advanced oxygen first aid...skills development (2.5 to 3 hours) the skills development portion of...

Advanced O

xygen First Aid

AdvancedOxygen First Aid

Student book / EN

1

DAN Advanced Oxygen first Aid for Scuba Diving Injuries

Editor: Guy ThomasAuthors: John Lippmann. Guy Thomas,

Contributors: Chris Young EMT, Dan Orr, M.S., Yoshiro Mano M.D., Frans Cronjé M.D., Alessandro Marroni M.D., Eric Douglas

Cover Layout: Andrew WestPhotos: Guy Thomas

© 2012 Divers Alert Network

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmit-ted, in any form or by any means, electronic mechanical, photocopying or otherwise, without prior written

permission of Divers Alert Network, P.O. Box DAN, 64026 Roseto, Italy.

First Edition published May 2002Second, updated Edition published July 2007

Third Edition published May 2011

Divers Alert Network Contact Information

DAN Southern AfricaPrivate Bag X197, Halfway House, 1685

DAN Building, Rosen Office ParkCnr Invicta & Third RoadsHalway Gardens, Midrand

Tel: +27 11 266 4900Fax: +27 11 312 0054

Website: www.dansa.orgEmail: [email protected]

DAN Advanced Oxygen first Aid for Scuba Diving Injuries2

Table of Contents

DAN Training would like to thank those individuals who, through their tireless efforts and dedication, have made the development of these training programmes a reality. Their actions make a difference in dive safety

DAN ADvANceD OxygeN first AiD fOr scubA DiviNg iNjuries 3

Course Overview 3Knowledge Development (1 hour) 3Skills Development (2.5 to 3 hours) 4Assessment and Certification 4Prerequisites 4Learning Objectives 5

1. Recognition of Injuries 7Heart Attack 7Asthma 8Severe Haemorrhage 8CO Poisoning 9Dangers and Precautions related to Oxygen Use 9

Review Questions 10

2. Advanced Resuscitation with Oxygen 12The use of Advanced Oxygen resuscitation devices 12

Regurgitation 13Early exhaustion of the oxygen supply 14

Review Questions 15

3. Manually Triggered Ventilator - Oxygen Resuscitation Valves 16

Manually Triggered Ventilators and Oxygen Resuscitators 16

Advantages 16Disadvantages 17

Using an MTV 19Preparation of the oxygen supply 19Breathing injured divers 19Non-breathing injured divers 20Cleaning and disinfecting the unit after every use 21

Review Questions 25

4. Bag Valve Masks (BVM) 28The Bag-Valve-Mask Resuscitator 28Description and Function of a Typical BVM Device 32

Ventilation Bag 32Patient Valve Assembly - Patient Connector Port 32Oxygen Reservoir Bag 33Reservoir Valve Assemble and Bag 33Special features 34

Using The Bag-Valve-Mask Device 35Preparation of the oxygen supply 35Pre-use tests for the BVM unit 35Breathing injured divers 36Non-breathing injured divers 37Disassembly, cleaning and disinfection 39

Review Questions 42

5. Advanced Oxygen Provider Skills Development 44

Skills Overview 44Scene Safety Assessment 44Initial Assessment with Basic Life Support 47Providing Care with an AED 50Oxygen Provider Skill Review 51Resuscitation with an MTV 52Resuscitation with a BVM 54

Divers Alert Network 56

Review Questions: Answers 57

Advanced Oxygen Course Evaluation 59

DAN Advanced Oxygen first Aid for Scuba Diving Injuries 3


DAN Advanced Oxygen First Aid for Scuba Diving Injuries

Course OverviewThe DAN Advanced Oxygen First Aid for Scuba Diving Injuries provider ("DAN Advanced Oxygen Provider") programme is designed to teach you the skills and knowledge needed to supplement Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) skills with resuscita-tion techniques to assist any diver who is not breathing. The course is divided into two parts: The use of the Manually Triggered Ventilator (MTV, also known as Resuscitation valve) and the use of the Bag Valve Mask (BVM).

According to local laws and regulations, providers will be trained in the use of the MTV only or in the use of both MTV and BVM.

Knowledge Development (1 hour)The Knowledge Development portion of this course is designed to pro-vide information that will allow you to:• List the instructions for providing oxygen to non-breathing injured

scuba divers• Outline the circumstances for using the MTV and/or the Bag Valve Mask.• List the directions for ventilations with the MTV and/or Bag Valve Mask.• List the potential problems associated with the use of the MTV and/or

Bag Valve Mask.• List the considerations for effective ventilations with the MTV and/or

Bag Valve Mask.• Explain the steps to follow for cleaning, disinfecting and maintenance

of the MTV and/or Bag Valve Mask.

You will attend a lecture provided by your DAN Advanced Oxygen Instructor. This lecture supports the information presented in this handbook. The handbook supplies information in a simple, easy-to-understand manner. At the end of each section, review questions are provided to help you assess your comprehension of the material previ-ously covered.


Skills Development (2.5 to 3 hours)The skills development portion of the course will give you an opportunity to use advanced “first aid” skills, and, under the guidance of a DAN Advanced Oxygen Instructor, to resusci-tate a non-breathing injured diver. This hands-on part of the course is designed to have you apply what you have learned in the knowledge development part of this course and any previously learned CPR/BLS skills.

Assessment and CertificationUpon completion of the DAN Advanced Oxygen Provider course, you will receive a DAN Advanced Oxygen Provider Card indicating that you have been trained to provide first aid to non-breathing divers, using the MTV or Bag Valve Mask (according to local laws). As you progress through the course, you will demonstrate mastery of the knowledge and skills necessary to correctly provide first aid using the MTV and /or Bag Valve mask.

PrerequisitesThe key to successfully beginning the chain of survival is Basic Life Sup-port or Cardiopulmonary Resuscitation (CPR). You will need to show proof of having completed CPR training from a recognised training association.

As this course also relies heavily on the knowledge learned in the Oxy-gen Provider course, you will also need to show proof of a DAN Oxygen Provider license.


Fig. 1: The use of the

MTV 100

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Learning ObjectivesAt the end of this programme, you will:1. List the instructions for providing oxygen to non-breathing injured

scuba divers.2. State the ideal concentrations of oxygen and the factors that can

influence them. 3. Inspect the MTV and/or Bag Valve Mask 4. Outline the circumstances for using the MTV and/or the Bag Valve

Mask.5. List the directions for ventilations with the MTV and/or Bag Valve

Mask.6. List the potential problems associated with the use of the MTV

and/or Bag Valve Mask.7. List the considerations for effective ventilations with the MTV and/

or Bag Valve Mask.8. Describe the characteristics of an effective ventilation using the

MTV and/or Bag Valve Mask9. Explain the steps to follow for cleaning, disinfecting and mainte-

nance of the MTV and/or Bag Valve Mask.10. Disassemble and reassemble the MTV and/or Bag Valve Mask.11. Demonstrate the correct technique for testing the MTV and/or the

Bag Valve Mask prior to using it.12. Use the MTV and/or Bag Valve Mask to resuscitate non-breathing

divers (during training this will be done on a mannequin)13. Use the MTV to provide oxygen to breathing divers.



The nature and scope of this course is limited to training Oxygen Provid-ers to provide first aid, using the MTV and/or the BVM for non-breathing injured divers. This course does not provide complete training for CPR.

This manual is intended of use in conjunction with the DAN Advanced Oxy-gen Provider course and should be taught by a DAN instructor qualified to teach this course. It cannot be used as a substitute for other manuals.


Fig. 2: The use of the BVM

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Section 1 | Recognition of Injuries

Recognition of Injuries

Oxygen administration helps to reduce any hypoxia by increasing the transport of oxygen to the blood through the surfaces of the lungs.

As a DAN Oxygen Provider, you should be able to recognise the signs and symptoms of the main diving accidents so you can identify them as soon as possible, and provide the appropriate first-aid, including oxy-gen administration with the minimum possible delay.

In the following sections, we shall discuss the recognition and manage-ment of some of the more serious problems that are not related to div-ing, but might be of interest for the Advanced Oxygen Provider .

Heart Attacks

Signs and symptoms:

The signs and symptoms can include: severe pain in the centre of the chest (Fig. 3) that can radiate to the arms and jaws, indigestion, nausea, paleness, perspiration, anxiety, difficulty breathing, loss of conscious-ness and absence of respiration and pulse.

First Aid :1. Send for medical assistance.2. Monitor the airways, breathing and pulse:

resuscitate if necessary. An unconscious but breathing injured diver should be posi-tioned on their side.

3. If the injured diver is conscious, allow him/her to assume a comfortable position.

4. Loosen any tight clothing and reassure the injured diver.

5. Administer additional oxygen (using a sys-tem with minimal breathing resistance such as a non-rebreather mask or a constant flow system).

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Asthma

Signs and symptoms:

Signs and symptoms can include: dyspnoea, breathing dif-ficulty, shortness of breath, difficulty speaking, cyanosis, loss of consciousness and others. (Fig. 4)

First aid

Reassure the injured person and allow them to assume a comfortable position (usually sitting).• Help the injured person to take their prescribed medica-

tion (if available). Encourage them to take 4-6 sprays of bronchodilator.

• If the condition does not improve, an ambulance should be called and the injured person should take another 4-6 sprays of medication.

Severe HaemorrhageA serious loss of blood can lead to a reduced distribution of oxygen to the vital organs (shock). The haemorrhage should be controlled immediately by exerting direct pressure on the injury, and raising the injured part if possible.

Oxygen administration can help to reduce hypoxia and prevent or mini-mise the damage caused by reduced circulation.

Note: Administer additional oxygen (using a system with minimal breathing resistance – such as a non-rebreather mask or a constant flow system).

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CO poisoningCarbon monoxide (CO) poisoning is usually caused by bad combustion or ventilation of certain types of heating installations.

Especially in wintertime, when people start using the heating again, these accidents can occur. During CO poisoning, carbon monoxide mol-ecules take the place of the Oxygen molecules in the haemoglobin and cause hypoxia.

Oxygen administration is the perfect first aid measure, and treatment in a hyperbaric chamber is usually necessary. CO poisoning is also possible during diving due to a contamination of the breathing gas.

Dangers and Precautions related to Oxygen UseSafe and effective use of oxygen equipment requires specific knowl-edge and skills that can initially be attained through proper training. However, regular practise is necessary in order to maintain the skills acquired during training, and retraining is necessary in order to main-tain the abilities acquired.

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Review answers are on page 57


Section 1REVIEW QUESTIONSWrite your answer in the space provided.

1. Which answer is not correct? 100% of oxygen should be delivered to a person who has signs or symptoms of:a. Decompression Illnessb. Near drowningc. Asthmad. Heart attacke. Severe haemmorrhagef. Nitrogen Narcosis

2. Oxygen administration helps to reduce any _________ by increasing the transport of oxygen to the blood through the surfaces of the lungs.a. Hyperoxia b. Blood loss c. Hypoxia d. Pain

3. You should administer oxygen using a system with minimal breathing resistance for an injured diver suffering from:a. Heart attack b. DCI c. Asthmad. Both A and C are correct

Section 1 | Review Questions

24/7 DIVING MEDICAL HOTLINEINTERNATIONAL DIVING INSURANCELEGAL ASSISTANCEMEDICAL ASSISTANCERESEARCHFIRST AID COURSES

INSURANCE COVERS• Policies specific to diving activities, through the best

insurance companies, valid world-wide and without any excess fee.

• Immediate activation of the insurance cover and an optional possibility of receiving the relevant documents within 24/48 hours.

• Assistance in and handling of the required formalities in the event of an accident.

DOCUMENTS AND OTHER PERSONAL BENEFITS

• Membership card with personal data and the telephone numbers to call in case of emergency

• International Insurance certificate• Subscription to the multi-lingual International Alert Diver

containing updates on diving medicine and safety in diving.• Catalogue of first aid goods, books, slides, videos etc. at

special prices reserved for members.• Useful gadgets and miscellaneous stickers.

ASSISTANCE• 24 hour a day diving medical assistance, provided by

world famous specialists.• Organisation of transport to the hyperbaric centre,

therapeutic support and, if necessary, medically assisted repatriation.

• Advice and answers to questions on diving medicine and saftey.

• Travel assistance following any injury or unexpected illness through the DAN Travel Assist service.

• Travel assistance for family members.

EDUCATIONAL ACTIVITIES• The possibility to participate in research programs.• Information on statistical data from the data banks

of International DAN through specific publications• Courses and update seminars in first aid

specifically designed for divers.

www.dansa.org

24/7 DIVING MEDICAL HOTLINEINTERNATIONAL DIVING INSURANCELEGAL ASSISTANCEMEDICAL ASSISTANCERESEARCHFIRST AID COURSES

INSURANCE COVERS• Policies specific to diving activities, through the best

insurance companies, valid world-wide and without any excess fee.

• Immediate activation of the insurance cover and an optional possibility of receiving the relevant documents within 24/48 hours.

• Assistance in and handling of the required formalities in the event of an accident.

DOCUMENTS AND OTHER PERSONAL BENEFITS

• Membership card with personal data and the telephone numbers to call in case of emergency

• International Insurance certificate• Subscription to the multi-lingual International Alert Diver

containing updates on diving medicine and safety in diving.• Catalogue of first aid goods, books, slides, videos etc. at

special prices reserved for members.• Useful gadgets and miscellaneous stickers.

ASSISTANCE• 24 hour a day diving medical assistance, provided by

world famous specialists.• Organisation of transport to the hyperbaric centre,

therapeutic support and, if necessary, medically assisted repatriation.

• Advice and answers to questions on diving medicine and saftey.

• Travel assistance following any injury or unexpected illness through the DAN Travel Assist service.

• Travel assistance for family members.

EDUCATIONAL ACTIVITIES• The possibility to participate in research programs.• Information on statistical data from the data banks

of International DAN through specific publications• Courses and update seminars in first aid

specifically designed for divers.

www.dansa.org


Section 2 | Advanced Resuscitation with Oxygen

2.1

Advanced Resuscitation with Oxygen

The use of Advanced Oxygen resuscitation devicesAs you know from the BLS, AED or Oxygen provider course, a non-breathing person should be resuscitated as soon as possible. While chest compressions take care of the circulation, ventilations are taking care of providing the necessary oxygen to the lungs. Hypoxia (a low oxygen level) is one of the main concerns during resuscitation. The higher the oxygen concentration that can be delivered to the lungs of a non breathing person, the more effective becomes the resuscitation.

When using these advanced resuscitation devices, the oxygen per-centage delivered to a non-breathing person increases from 16 per-cent (during mouth-to mouth) or from 50 percent (when using a resuscitation mask with supplemental oxygen) to almost 100%, pro-vided that a perfect seal is obtained with the mask.

While obtaining a seal is relatively simple during mouth-to-mouth or mouth-to-mask, it becomes a bit more complicated when using the MTV o BVM.

These devices can be used by one rescuer only. However, many stud-ies have clearly shown that the technique applied by a single res-cuer in general produces very poor ventilations.

DAN recommends that when using an MTV or BVM, it should be used by a minimum of two rescu-ers. The first rescuer should take care of managing the airways and the mask seal while the second takes care of ventilations.

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Fig. 5: Manually Triggered

Ventilator - MTV

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Fig. 6: Bag Valve Mask - BVM



RegurgitationRegurgitation happens when air or oxygen enters the stomach dur-ing resuscitation. This increases the pressure in the stomach and this increased pressure pushes out the content of the stomach. It is similar to vomiting, but during vomiting the muscles are what forcefully push out these contents (using muscular spasms). During regurgitation the contents of the stomach flow out of the mouth of the injured person gradually (not forcefully).

Vomiting indicates that the muscles are receiving a certain amount of oxygen. Therefore it can be a positive sign if the non-breathing per-son vomits during resuscitation since it is a sign that he is beginning to breathe again. Regurgitation, however, is not positive at all and should be avoided.

If vomiting or regurgitation occurs during rescue breathing, the injured person should be quickly turned over to one side and the airway cleaned. In the case of vomit, immediately check whether the injured person is breathing again.

It is very important to clean the airway in order to prevent the contents of the stomach from entering into the airway or the lungs, as this can result in serious consequences.

When does regurgitation happen?

At the level of the diaphragm there is a sphincter that separates the oesophagus from the stomach. In an adult, pressure of more than approximately 15/20 cm H2O causes this muscle to open and allow air to enter the stomach.

Although it can happen during mouth-to-mouth and mouth-to-mask as well, there is an increased possibility of regurgitation during resuscita-tion with advanced resuscitation devices, particularly if the airway is not sufficiently open, if the rescuer ventilates excessively or did not receive sufficient training in the use of the advanced resuscitation materials.

To avoid regurgitation, the rescuer should:1. Ensure that the airway is clean 2. Open the airway well by tilting the head as well as raising the jaw. 3. Blow slowly and gently



4. Ventilate just enough to make the chest rise slowly. 5. Stop blowing as soon as the chest rises. 6. Allow the chest to fall completely between breaths.7. Avoid increasing the pressure on the stomach

Early exhaustion of the oxygen supplyIdeally, an injured diver should breathe high concentrations of oxygen from the moment he/she is rescued until specialised medical assistance is available. If the supply of oxygen runs out prematurely the injured diver’s condition could worsen.

Some respirators, such as the positive pressure type, cannot function without an oxygen supply. Even though the BVM device can be used to ventilate a non-breathing injured diver using air (21% oxygen), this is not the best option.

Note: Vomit and regurgitation are extremely common during resuscitation and with injured divers of near-drowning. Although it can happen as a result of poor resuscitation technique, it can also happen if this is not the case.

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Section 2REVIEW QUESTIONS

1. True or False: When vomiting or regurgitation occurs, it is very important to turn the injured diver on his side to prevent the contents of the stomach from entering into the airway or the lungs.

2. Which answer is not correct? To reduce the risk of the stomach swelling again and regurgitation, the rescuer should:a. ensure that the airway is cleanb. open the airway well by tilting the head as well as raising the jawc. blow slowly and gentlyd. ventilate just enough to make the chest rise slowly.e. allow the chest to fall completely between breaths. f. increase the pressure on the stomach



Section 3 | Manually Triggered Ventilator - Oxygen Resuscitation Valve

3.1

This section of the training manually is designed to provide potential users of oxygen resuscitator valves with impor-tant information regarding the design, functionality, practical use and mainte-nance of the unit.

Manually Triggered Ventilators and Oxygen Resuscitators

Advantages

Manually Triggered Ventilators (MTV for short), also referred to as Oxy-gen Resuscitation valves or Flow Restricted Oxygen Powered Ventila-tors. It allows the user to start or stop the oxygen, immediately at the touch of a button.

This control allows the provider to resuscitate an injured diver in respi-ratory arrest to be resuscitated using 100% oxygen. In addition, most of these devices incorporate a demand valve that can provide concentra-tions of oxygen up to 100% to breathing injured divers.

Manually Triggered Ventilator - Oxygen Resuscitation Valve

Warning: Because of the potential dangers associated with oxygen administra-tion, it should only be administered by divers trained in its use. The potential users of the Manually Triggered Ventilator (MTV) should ensure that they are adequately trained in its use. Neither the author of this manual nor DAN can guarantee that the informa-tion, the practice and the procedures presented in this manual can guar-antee appropriate or adequate treat-ment.

Fig. 8: Flow-restricted oxygen-

powered resuscitator

Fig. 7: Oxygen flow by

activating a button

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Advantages of using the MTV are:

• The delivery of higher oxygen concentra-tions (compaired to mouth -to-mask breath-ing with supplemental oxygen)

• It is less tiring for the rescuer administering it. • The high concentration of oxygen available

compensates for any losses that arise from a poorly masked seal.

An MTV can distribute a flow greater than 100 lpm to a breathing injured diver, an amount

that is significantly more than that which is required to satisfy the breathing requirements of an individual. It can allow oxygen to be distributed at 100% (provided that a perfect mask seal is obtained).

If the MTV is used for a non-breathing injured diver, the flow rate is automatically reduced to 40 litres per minute, thereby reducing the risk of introducing gas into the stomach and regurgitation. In order to correct some of the problems that could occur using the first/older devices, modern MTVs are designed to terminate either the flow or the pressure if excessive pressure is detected in the airways. In addition, a redundant valve was added for use in the event that the first one failed.

Disadvantages

There are some potential problems associated with older models of oxygen powered ventilators:• When the resuscitation button is pressed completely, some

older models can distribute flows exceeding 160 lpm. Previ-ously it was thought that this amount was necessary to venti-late an injured diver. However, such a high flow rate can very easily cause expansion of the stomach, which can lead to regur-gitation, and the aspiration of the contents of the stomach. Moreover, a high flow rate could potentially damage the lungs. The most recent recommendations are that a lower flow rate should be used in order to reduce these complications.

• Some units terminate the flow but do not allow the pressure to be released, which could impede the injured diver’s exhala-tion. When used on an adult, the safety valve should prevent pulmonary injuries, but might not prevent the distension of the stomach (which normally occurs when the oesophagus

Fig. 9: Function as a

demand valve

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Fig. 10: Safety valve

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pressure is greater than 15/20 cm H2O). To prevent the outward pressure from exceeding the expected limits, a safety valve was inserted in most of the modern positive pressure resuscitators. The oxygen flow terminates when this valve detects mounting pressure of greater than approximately 40-60cm H2O (depending from the manufacturer).

• Some devices can stop distributing gas prematurely without alert-ing the operator. This can happen above all when the lungs of the injured diver present resistance or when there is a poor response from the lungs, as can happen when ventilating an asthma suff-erer or an injured diver who has experienced a submersion acci-dent. Some MTVs signal an acoustic alarm that alerts the operator of excessive levels of pressure in the airways. If the device does not signal an acoustic alarm, the operator may not become aware of the resistance during resuscitation and therefore an obstruction in the airway or an over-expansion of the lungs may not be detected.

When manually Triggered Ventilators and resuscitators are compared to other ventilation techniques, some disadvantages become appar-ent. The first and most important is that they rely on the supply of oxy-gen, and thus when this is exhausted they can no longer be used.

Note: Devices that allow high flow rates can easily cause the swelling of the stom-ach and regurgitation, particularly if used by inexperienced individuals. More importantly, if the safety valve does not function perfectly or if the ventilator is used on a small diver, it can result in lung injury.



3.2Using an MTV

Preparation of the oxygen supply• Ensure that the area is well ventilated and that nothing is burning

in the immediate vicinity. • Open the Oxygen unit and take out the required equipment.

• Ensure that your hands, the fittings and the multifunction regu-lator (with the adapter if required), are clean and free of all traces of oil or fat.

• Holding the pressure gauge away from those present, open the cylinder slowly and pressurise the regulator.

• Check that there are no leaks and that the pressure gauge remains stable. If there is a leak, prevent it.

• Check the gauge to determine how much oxygen is available.

Breathing injured diversAn MTV can provide 100% oxygen to a breathing injured diver. How-ever, the diver should be breathing normally. An injured diver who is breathing too rapidly or weakly can have difficulty using an MTV, and should be resuscitated with additional oxygen using a continuous flow valve with minimal breathing resistance.• Reassure the injured diver and explain what you are doing.• Position the injured diver suitably. An unconscious, breathing

injured diver should be positioned on their side. • Attach the mask directly onto the MTV and inhale from it to check

that it is functioning correctly.• Position the mask carefully over the mouth and nose of the injured

diver checking that there is a good seal and that the valve functions correctly.

• Ask the injured diver to breathe normally. If the MTV does not acti-vate ask the injured diver to breathe a little more deeply.

• If the injured diver experiences too much difficulty using the MTV, change to a continuous flow system such as a non-rebreather mask, an ordinary mask or a pocket mask.



• Monitor the injured diver’s condition attentively and never leave him/her unobserved.

• Check the oxygen supply carefully and remove the mask before the supply is exhausted.

Non-breathing injured diversHow to ventilate a non-breathing injured diver using an MTV (tech-nique for two rescuers):

1. The first rescuer starts the ventilations / BLS using an oro-nasal resuscitation mask while the second rescuer pre-pares the oxygen equipment.

2. Check the safety valve to ensure that it functions perfectly (rescuer 2). Block the oxygen outlet with your hand and press the resuscitation button. (Fig. 11) The oxygen flow should stop and the gas should be released.

3. Connect the mask to the MTV adapter.4. Position the mask over the mouth and nose of the injured

diver, while making sure to seal it well (rescuer 1).5. Support the airway. It is often useful and more effective

to position yourself behind the head of the injured diver and open the airway by lifting the jaw.

The first rescuer should take care of managing the airways and the mask seal while the second takes care of ventilations.

1. Ventilate the injured diver (rescuer 2) (Fig. 12) by pressing the button carefully, observing the chest and releasing the but-ton relatively quickly. Ventilate enough to see the rise of the (lower) chest and the (upper) abdomen. Release the resuscita-tion button as soon as the chest begins to rise. Each ventilation should take about 1 second.

2. Watch the expansion of the stomach to avoid regurgita-tion. Placing one hand gently on the centre of the (lower) chest can help to assess that a ventilation is adequate and not excessive.

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3. Continue to ventilate the injured diver with the appropriate flow and volume (as a part of CPR). (Fig. 13)

4. Monitor the supply of oxygen attentively and be prepared to resume rescue breathing if the supply is exhausted.

5. Check the injured diver’s colour and monitor signs of cir-culation.

6. Never leave the injured diver alone.

Cleaning and disinfecting the unit after every useCleaning and disinfecting procedures may vary depending from the kind of MTV used. Refer to the owners manual for the specific cleaning guidelines for the MTV which you use. Below you will find the most common procedures.

Important:

All disinfection procedures should be carried out in an area free of hydrocarbon residue because of the danger of combustion when these are exposed to oxygen.

1. Remove the outlet adapter and the exhalation valve assembly from the body of the MTV. Do not remove the hose.

2. Clean all foreign matter from the outlet adapter and the exhala-tion valve assembly with a mild soap solution, being careful not to get any liquid inside the MTV’s subassembly. It can be effective to carefully clean it using a soft brush. Rinse the parts thoroughly in clean water.

3. Rinse outlet end of the MTV’s body assembly parts thoroughly in clean water.

Important: An MTV should only be used by operators who are properly trained and certified. Ventilating a non-breathing injured diver requires two rescuers. This device should not be used to ventilate children.

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4. Examine all parts and replace those that appear cracked or damaged.

5. Disinfect the body of the MTV and compo-nents by cold disinfecting.

Cold Disinfection1. Immerse the outlet adapter and the exhalation valve assembly

from the MTV in a disinfectant solution according to the disinfect-ant manufacturer’s instructions.

2. The MTV body assembly can be flushed with water and disinfect-ant. Afterwards rinse with sterile water.Important: Do not immerse the body of the MTV completely in any liquid.

3. Remove the outlet adapter and the exhalation valve assembly out of the disinfectant solution and rinse with sterile water. Rinse repeatedly to ensure that all the disinfectant solution is completely rinsed away.

4. Connect the MTV body assembly to the oxygen supply. Open the valve and depress the manual control button several times to blow out any water that might have entered.

5. Check the exhalation valve assembly to ensure that the flapper valve is not twisted and that the location bosses are correctly posi-tioned (see below).

Fig. 14:

1. The body

2. The exhalation valve assembly

3. Outlet adapter

If the flapper valve (Fig. 15) is twisted or the locating bosses are not properly positioned, the MTV will not function properly.

Ensure that the flapper valve lies flat against the seat. (Fig. 16)

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15 16

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6. Reassemble all of the parts and test that the unit functions. Some manufacturers have a special test kit available in order to perform this test.

Testing the UnitThe MTV should be periodically tested to ensure that it functions per-fectly. The test should be conducted every time the unit is dissembled and cleaned and at least every 3 months if the unit has not been used.

Initial Test

1. Connect the MTV to the DAN multifunctional regulator.2. Open the cylinder valve slowly. 3. Depress the manual control button. The oxygen should start to

flow. Release the button. The flow should stop immediately. 4. If the MTV continues to flow oxygen, or if there is a leak it should

be repaired, and the unit should NOT be used on an injured diver. Send the MTV to an authorised repair centre.

Positive Pressure Test

Some manufacturers (like Life Support Products) have a special test kit available for performing the following test:

1. After performing the initial test (described above), insert the outlet of the MTV into the open tee fitting on the test lung assembly

2. Slowly depress the manual control button. The gauge reading should reach 44-48mm Hg (60-65cm H2O, depending from manu-facturer), then immediately drop to zero.

3. If the MTV valve tests out of limits, do NOT use on any injured diver. Return it to an authorised repair facility.

In order to obtain accurate test results, the test lung should be free of cracks, holes or tears.



Storage and Maintenance• Ensure that the cylinder is full, with a closed valve and that the reg-

ulator is depressurised before being put away.• Keep the equipment clean, dry and in a safe place. Never allow oil,

fats or other inflammable substances to come in contact with it. • Store it in a ventilated place, far way from sources of heat and com-

bustible materials.• Check that the unit functions correctly and check the contents

of the bottle regularly to guarantee that it will operate. How fre-quently it needs to be checked depends on the level of use, but should be carried out at least every 3 months.

• The oxygen unit should be inspected and serviced by a specialised technician at regular intervals. DAN recommends that the MTV should be sent to an authorised service centre every two years for a full service and to monitor whether the periodic checks have been conducted as indicated in the instructions accompanying the unit. However, if periodic testing is not performed, the MTV should be overhauled every year.

• Have the cylinders filled by qualified and authorised vendors. • The oxygen cylinders should be periodically inspected visually and

hydrostatically. Ensure that the cylinders are approved and con-form to the regulations in force.

• Always keep replacement washers available as part of the equipment.

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1. An MTV can only be used to provide oxygen to non-breathing divers:a. True b. False

2. When using an MTV to ventilate non-breathing divers, the duration of the ventilation should last:a. until the stomach risesb. until the chest rises c. cover 2 secondsd. doesn’t matter

3. Before using the MTV on non-breathing divers, you should:a. Connect the MTV to the constant flow outletb. Check the safety valvec. Perform 2 minutes of mouth-to-mask rescue breathingd. Prime the reservoir bag

4. When using the MTV on a non-breathing diver, the first rescuer should _______________ while the second takes care of ventilationsa. take care of managing the airways and the mask seal b perform CPR c. prepare the oxygen unitd. perform mouth-to-mask rescue breathing




26

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5. True or False? You should release the resuscitation button as soon as the chest begins to risea. True b. False

6. You should ____________ to avoid vomiting.a. ventilate less than 0,5 secondb. watch the expansion of the stomachc. increase the pressure on the stomach




Section 4 | Bag Valve Mask (BVM)

Bag Valve Mask (BVM)This training manual is designed to provide potential users of the Bag-Valve-Mask (BVM) resuscitation unit with important information regarding its design, function, practical application and maintenance.

The Bag-Valve-Mask ResuscitatorA Bag-Valve-Mask ventilator (Fig. 17) can be used with a mask that has a seal, or an advanced device (for example, an endotracheal tube). The Bag-Valve-Mask (BVM) consists of a self-inflating bag connected, by means of a mechanism with several one-way valves, to a mask with a seal. When the bag is compressed, the air (oxygen) is directed into the injured diver’s lungs from a one-way valve.

Several models of the Bag-Valve-Mask are available on the market. Among the distributors are Allied, Laerdal, Ambu and Draeger.

These devices are intended for ventilating non-breathing injured divers in situations where physical contact is not desired. Since they ven-tilate with air, some devices provide oxygen at concen-trations of 21%, an amount that is more than the 16-17% present in expired air. Some of these, however, incorpo-rate a connection that can be attached to an additional supply of oxygen in order to increase the concentration of the gas. Some of these units can provide more than 73% oxygen at a flow of 10 lpm. The amount can increase to 95-97% oxygen at a flow of

15 lpm (without using the reserve bag). However, these concentrations are difficult to achieve in practise.

Warning: Because of the potential hazards asso-ciated with oxygen administration, it must not be administered by persons those not spe-cifically trained in its use.The potential users of the Bag-Valve-Mask should ensure that they are properly trained to use it. Neither the author of this manual nor DAN assert that the practise and procedures set out in this manual guarantee appropriate or adequate treatment.Bag-mask ventilation is a complex technique that requires considerable skill and practice. Such a skill is difficult to maintain when prac-ticed infrequently.

17

4.1



The bag and the mask are available in sizes suitable for adults, children and infants. Most adult masks have a volume of 1600 ml. A system for an adult should never be used on a child since the bag can over-expand the lungs of a child. As well as having a smaller bag, some systems for children include a system for preventing over-expansion of the lungs.

The current models of the Bag-Valve-Mask incorpo-rate either a connection for oxygen, or a reserve bag (or tube) which is usually connected to the base of the resuscitation bag. Oxygen passes into both of them every time the reservoir is compressed. When the bag is released, it is refilled again as a result of the reserve bag and also because of atmospheric air until it is full.

By increasing the supply of oxygen, a higher concentra-tion of oxygen goes into the reserve bag. This means that a small quantity of atmospheric air enters into the bag when it is released.

For efficient oxygenation during ventilation, the bag should receive oxygen in amounts equal to or greater than the ventilations per minute of the injured diver. This means that, if a injured diver requires a litre for each breath, 15 times a minute, a flow of 1x15= 15lpm will be necessary. In addition, the reservoir should have a volume equal to or greater than the compressible bag. In short, it should be more than the maximum ventilatory capacity of the injured diver (for example the volume of gas required for each breath).

The units that have a reserve bag can provide concentrations of 95 to 100% at a flow that varies between 10 to 15 lpm.

However, when measured in actual fact, it rarely exceeds 95%. The con-centrations of oxygen are substantially reduced if the mask seal is not airtight (a common occurrence), or if the injured diver is of large stature and/or hyperventilating. For example, with a good mask seal and a flow of 10lpm, Laerdal specifies that its device with a reservoir can distribute oxygen at concentrations of 100% to a person with a lung capacity of 750 ml with a breathing rate of 12 breaths per minute.

However, for a person that has a lung capacity of 1 litre and breathes at a rate of 24 breaths a minute, it can distribute oxygen at concentrations of 53%.

If you want to maximise the concentrations of oxygen, and the gas sup-

Fig. 18: Connection for oxygen

and reserve bag

18



ply is limited, the best way to save oxygen is to regulate the flow so that the reservoir is neither filled nor emptied completely during ventilations.

The Bag-Valve-Mask unit can be used on breathing injured persons as well as on non-breathing injured persons.

To ventilate a non-breathing injured diver, the rescuer should first check that the airways are clear, while ensuring that the mask is sealed well on the face. It can be difficult for a sole rescuer to successfully adhere the mask to the face, maintaining the diver's head tilted back, while simutaneously using the other hand to com-press the bag. The injured diver’s mouth sometimes stays partially closed beneath the mask requiring a high flow of gas to counterbalance nasal obstruction. Leaks are dif-ficult to prevent and the bag might not have sufficient volume to compensate for this.

The problem of potential leaks can be minimised by reg-ular practise and a good knowledge of the various tech-niques, such as using the knees to keep the head tilted. Some brands of BVM have an extensible tube that allows the bag to be compressed between the pulse and the chest so that one hand can be kept free. However, despite these techniques and aids, many studies have clearly shown that when the technique is applied by a sole rescuer, even one who is highly trained and conducting the procedure per-fectly, the ventilations produced are generally poor.

Futhermore, when a good seal is obtained on the injured diver’s face, there is the risk that the bag-valve unit can produce so much pressure that it expands the stomach and causes damage to the lungs.

Despite these potential problems, the bag-valve can, in certain circum-stances, be very effective if used by a properly trained rescuer.

Note: It is recommended that when using the bag-valve unit, it should be used by a minimum of two trained rescuers in order to guarantee the ventilation of a non-breathing injured diver. One manages the airway and the keeps the mask sealed securely, while the other compresses the bag.

Fig. 19: The technique

applied by a single rescuer produces

very poor ventilations

19



To maximise bag-valve performance, the first rescuer should be behind the injured diver's head, and assure that the injured diver's airway is open. The second rescuer will slowly squeeze the bag, until the chest rises. (Fig. 20)

Because of the difficulties of operating on a child and also because of the increased risk of over-expansion of lungs and/or or swelling the stomach, the first

rescuer should avoid applying the bag-valve on a non-breathing child unless a resuscitation device of the correct size is available.

However, if properly positioned and equipped with a mask of the appropriate size, many devices can be effectively used to administer oxygen to a breathing child.

Some bag-valve devices can be connected on a demand or refill valve. With this system, the bag fills with 100% oxygen from the refill valve.

Note: • Resuscitation bag-valve devices should only be used by certified and

properly trained rescuers.

• Ventilating a non-breathing injured diver usually requires two trained rescuers.

• Continued practise as well as annual retraining is necessary in order to main-tain the requisite level of competence. These apparatuses should not be used by rescuers for ventilating a child.

20



4.2 Description and Function of a Typical BVM DeviceAlthough different models of BVM have differing design details or char-acteristics, the operating principles are the same. You should become familiar with the model you use.

Ventilation BagThis bag (Fig. 21) is designed to re-inflate after it is compressed. It refills with air through a suction valve at the end of the bag. The suction valve func-tions also as a non-return valve, preventing the gas from escaping from the bottom of the bag and forc-ing it out at the neck of the bag.

Patient Valve Assembly - Patient Connector Port Depending from the manufacturer, this assembly con-tains one or two one-way valves. The first is the "lip valve" which opens when the gas exits from the ventilation bag, and closes when the gas goes in the opposite direction. This allows the gas contained in the ventilation bag to be directed towards the injured diver and prevents the expi-red gas from re-entering the bag.

The expired gas is directed from the assembly through a separate membrane or through the lip valve, which rises

to allow the gas to be disper-sed. This membrane also pre-vents the air from returning to the injured diver when he/she is breathing, so that only the gas from the bag is breathed.

Fig. 22: Deflector

Fig. 23: Particular of the

membrane

Fig. 24:Lip valve

22

23

24

21



Oxygen Reservoir BagThe majority of BVM devices have a reserve bag of some type. The reserve bag is designed to collect the oxygen during the expiration cycle so that it is available for the inspiration cycle.

The BVM should include a system for preventing excess of pressure in the system and/or in the reserve bag caused by the introduction of unused gas. Some systems have slits in the reserve bag that open under pressure and allow excess gas to escape. Other devices, use an outlet valve or a membrane.

In addition, the BVM requires an inlet that allows a certain amount of air to re-enter when the reserve bag is used if there is insufficient gas to allow the ventilation bag to refill.

The best way to conserve oxygen is to ensure that the reserve bag is not allowed to empty or refill completely during ventilation cycles.

Reservoir Valve Assemble and BagThe reserve bag valve component of BVM unit’s includes two mem-brane valves. The outlet valve only opens when the reserve bag is too full and the gas has to be expelled. The inlet valve only opens when there is not enough oxygen in the reserve bag to allow the ventilation bag to refill. Some of the oxygen flow that enters from the port will open the valve that is positioned at the end of the ventilation bag and will enter into the bag. The rest of the oxygen will be collected and stored in the reserve bag.

If the reserve bag stays flat during the ventilation cycle more oxgen will not be available.

The best way to conserve oxygen is to ensure that reservoir bag is not allowed to empty or fill completely during the ventilation cycles.

26 27

Fig. 26: Reservoir Valve Assembler

Fig. 27: Valve and Oxygen Enrichment Port

Fig. 28:The reserve bag is designed to collect the oxygen during the expiration cycle

28

25

Fig. 25: Oxygen

Reservoir Bag



Special features

Pressure Relief Valve – Flow Restrictor

Some BVMs incorporate a pressure relief valve or flow restriction valve (like for example the SMART BAG® from O-Two Medical Technologies). (Fig. 29)

These BVMs offer accurate controlled ventilation that signifi-cantly reduces the risk of gastric insufflations (regurgitation).

The valve (Fig. 30) will be activated at a certain pressure, avoiding the airway pressure from getting to high and gas from entering the stomach.

Airway Pressure Manometer

Also this device is used to avoid gastric insufflations and regurgi-tation. Thanks to a small pressure gauge attached to the side of the Patient Valve Assembly, the rescuer is able to monitor the airway pressure. Airway pressures greater then 15-20 cm H2O will force gas into the stomach.

Not all BVM models can be attached to the Airway Pressure Manometer. This optional manometer is available for models such as the “Disposable Bag Mask Resuscitator” from Allied Healthcare Products. (Fig. 31)

Oxygen Refill Valve BVM

Not all types of BVM have an Oxygen Reservoir bag. Some types have a special Patient Valve Assemble to which an oxygen refill valve (similar to a demand valve) or a professional “Oxygen Enrichement Assembly” can be connected. In this case the BVM is only open at the top side and the oxygen enters the Ventilation Bag directly (through the back of the Patient Valve Assembly).

When using this type of BVM there is no need to set a flow rate or attach any oxygen tubing at the bottom of the BVM.

An Oxygen Refill Valve (demand valve) (Fig 32) can also be connected

29

30

31

32



4.3

to some models of “constant flow” BVMs. In this case, however, the constant flow inlet should be sealed to avoid air from entering the BVM through this opening.

Using The Bag-Valve-Mask Device

Preparation of the oxygen supply• Ensure that the area is well ventilated and that nothing is burning

in the immediate vicinity.• Open the oxygen unit and take out the required equipment• Ensure that your hands, the fittings and the regulator (and the

adapter if required) are clean and free of all traces of oil.• Hold the pressure gauge away from those present.• Open the cylinder and pressurise the regulator.• Check that there are no leaks and that the needle of the pressure

gauge remains stable.• Check the gauge to determine the amount of oxygen available.

Pre-use tests for the BVM unit

Check that the valves function:

1. Press and release ventilation bag (Fig. 33) and listen for gas being expelled from the patient valve assembly while observing the lip valve. Quick bag re-expansion confirms efficient air intake

2. Block the outlet of the patient valve assembly and compress the ventilation bag. (Fig. 34) It should stay inflated and no gas should escape.

3. Eliminate any leaks or malfunctions.4. If a pressure relief valve is used, block the outlet of the

BVM and compress the bag several times. If a flow restriction valve is used, squeeze the bag forcefully without blocking the outlet. Visual observation of the activation of the valve verifies proper function.

33

34



i. Connect the reserve bag valve (if present) (Fig. 35) and/or the reserve bag to the ventila-tion bag. Compress the ventilation bag and check that the reserve bag empties correctly. Stop any leaks.

ii. Ensure that the oxygen tube or demand valve is connected properly to the inlet port of the BVM and the outlet port of the regulator.

iii. Choose the appropriate sized mask and connect it to the patient valve assembly.

iv. Set up the correct flow rate: In the case of a diver suspected of having DCI, a flow rate of 15 lpm should be used.

v. Check that the reserve bag refills with oxygen.vi. Once the oxygen is on, it is recommended to squeeze the

Ventilation Bag a few times to increase the initial oxygen concentration in this ventilation bag.

Breathing injured divers1. Check that the injured diver is breathing.2. Position the injured diver correctly. It is recommended that an

unconscious breathing injured diver is positioned on his side.3. Conduct the pre-use tests for the BVM (if not already completed). 4. Reassure the injured diver and explain what you are doing. 5. Position the mask over the mouth and nose with the firm part at

the top, ensuring that a proper mask-to-face seal. If the injured diver is conscious, ask them to hold the mask in place if necessary.

6. Ask the injured diver to breathe normally. 7. Monitor the injured diver’s condition carefully, checking the air-

ways, breathing, pulse and colour, and react accordingly.8. If necessary, regulate the flow so that the reserve bag does not

deflate or remain completely full. 9. Monitor the oxygen supply carefully and remove the mask before

the supply begins to run out. 10. Never leave the injured diver alone.

35



Non-breathing injured diversVentilating a non-breathing injured diver using the BVM usually requires two rescuers. The first begins the mouth to mask ventilations as soon as possible and continues until the oxygen equipment is prepared by the second rescuer. Then the first operator ensures that the airways are kept clear and keeps the mask sealed while the second compresses the bag and operates the oxygen equipment.

The ventilations should be slow and gentle and should last about 1 sec-ond (enough to cause the upper abdomen and lower chest to rise) in the ventilation phase, allowing the chest to fall completely before each ventilation.

When the equipment is ready, the rescuers should:

1. Position the mask over the mouth and nose (rescuer 1), ensuring that it is sealed properly.

2. Support the injured diver’s jaw and tilt the head backwards. It is usually more effective to position yourself behind the injured div-er’s head and open the airways by raising the jaw.

3. Ventilate the injured diver (rescuer 2) with enough rhythm and speed and energetically enough to cause the lower chest and upper abdomen to rise. The breaths should be slow and gentle, and should last for about 1 second for the ven-tilation phase. Allow the chest to fall completely before each new ventilation.

4. Watch the stomach for signs of expansion and to prevent regurgitation.

Fig. 36: A bag valve mask

is best used by two rescuers working

together

36



5. Check the injured diver carefully, and react accordingly. (Fig. 37)

6. Check the supply of oxygen. This is essential when using the BVM with a bag that has a refill valve as it should be immediately disconnected if the supply of oxygen runs out or if the resuscitation bag does not re-fill.

7. Never leave the injured diver alone.

Warning: The Bag-Valve-Mask resuscitator should only be used by properly trained oper-ators who are well practised and trained in the techniques. Ventilating a non-breathing injured diver normally requires two rescuers. First aid rescuers should not use this device for ventilating children.

37



4.4Disassembly, cleaning and disinfectionIt is important to clean and disinfect the re-usable BVM after use.

Most manufacturers recommend that the reusable device may be disinfected by any of these methods: Boiling, disinfecting solution or autoclaving.

The following are some general recommendations that can be used for the majority of devices. However, you should follow the specific guide-lines for the device, as indicated in the instruction manual.

• Put the used parts aside and dispose of them. • Disassemble the appropriate parts. This will always include the

mask and the tolerance valve, since the injured diver’s expiration passes through these parts. It can also include the resuscitation bag (with all the valves) and the reservoir valve (if present).

• Rinse these components with cold running water.• Wash the parts in hot water using a detergent suitable for the mate-

rials that are used in the device. It can be useful to gently rub the parts using a soft brush.

• Rinse the parts with cold clean water.• Dry all the parts thoroughly. • Immerse them in the recommended sterilisation solution for the

recommended / required length of time. • Rinse the parts.• Dry them thoroughly.• Inspect each part carefully before reassembly. • Test the unit after reassembling it to make sure that it functions

correctly.



Tests to conduct after cleaningAfter the unit is cleaned and reassembled, it should be checked to ensure that it functions correctly. The valves should be checked thor-oughly to make sure that they function.

The procedure for testing the Laerdal BVM Laerdal is indicated below. These procedures can be used for many similar devices.

1. Inlet valve: Press the ventilation bag with one hand while lightly closing the neck with the other the other, allowing the air to exit.

Hold the neck of the bag, sealing it with one hand before letting it refill. The bag should re-inflate quickly, indicating thus that enough air is entering.

Then seal the neck of the bag with one hand, while compressing the bag with the other. The bag should not show variations, indi-cating that the valve closes against the flow.

2. Patient Valve Assembly: Squeeze the ventilation bag while observing the lip valve in the patient valve assembly. This lip valve should open when squeezing the bag and close against the flow when the bag refills. This indicates that the lip valve prevents the expired gas from re-entering into the resuscitation bag.

3. Oxygen Port: When the patient valve assembly is in place, use one hand to block the inlet valve at the base of the resuscitation bag and compress the bag. This should be slowly refilled through the oxygen port indicating that the port is free of obstructions.

4. Reserve bag Valve: Fill the reserve bag with oxygen. Close the outlet of the patient valve assembly and compress the reserve bag gently. Verify that the excess gas exits from the one way valve in the reserve bag valve assembly.Compress the ventilation bag several times, without oxygen flow to the oxygen inlet. If the bag refills rapidly, despite an empty res-ervoir bag, it confirms that the inlet membrane of the reservoir valve functions correctly.



Storage and Maintenance• Ensure that the cylinder is full, with a closed valve and

that the regulator is depressurised before putting it away.

• Store the equipment clean, dry and in a safe place. Never allow oil, fats or other inflammable substances to come in contact with it.

• Store in a ventilated area, far away from sources of heat or combustible materials.

• Check the contents of the cylinder and the test that the device functions regularly to make sure that it operates correctly. The frequency of the tests will depend on how often it is used, but should be conducted at least every three months.

• The oxygen unit should be inspected and serviced by a specialised technician at regular intervals.

• Ensure that the cylinder is refilled only by qualified and authorised vendors.

• The cylinders should be inspected visually and hydro-statically at least every 10 years. Ensure that the cylin-der is approved.

• Replacement parts should be kept with the equipment.

Fig. 38: DAN Oxygen Unit is a self-

contained kit that has all the necessary equipment to provide

first aid for both breathing and non-breathing injured divers.

38

42

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1. A Bag Valve Mask:a. Should be used by one rescuerb. Should be use by 2 rescuers. The first performs chest compressions

while the second operates the resuscitation system.c. Should be used by 2 rescuers. The first manages the airway and hold

the mask in place while the second operates the resuscitation device.

2. Which answer is not correct? Prior to ventilate non-breathing injured diver’s you should:

a. Check the function of the resuscitation deviceb. Assess the airway.c. Assess breathing.d. None of the above

3. When providing Oxygen with a resuscitation device, the duration of the ventilation should last about 1 second until the chest rises.a. True b. False



43

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4. When resuscitating an injured diver you should:a.Allow the chest to fall completely before each new ventilation.b. Watch the stomach for signs of over-expansion and to prevent

vomitingc. Check the injured diver’s colour and look for signs of circulationd. All of the above

5. Select one of the following which is not true:a. Oxygen should be used in well ventilated areasb. You should clean the masks after each usec. Skills learned in this course should never been refreshed and peri-

odic retraining is not recommended d. You should use barriers (mask and glove) to prevent the risk of dis-

ease transmission



Section 5 | Advanced Oxygen Provider - Skills Development

Advanced Oxygen Provider Skills Development

Skills Overview:1. Scene Safety Assessment2. Initial Assessment with Basic Life Support3. Providing Care with an AED (optional)4. Oxygen Provider Skill Review5. Resuscitation with an MTV6. Resuscitation with a BVM



5.1 Scene Safety Assessment

Follow these steps to perform Scene Safety Assessment

Remember S-A-F-E

S Stop

• Stop• Think• Act

A Assess Scene

• Is the scene safe?• Is it safe to approach the injured diver?• Are there any environmental hazards present?• Do other divers need to be recalled?• Any other hazards present?• Are there stinging tentacles still on the diver?

F Find and Locate First Aid kit (and Oxygen and AED Unit)

• First Aid Kits contain critical supplies such as barriers.

E Exposure Protection

– Body Substance Isolation

• Use barriers such as gloves and mouth-to-mask barrier devices.

REMEMBER• Be SAFE.

• SAVE yourself first

• Use barrier devices

AVOID• Rushing to help without

assessing the scene

• Contact with blood and other body fluids

Fig. 39 - 40: Take your time to

think and assess the scene to make

sure your safety as a rescuer is assured.

39

40



5.2 Initial Assessment with Basic Life Support

41 42

Fig. 42: Head tilt – chin lift

Fig. 41: Assess responsiveness

1. Make sure you, the injured person and any bystanders are safe

2. Check the injured person for a response • State your name, training and desire to help.• Ask permission to help.• Gently shake the injured person’s shoulders and ask loudly: “are

you all right?” (Fig. 41)

3a. If he responds:• Leave him in the position in which you find him provided there is

no further danger• Try to find out what is wrong with him and get help if needed• Reassess him regularly

3b. If he does not respond:• Shout for help.• Turn the injured person on his back and then open the airway

using head tilt and chin lift (Fig. 42):• Place your hand on his forehead and gently tilt his head back • With your fingertips under the point of the injured person’s

chin, lift the chin to open the airway.



43

Fig. 43: Assess breathing

4. Keeping the airway open, look, listen and feel for breathing (Fig. 43)• Look for the chest movement.• Listen at the injured person’s mouth for

breath sounds.• Feel for air on your cheek.• Decide if breathing is normal, not normal

or absent.

In the first minutes after cardiac arrest, an injured person may be barely breathing, or taking infre-quent, noisy gasps. Do not confuse this with normal breathing. Look, listen and feel for no more than 10 seconds to determine whether the injured person is breathing normally. If you have any doubt whether breathing is normal, treat the situation as you would for abnormal breathing.

5a. If he is breathing normally:• Turn him into the recovery position• Send or go for help / call an ambulance• Continue to assess that breathing remains normal

5b. If the breathing is not normal or absent:• Send someone for help and to find and bring an AED if available;

or, if you are on your own, use your mobile phone to alert the ambulance service - leave the injured person when there is no other option

• Start chest compressions as follows:• Kneel by the side of the injured person;• Place one heel of one hand in the centre of the chest (which is

the lower half of the injured person’s breastbone (sternum);• Place the heel of your other hand on top of the first hand:• Interlock the fingers of your hands and ensure that pressure

is not applied over the injured person’s ribs. Keep your arms straight, Do not apply pressure over the upper abdomen or the bottom end of the sternum ;

• Position yourself vertically above the chest and press down on the sternum at least 5cm (but not exceeding 6cm);

• After each compression, release all the pressure on the chest



without loosing contact between your hands and the sternum; repeat a rate of at least 100/minute (but not exceeding 120/minute).

• Compression and release should take equal amounts of time.

6a. Combine chest compressions with rescue breaths.• After 30 compressions open the airway again using the head tilt

and chin lift• Use an oronasal resuscitation mask (Fig. 44) or pinch the soft part

of the nose closed, using the index finger and thumb of your hand of the forehead .

• Allow the mouth to open, but maintain chin lift• Take a normal breath and place your lips on the inlet of the

oronasal resuscitation mask, or around his mouth, making sure that you have a good seal.

• Blow steadily in to the mask / mouth while watching the chest to rise, taking about 1 second as in normal breathing; this is an effective rescue breath (Fig. 45).

• Maintaining head tilt and chin lift, take your mouth away from the injured person and watch for the chest to fall as air comes out.

• Take another normal breath and blow into the person’s mouth (or in the mask), to achieve a total of 2 effective rescue breaths. The two breaths should not take more than 5 seconds in all. Then return your hands without delay to the correct position on the sternum and give another 30 compressions

• Continue CPR in a ratio of 30:2• Stop to recheck the injured person only if he

starts to wake up: to move, open eyes and to breath normally. Otherwise do not interrupt resuscitation.

• If your initial rescue breath do not make the chest rise as in normal breathing, then before your next attempt:• Check the injured person’s mouth and remove

any obstruction.

44

45

Fig. 45: Rescue breathing

Fig. 44: The use of a

resuscitation mask



• Recheck that there is adequate head tilt and chin lift• Do not attempt more than 2 breaths each time before

returning to chest compressions• If there is more than one rescuer present, another rescuer should

take over delivering CPR every 2 minutes to prevent fatigue. Ensure that interruption of chest compressions is minimal during the changeover of rescuers.

6b. Chest-compression-only CPR may be used as follows:• If you are not trained, or are unwilling to give rescue breaths,

give chest compressions only• If chest compressions are given, these should be continuous, at a

rate of at least 100/minute (but not exceeding 120/minute)

7. Do not interrupt resuscitation until:• Professional help arrives and takes over; or• The injured person start to wake up: to move, opens eyes and

to breathe normally; or• You become exhausted

Note:For victims of drowning: Give 5 initial rescue breaths before starting chest compressions and perform 1 minute of CPR before getting help



5.3 Providing Care with an AED (optional)

This course does not qualify you in the use of an Automated External Defibrillator (AED). Special Training is required! These steps should not be performed if not trained. Your AED Instruc-tor can show you this skill as an introduction to the AED.

Remember S-A-F-E

Unresponsive.• Shout for help

Not breathing normally.• Send or go for AED and call EMS• CPR 30:2 until AED is attached• Attach the defibrillator pads to the patient and AED.• Allow the AED to analyse heart rhythm.• Don't touch the patient.

If shock required: Follow the AED unit's prompts.• Visually and physically clear the patient.• State “I’m clear. You’re clear. All clear.”• Administer shock. (Fig. 48)• Resume CPR 30:2 for 2 minutes• Continue as directed by the voice/visual prompts

If no shock required:• Continue CPR 30:2 until the injured person starts to wake

up: to move, open eyes and to breathe normally• Continue as directed by the voice/visual prompts

Note: While AEDs can be used in an aquatic environment, you must dry the chest off before placing the pads. The AED pads should be placed on the injured person's chest according to the diagrams on the pads and then the first aid provider should follow the unit's prompts.

48

47

46

Fig. 46: Switch on the AED

Fig. 47: Place the defibrillator pads on the person

Fig. 48: Deliver the shock



5.4 Oxygen Provider Skill Review

Review the previous learned DAN Oxygen Provider skills in order to provide Oxygen to injured divers.

Oxygen first aid should be provided to injured divers as soon as equip-ment becomes available.

• If diver is breathing, provide oxygen using: – Demand inhalator valve (or MTV) with oronasal mask; or – Non-rebreather mask with a minimum 15 lpm of oxygen flow

• If diver is not breathing, set up oxygen unit, attach oxygen tubing to oronasal resuscitation mask and set flow rate to 15 lpm. Con-tinue rescue breathing.

Note that the MTV can be used instead of a normal demand valve when administering oxygen to a breathing injured diver.

Fig. 49: Make sure you

have a good seal

Fig. 50: Correct mask

placement

Fig. 51: Placement of the Non-Rebreather

mask

49 50 51



Follow these steps to resuscitate a non-breathing injured diver using an MTV.

Although an MTV can be used by one rescuer only, DAN recommends that the MTV is used by two trained rescuers when ventilating a non-breathing injured diver .

The first rescuer should take care of managing the airways and the mask seal while the second takes care of the oxygen unit and the ventilations.

1. The first rescuer starts the ventilations (as a part of BLS) using an oronasal resuscitation mask pocket mask or something similar while the sec-ond diver prepares the oxygen equipment.

2. Check the safety valve (rescuer 2) to ensure that it functions perfectly. Block the oxygen outlet with your hand and press the resuscitation but-ton. The oxygen flow should stop and the gas should be released.

3. Connect the mask to the MTV adapter.4. Position the mask over the mouth and nose of the

injured person, while making sure to seal it well.5. Support the jaw and tilt the head backwards. It is

often useful and more effective to position res-cuer 1 behind the head of the injured diver and open the airway by lifting the jaw.

6. Ventilate the injured diver (rescuer 2) by press-ing the button carefully, observing the chest and releasing the button relatively quickly. Ventilate enough to see the rise of the (lower) chest and the (upper) abdomen. Release the resuscitation button as soon as the chest begins to rise. Each ventilation should take about 1 second.

5.5 Resuscitation with a Manually Triggered Ventilator

52

53

Fig. 52: Press the resuscitation

button, and then block the oxygen outlet of the MTV-100 with your hand

Fig. 53: Position the mask over the mouth and nose of

the injured diver



7. Watch the expansion of the stomach to avoid regurgitation. Placing one hand gently on the centre of the (lower) chest can help to assess that a ventilation is adequate and not excessive.

8. Continue to ventilate the injured diver with the appropriate flow and volume.

9. Monitor the supply of oxygen attentively and be prepared to recommence mouth-to-mask rescue breathing should the supply run out.

10. Check the injured diver’s colour and check for signs of circula-tion, and react accordingly.

54

Fig. 54: Ventilate the injured

diver by pressing the resuscitation button

carefully



Follow these steps to resuscitate a non-breathing injured diver using a BVM.

Although an BVM can be used by one rescuer only, DAN recommends that the BVM is used by two trained rescuers when ventilating a non-breathing injured diver .

The first rescuer should take care of managing the airways and the mask seal while the second takes care of ventilations.

1. The first rescuer starts the ventilations (as a part of BLS) using an oronasal resuscitation mask while the second diver prepares the oxygen equipment.

Rescuer 2: BVM operator2. Connect the reserve bag valve (if present),

patient valve assembly and/or the reserve bag to the ventilation bag. (Fig. 55)

3. Check that the oxygen supply is connected and/or set a flow when the BVM is attached to the constant flow outlet.

i. Attach the oxygen tubing to the constant flow inlet at the bottom of the BVM (con-stant flow version) – Flow needs to be set to 15 lpm.

ii. Attach the Refill or Demand Valve at the Patient Valve Assembly when using a “non constant flow” version. (Fig. 56)

iii. Press and release ventilation bag and lis-ten for gas being expelled from the patient valve assembly while observing the lip valve. Quick bag re-expansion confirms efficient air intake. (Fig. 57)

• Check if the reserve bag empties/fills correctly.

5.6 Resuscitation with a Bag Valve Mask

55

56

57



iv. Block the outlet of the patient valve assembly and compress the Ventilation bag. It should stay inflated and no gas should escape. (Fig. 58)

v. If a pressure relief valve is used, block the outlet of the BVM and compress the bag several times. If a flow restriction valve is used, squeeze the bag force-fully without blocking the outlet. Visual observation of the activation of the valve verifies proper function.

4. Attach the mask to the patient valve assembly5. Squeeze the Ventilation Bag a few times to increase the

oxygen concentration. (Fig. 59)6. Position the mask over the mouth and nose, ensuring

that it is sealed properly.7. Position rescuer 1 behind the injured diver and have him

support the jaw and tilt the head backwards (open air-way).

8. Rescuer 2 should position himself at the side of the non breathing person

9. Ventilate the injured person with enough rhythm and speed and energetically enough to cause the lower chest and upper abdomen to rise. The ventilation should be effective, and should last for about 1 second. Allow the chest to fall completely before each new ventilation.

10. Watch the stomach for signs of expansion and to prevent regurgitation.

• Placing one hand gently on the centre of the (lower) chest can help to assess that a ventilation is adequate and not excessive and check the injured div-er’s pulse and colour carefully, and react accordingly.

11. Check the supply of oxygen.12. This is essential when using the BVM with a bag that has a refill valve as it

should be immediately disconnected if the supply of oxygen runs out or if the resuscitation bag does not re-fill.

58

59


Founded in 1980, DAN is an interna-tional, non-profit dive safety organisa-tion, committed to improving diving safety and to conducting dive research.

IDAN (International DAN) with its head-quarters in the USA and affiliates in Southeast Asia-Pacific, Japan, Southern Africa and Europe can assist you in the unlikely event of a scuba diving acci-dent or injury.

DAN also consults with the emergency medical professionals who continue care after your initial first aid.

If you suspect you've been injured while scuba diving, you can call the DAN Div-ing Emergency Hotline. DAN provides this service to the diving community 24 hours a day, 365 days a year to assist and help arrange for evaluation and treat-ment of injured divers. Whenever you need help, DAN is there for you.

DAN also works to prevent diving inju-ries and accidents. If you have a ques-tion concerning diving medicine, dive safety, fitness for diving or for a referral to a physician knowledgeable in diving medicine, you can call the DAN Dive Safety and Medical Information Line.

DAN also conducts research on scuba diving such as the DAN Diving Safety Laboratory and looking into how flying after diving and various environmental and physiological conditions may affect diver health.

Another way DAN improves dive safety

is through training and education. DAN has developed an Automated External Defibrillator programme, oxygen first aid programmes and related oxygen delivery equipment to promote the ben-efits of emergency oxygen first aid for injured divers. DAN also offers training programmes for physicians and emer-gency medical services personnel.

DAN provides these valuable services to the entire dive community because of the support of the world's largest asso-ciation of recreational divers, the DAN membership. For an annual fee, DAN members receive many valuable ben-efits including dive accident insurance, Alert Diver, diving's leading safety maga-zine; DAN Travel Assist, access to poten-tial evacuation in a medical emergency when you travel, and others.

DAN is Your Dive Safety Association!

Divers Alert Network


Review Questions: Answers

Section 1:

1. F2. C3. D

Section 2:

1. True2. F

Section 3:

1. B2. B3. B4. A5. A6. B

Section 4:

1. C2. D3. A4. D5. C

Automated External Defibrillation course (AED)

Sudden Cardiac Arrest is responsible for thousands of deaths each year.Providing CPR delays the inevitable by helping to oxygenate blood and keep it circulating throughout the body. CPR cannot reset the heart rhythm and start it beating again; only defibrillation can.

Every minute defibrillation is delayed, the chance of survival drops by 7 to 10 percent.

The DAN AED course teaches you how to provide care with an AED, making your role as rescuer crucial in the chain of survival.This four hour course could mean the difference between life or death.

Ask your instructor how to become a DAN AED Provider, or visit our website at www.dansa.org

Automated External Defibrillation course (AED)


Advanced Oxygen course evaluation

Congratulations on completing your DAN Advanced Oxygen Provider Course!To help us improve this programme, please complete and return this questionnaire.

Safe Diving!

Sincerely,Guy ThomasDAN Europe Director of TrainingStrongly Agree: 5Agree: 4Neutral: 3Disagree: 2Strongly Disagree: 1

1. The course met my expectations. 5 4 3 2 12. The course was taught in a relaxed, positive manner. 5 4 3 2 13. The course was fun. 5 4 3 2 14. The instructor clearly understood the material. 5 4 3 2 15. I feel confident in providing care with a BVM/MTV. 5 4 3 2 16. Did you learn and practise these skills? 5 4 3 2 1

Scene Safety Assessment Yes / No / UnsureInitial Assessment with BLS Yes / No / UnsureProviding care with an AED Yes / No / UnsureOxygen Provider Review Yes / No / UnsureResuscitation with an MTV Yes / No / UnsureResuscitation with a BVM Yes / No / Unsure

7. How many hours was your course? ________________8. Course Date: ________________________9. Overall quality of the course ___________________ (1 Low – 10 High)

10. Instructor’s name: __________________________________________11. Your name (optional): _______________________________________12. Comments or suggestions: ________________________________________

__________________________________________________________________________________________________________________

Please copy this form and return it to your DAN Instructor.

60

ReferencesAuerbach, P. Medical Guide to Hazardous Marine Life. Flagstaff: Best Publishing, 1996.Bennett, P. and D. Elliott. The Physiology and Medicine of Diving. 4th ed. London: W.B. Saunders, 1998.Dovenbarger, J., ed. DAN Report on Decompression Illness and Diving Fatalities. Durham, NC: Divers Alert Network, 1987-1998 annual.Edmunds, C. Dangerous Marine Creatures. Flagstaff, AZ: Best Publishing,1995.Edmunds, C., C. Lowry and J. Penne Father. Diving and Subaquatic Medicine. Bath, Avon, England, Butterworth-Heinemann, Ltd. 1992.Lippmann, J. and S. Bugg. The DAN Emergency Handbook. 3rd ed. Carnegie, Australia: J.L. Publications, Revised edition 1999.Orr, D. and B. Clendenen, DAN Pocket Guide for Hazardous Marine Life Injuries. Durham, NC: Divers Alert Network, 1999.Orr, D. and B. Clendenen, DAN Pocket Guide for Scuba Diving Injuries. Helena, MT: Greycliff Publishing Co., 1998.Thalmann, E.D. DAN Dive and Travel Medical Guide. Durham, NC: Divers Alert Network, 1999.Williamson, J., P. Fenner and J. Burnett eds. Venomous and Poisonous Marine Animals. Sydney, Australia: University of New South Wales Press, 1996.

First Aid GuidelinesNational Guidelines for First Aid Training in Occupational Setting, April 1998.

Resuscitation GuidelinesEuropean Resuscitation Council Guidelines for Resuscitation 2010

Divers Alert Network Contact Information

To become a DAN Member, visit our website: www.dansa.org


Notes:

advanced oxygen first aid...skills development (2.5 to 3 hours) the skills development portion of...

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