ECHM Consensus Recommendations of Adjunctive Therapy and First Aid 131132

Following both ECHM Consensus Conferences, and after extensive presentations by leading international experts, the two International Juries formulated Recommendations that have since been adopted in Europe as the current standards for the treatment of DI in Europe. These are:

• On-site 100% oxygen first aid treatment

• On-site fluid administration

• Therapeutic recompression must be initiated as soon as possible

• "Low pressure (2.8 ata) oxygen treatment tables" are recommended as the treatment tables of choice, with

• High pressure oxygen/inert gas mixture tables used in selected and/or refractory cases. Deep, mixed gas or saturation diving require special treatment protocols.

Adjunctive pharmacological treatment remain controversial but:

• I.V. fluid therapy is recommended

• The use of steroids and anticoagulants is considered optional

• Recompression and rehabilitation is recommended until no further significant improvement is observed.

Other relevant recommendations which emerged from the ECHM Consensus Conferences included the following: General

• Implementing diving medical / fitness standards respectively for recreational and commercial diving

• Implementing a appropriate classification system for Decompression Accidents

• Implementing a coordinated network for the collection and the retrospective analysis of data concerning decompression accidents.

• Improving recreational diving safety standards towards achieving the same safety record attained in commercial diving, with special regard to:

• availability of oxygen on every dive site

• availability of a recompression chamber within 4 hours

• preparation of an emergency plan before any dive

• training in the recognition of signs and symptoms of decompression accidents.

First Aid

One hundred percent oxygen should be administered immediately to all diving casualties; it is the single most important first aid treatment for surface-oriented diving. Appropriate rehydration is an important adjunctive first aid measure. First aid measures should not delay or defer definitive treatment.

Fluid Replacement / Resuscitation

Diving activity usually results in some level of dehydration due to immersion diuresis, increased respiratory fluid loss, perspiration and reduced fluid intake. In addition, DI causes hemoconcentration due to capillary leakage and inflammation. Identifying and treating dehydration is an important component in the treatment of DI. The degree of dehydration should be evaluated on site (from history, dive conditions, thirst, clinical evaluation of neurological conditions, hemodynamics, temperature, vasoconstriction, dryness of mucosa, urinary output) and at the hospital (from urinary output - beware of urinary retention with spinal DI, hemodynamics including CVP, hematocrit, plasma proteins and electrolytes). Recommended Hydration Protocols are: On Site:

• Oral hydration: recommended only if the patient is fully conscious. Absolute contra-indications to oral re-hydration are:

o depressed level of consciousness or loss of airway control o nausea and vomiting o suspected illness or injury of the gastro-intestinal tract This should be done with non-carbonated, non-caffeinated, isotonic fluids or drinking water if this is all that is available. If the patient is hyperthermic, the liquid should be cooled. High glucose content is not recommended. The amount of fluid should be adapted to the patient's thirst and willingness to take them.

• Intravenous rehydration: preferred if a trained healthcare professional is available. Access should preferably be via 18 gauge catheter with Ringer's Lactate or Saline as the infusion fluid. Glucose containing solutions are not recommended. Colloids can be considered if large quantities of fluids are needed. Recommended colloids, in order of preference, are starch-containing solutions, gelatines, and haptene added dextranes.

In Hospital:

• intravenous rehydration is recommended

• urinary output, hemodynamics, CVP, standard laboratory tests should be performed.

Drug treatment

Normobaric Oxygen (Strongly recommended):

• The administration of normobaric oxygen allows for the treatment of hypoxemia and favors the elimination of inert gas bubbles.

• Oxygen should be administered with an oro-nasal mask with reservoir bag, at a minimal flow rate of 15 L.p.m., or CPAP mask and circuit, using either a free flow regulator or a demand valve, in such a way as to obtain a FiO2 close to 1.

• In case of respiratory distress, severe shock or coma, the patient should be intubated and ventilated with a FiO2 = 1 with settings to prevent pulmonary barotrauma. Normobaric oxygen should be continued until hyperbaric recompression is started (with a maximum of 6 hours when the FiO2 is 1).

Resuscitation Drugs and DVT Prophylaxis (Recommended).


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