use only the middle and ring finger to compress the sternum. Because of wide variations in the sizes of the rescuers hands and the infant’s chest it is important that you do not compress over the xiphoid process. Compress the chest between 1/2 to 1 inch ( approximately 1/3 to 1/2 the depth of the chest ). Compres-sions should be at least 100 times per minute. After each five compression’s give one rescue breath.3. Complete 20 cycles of compres-sion’s and rescue breaths.

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4. Call 911. Activate the EMS system quickly.5. Check for a brachial pulse.6. If there is no pulse, continue CPR.7. Check for a pulse every few minutes.8. If a pulse is present, check for spontaneous breathing also. If there is still no breathing, give 1 rescue breath every 3 seconds. If there is breathing and a pulse, place in the recovery position. Maintain an open airway and continue to check the breathing and pulse.

OBSTRUCTED AIRWAY FOR CONSCIOUS INFANTLESS THAN 1 YEAR OLD

This procedure is to be performed only on a completely obstructed airway. Evidence of airway obstruction is: ineffective cough, no strong cry, no air flow from infant, serious breathing difficulty, foreign object. If the infant is crying this is an indication that air is moving and actions should not be taken for an obstructed airway. Continue to monitor the infant for breathing. If the obstruction is caused by infection or illness and swelling is present the infant needs immediate attention. If there is rescue service in your area call 911 immediately. Keep in mind that rescue in most cases can respond quicker than you could reach a medical facility safely. If necessary, transport the infant to the near-est emergency medical facility. Continue to follow the protocol for obstructed airway on a conscious infant less than 1 year old. If you have access to a cell phone keep in contact with 911 for medical instructions and directions.

1. Assess for airway obstruction. No breath sounds, no crying or weak cry, breathing difficulties, dusky color, blue lips or face, cyanotic appear-ance.2. Place the infant face down the length of your arm. Place the infant,s face in the palm of your hand with your fingers spaced (take care not to cover the mouth or nose) and sup-porting the cheeks. The length of your

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arm supporting the infant’s body. Lower the infants head lower than the trunk of the body. Deliver up to 5 back blows forcefully between the shoulder blades with the heel of your other hand.3. Turn the infant over and switch hands. Support the infant’s head and body with your arm. Keep the infant’s head and body in a downward position. This may help to expel the foreign object. Using the same landmarks as those you use for infant chest com-pression’s deliver up to 5 thrusts in the mid sternal area. Use the same ring and index finger as you would use for compression’s. Deliver these chest thrusts slower than when doing chest com-pression’s. 4. Continue to repeat steps 2 and 3 until the foreign object is expelled or the infant becomes unconscious.

If the infant becomes unconscious 1. Place infant on his back and at the same time call for “help”. If someone comes to your aid have them call 911 and activate the EMS system immediately.2. Use the tongue - jaw lift. Don’t perform a blind finger sweep. Remove foreign body only if it is visible.3. Attempt to give rescue breaths. Open the airway with the head tilt - chin lift method, try to give rescue breaths.4. Try again to give rescue breaths. If this fails, reposition the head and try again to give rescue breaths.5. Reposition infant and give up to 5 back blows, 6. Turn infant to chest thrust position and give up to 5 chest thrusts. 7. Perform tongue - jaw lift and remove any foreign body that is visible.8. Attempt to again give rescue breaths. Keep the airway open with the head tilt - chin lift.9. Repeat steps 4 through 8 until successful.10. If alone and your efforts are not successful activate the EMS system after about one minute of trying to clear the airway. Con-tinue to call for help periodically or EMS arrives.11. If obstruction is removed, check for breathing and a pulse.

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12. If there is breathing, place the infant in the recovery position. Closely monitor the breathing and pulse. Maintain an open airway. If there is no breathing, give 20 rescue breaths per minute and monitor the pulse.13. If there is no pulse, give 2 breaths and start CPR. If a pulse is present, open the airway and check for breathing.

Obstructed Airway for Unconscious Infant Less Than 1 Year Old

1. Determine unresponsiveness by gently shaking or tapping the infant’s shoulder.2. Call for “Help”.3. Place infant on his back. Use a hard firm surface, making sure to support the head and neck.4. Open the airway using the head tilt - chin lift. Be careful not to hyperextend the neck by tilting the neck back too far.5. Determine if the infant is not breathing. Maintain an open airway, place your ear over the infant’s mouth and listen for breath sounds. Feel for breath movement on your ear. Look at the chest for the rise and fall of breathing.6. If there is no indication of breathing, attempt to give rescue breaths using the mouth over mouth and nose seal method.7. Attempt again to give rescue breaths. Reposition head and check mouth over mouth and nose seal.8. Activate the EMS system. If there is help, have them activate the EMS system while you continue your efforts. 9. Continue your efforts, deliver up to 5 back blows.10. Deliver up to 5 chest thrusts.11. Use the tongue - jaw lift and look for any foreign object. If you see an object, remove it.12. Attempt to give rescue breaths.13. Repeat steps 9 through 12 until successful.14. If you are alone and have no success in you efforts, activate the EMS system after about 1 minute of trying to clear the airway.15. If obstruction is cleared, check for breathing and a pulse.16. If the infant is breathing, place him in the recovery position and monitor his breathing and pulse. Make sure to keep an open

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airway. If there is no breathing, give 20 rescue breaths per minute and check pulse.17. If there is no pulse, administer two rescue breaths and start CPR. If there is a pulse open the airway and check for breathing.

BASIC LIFE SUPPORT AND THE TRAUMA VICTIMIt is imperative to recognize and provide immediate Basic Life Support intervention for all trauma victims. Resuscitation should begin as soon as possible after an injury. Improper resuscitation and failing to main-tain an open airway has been identified as a major cause of prevent-able trauma deaths.Pediatric victims of trauma require close and meticulous support of the airway, breathing and circulation. Airways can easily be blocked by soft tissue injury, blood or dental fragments. When a head or neck injury is suspected in children or adults, the cervical spine must be completely immobilized with an open airway. The best way to handle this is a combination using the jaw - thrust and spinal stabilization methods. Extreme caution should be used while establishing an open airway. Use only the minimal amount of manual control necessary to prevent cranial and cervical motion. Do not use the head tilt - chin lift. It may cause additional damage or worsen the injury. If two rescuers are present, the first rescuer should open the airway with a jaw - thrust while the second rescuer ensures that the head and cervical spine is completely stabilized in a neutral position. The objective is to conduct the needed ABCs without doing any fur-ther damage to the cervical spine.Immobilization of the cervical area should be accomplished before the victim is moved. After checking the ABC’s, the most important action is splinting the cervical area or spine. If 911 has been called and their arrival time is short (5 to 15 minutes) simple hand held traction of the cervical spine may be adequate. This may be accomplished by having a helper or bystander hold gentle traction on

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both sides of the head. There must be absolutely no movement, no matter how slight, by the victim or person holding gentle traction. Is very important that no movement occurs. If the victim of a cervical spine fracture moves even the slightest amount, the single move may cause death or paralysis. If the arrival time of EMS is longer than 15 minutes, the victim’s cervical area and spine should be immobilized. Improvised head restraints may be made from a diver’s soft weight belt or a standard weight belt wrapped in towels for padding. If the injured victim is in the water, provide the ABC’s and immobilize the victim in the water before attempting to remove the victim. Paralysis and death has been attributed to attempts to move an accident victim without immobilizing the cervical area and spine.

IDEA DIVE MEDIC TEXT SUMMARY No First Aid course can cover all that an individual needs to know about First Aid. There are thousands of scenarios that can present themselves to the first aid provider. Adding a few basic skills and knowledge can offer a higher level of care to sick or injured victims. IDEA’s Dive Medic I and II courses increase the level of care you may provide until relieved by EMS personnel. Responsible divers will recognize the importance of successfully completing courses in oxygen administration, and cardiopulmonary resuscitation (CPR). These courses may be taken as part of the IDEA Dive Medic course or obtained individually by Instructors from the American Heart Asso-ciation, American Red Cross or DAN. Individuals trained as IDEA Dive Medic I are required to complete certification in artificial resus-citation and CPR. The IDEA Dive Medic II certification also requires training and certification in oxygen administration. Diver Alert Network (DAN) is the program endorsed by IDEA. Other Oxygen Provider pro-grams may be used with approval from IDEA headquarters. IDEA Dive Medics should familiarize themselves with the signs, symptoms, and treatment of lung expansion injuries. Lung expansion injuries may present themselves more frequently than other diving accidents. Recognition and treatment of other pressure related (Baro-trauma) injuries is also required. Review the signs and symptoms of diving accidents on a regular basis. The Dive Medic should be pre-pared and ready to act in the event first aid care is needed. More than

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likely the first aid provider will encounter many more first aid situa-tions that are not caused by diving accidents. By having a complete first aid kit, oxygen administration training and training in first aid and CPR you will have a positive effect on the care of a victim of illness, accident or injury. The quality of care you can provide until EMS units arrive will have a direct effect on the victim’s recovery and survival. Quality pre hospital care begins with first aid. If you have enjoyed the additional first aid skills that you learned in your IDEA Dive Medic course, IDEA recommends that you consider taking a First Responder course. First Responder courses are offered by many fire and rescue departments, technical schools and commu-nity colleges. You may also enjoy participation as a member of a dive rescue team with your local fire, rescue or law enforcement agen-cies.