on site neurological assessment for divers · 4 dan on-site neurological assessment for divers...

On Site NeurologicalAssessment for Divers

On Site N

eurological Assessm

ent for Divers

Student book / EN

DAN On-Site Neurological Assessment for Divers 3

DAN On-Site Neurological Assessment for Divers

Principal Author: Eric Douglas, DMT Editors: Jeff Myers, Guy Thomas, EMT

Contributors: E. Wayne Massey, M.D., Richard Moon, M.D., Frans Cronjé, M.D., John Lippman, Alessandro Marroni, M.D.

Photos: Sarah Shoemaker LindIllustrations: Lisa Sparks

© 2011 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 European Edition published November, 2007Second European 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 On-Site Neurological Assessment for Divers4

Table of Contents

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

DAN ON-Site NeurOlOgicAl ASSeSSmeNt fOr DiverS 3

Course Overview 3Knowledge Development (1 hour) 3Skills Development (3 hours) 3Assessment and Certification 4Prerequisites 4Course Introduction 5

1. Review of Decompression Illness 7Arterial Gas Embolism 7Decompression Sickness 8Review Questions 10

2. The Purpose of an On-Site Neurological Assessment 11

Review Questions 12

3. The five areas evaluated as part of an On-Site Neurological Assessment 13

Mental Function 13Cranial Nerves 14Motor Function (Strength) 14Sensory Function 15Balance and Coordination 15Review Questions 16

4. On-Site Neuro Provider Skills Development 17

Skills Overview: 17Taking Vital Signs 20Mental Function 22Cranial Nerves 25Motor Function (Strength) 27Sensory Function 29Balance and Coordination 31

5. Summary 33

Divers Alert Network 34

Review Questions Answers 36

On-Site Neurological Assessment for Divers course evaluation 37




Course OverviewThe DAN On-Site Neurological Assessment for Divers course is an addi-tional training programme for those individuals who have successfully completed the DAN Oxygen First Aid for Scuba Diving Injuries course within the past two years (24 months). It is designed to train DAN Oxy-gen Providers to perform a basic neurological assessment on a poten-tially injured diver.

The information gained during this assessment will:1. Provide a reliable system to judge the urgency of a dive emergen-

cy, depending on the symptoms reported to them by the divers on the scene.

2. Demonstrate to an injured diver that there is a problem, if one ex-ists, that may help convince the injured diver of the need for first aid treatment such as oxygen first aid, aiding in the resolution of symptoms.

Knowledge Development (1 hour)The Knowledge Development portion of this course is designed to pro-vide information that will allow you to:• Refresh your knowledge of the warning signs of a dive emergency;• Identify when it is appropriate to conduct an on-site neurological

assessment;• Conduct an on-site neurological assessment.

Skills Development (3 hours)• Taking a History• Taking Vital Signs• Mental Status• Consciousness• Speech and Language

– Orientation to Time and Place – Judgment – Short-Term Memory


– Abstract Reasoning – Calculations

• Cranial Nerves – Eye Control – Facial Control – Facial Sensation – Hearing

• Motor Strength – Deltoids – Biceps – Triceps – Finger Spread – Grip Strength – Hip Flexors – Quadriceps – Hamstrings – Feet

• Sensory Function – Light Touch – Sharp Touch

• Balance and Coordination – Walking – Finger-Nose-Finger

Assessment and CertificationUpon completion of the DAN On-Site Neurological Assessment for Divers course, you will receive a DAN On Site Neurological Assessment for Divers Provider Card indicating that you have been trained to as-sess dive injuries and deliver that information to emergency medical personnel in the event of a dive emergency.

PrerequisitesCurrent status as a Provider in the DAN Oxygen or Advanced Oxygen First Aid for Scuba Diving Injuries course is required for participation in this programme.


Other DAN training programmes provide detailed information on first aid for injured divers. These include performing cardiopulmonary re-suscitation (CPR), using an automated external defibrillator and treat-ing hazardous marine life injuries.

While certification in these programmes is not required for participa-tion in the DAN On-Site Neurological Assessment for Divers course, it is strongly recommended that you obtain training in these essential lifesaving skills. These skills will also help improve your understanding of the dive emergency.

Course Introduction Approximately two-thirds of divers with decompression illness have evidence of damage to the nervous system. These signs are often vague and can go unrecognised by the diver. This can cause these signs to be dismissed as insignificant or not dive-related.

This programme focuses on how to obtain essential information about a diver involved in a dive emergency and what information to relay to emergency medical services.

Only medical professionals should diagnose medical conditions. The information you gather while performing a neurological assessment will be useful to help the dive physician: 1) understand the extent of the injury and 2) how it has changed in the time it took to get the diver from the dive site to definitive care.

The sections of the book include:• Review of Decompression Illness• The Purpose of an On-Site Neurological Assessment• The Five Areas Evaluated as Part of an On-Site Neurological Assess-

ment. including: – Mental Function – Cranial Nerves – Motor Function – Sensory Function – Balance and Coordination

• Taking a Dive History• How to Perform an On-Site Neurological Assessment

www.dansa.org

Wherever you are DAN is there

www.dansa.org


Section 1 | Review of Decompression Illness

1.1

Review of Decompression IllnessDecompression illness (DCI) is used to describe the signs and symp-toms of an injury caused by breathing compressed gas at depth. DCI encompasses both arterial gas embolism (AGE) and decompression sickness (DCS) injuries. For both AGE and DCS, first aid treatment is the same.

Arterial Gas EmbolismIn the case of AGE, also known as air embolism, air is trapped in the al-veoli (small air cells in the lungs) and expands during the diver’s ascent. As the ascent and subsequent air expansion progress, air may be forced through the thin alveolar lining directly into the bloodstream, with lit-tle or no physical damage to lung tissue.

Alternately, air expansion may cause the alveoli to rupture, introduc-ing air into either the bloodstream or into the surrounding tissues. Air introduced into the bloodstream returns to the heart; it may then go directly to the brain, causing rapid and dramatic symptoms.

• AGE often has rapid and dramatic symptom onset.

• Contributing factors may include rapid ascent, breath-holding, lung damage, lung congestion, asthma or other air-trapping mechanism.

• AGE may accompany other pulmonary barotrauma.

• AGE is the most serious result of a lung-expansion injury.

Fig.1: Arterial Gas Embolism

1



1.2 Decompression SicknessDecompression sickness (DCS) is the result of excess nitrogen absorbed into the tissues from the dive; this excess nitrogen can form into bubbles on ascent. The development of these nitrogen bubbles may cause direct tissue damage; or the bubbles may block the flow of oxygenated blood to tissues, in-cluding the spinal cord. Symptoms of DCS in divers often are described as vague; divers may ignore them until the symptoms get worse or persist.

• DCS usually has a delayed symptom onset.

• Contributing factors for bubble formation includes excess nitrogen, rapid ascent and decreasing pressure such as when flying after diving.

• Bubbles as a result of DCS cause various signs and symptoms based on their location in the body.

• Any area of the body may be involved.

Since first aid for DCI is the same, avoid trying to identify the type of injury (AGE or DCS). Instead, recognise the symptoms and provide oxygen.

Some of the most common warning signs of decompression illness are:

• Numbness and tingling• Pain• Headaches• Dizziness and vertigo• Nausea• Difficulty walking• Altered skin sensation• Weakness• Unusual fatigue

Fig. 2: Decompression Sickness

2



Other possible, although less common, warning signs include:• Rash and itching• Difficulty breathing• Visual disturbance• Restlessness• Paralysis• Unconsciousness• Personality change• Speech disturbance• Altered level of responsiveness• Bladder or bowel control problems• Hearing loss or ringing in the ears• Convulsions

This is by no means a comprehensive list of all the warning signs of de-compression illness. However, you can see that many of these injuries relate to the nervous system.

For more information about dive emergencies and how to provide first aid care for an injured diver, refer to the DAN Training programme Oxy-gen First Aid for Scuba Diving Injuries


Section 4 | On-Site Neuro Provider Skills Development

12

?

Review answers are on page 70

Section 1

REVIEW QUESTIONS

Remark: Some of the multiple choice questions in this manual can have more than one correct answer. Please check all correct answers.

1. Bubbles as a result of DCS cause various signs and symptoms based on their location in the body.a. True b. False

2. List five common signs or symptoms of decompression illness.a. _________________b. _________________c. _________________d. _________________e. _________________

3. It is important to identify if injured diver AGE or DCS to provide proper first aid techniques.a. True b. False

4. Many of warning signs of decompression illness relate to the nervous system.a. True b. False

Section 1 | Review Questions


Section 2 | The Purpose of an On-Site Neurological Assessment

The Purpose of an On-Site Neurological Assessment

When you are managing a dive-related injury, you should: 1. initiate basic life support procedures; 2. provide oxygen first aid; and 3. activate your emergency plan.

You can also record vital signs, such as pulse and respirations. If trained to do so, note blood pressure as well.

In the case of suspected decompression illness, you should perform a neurological assessment. The information you gather can help the dive physician decide the initial course of treatment and, ultimately, the outcome of that treatment. It can also help you, as the first aid pro-vider, determine whether it is necessary to deliver oxygen first aid, and to convince the injured diver of the necessity of that first aid. A neuro-logical assessment also helps a physician determine whether decom-pression illness is affecting the brain, spinal cord or nerves.

Performing an on-site neurological assessment should never inter-fere with providing essential first aid measures or the evacuation of a diver to professional medical care. However, as most diving inju-ries are not life-threatening, and as there is frequently a delay before emergency medical services arrive, it is both appropriate and helpful to the care of the diver to perform this examination

Fig. 3: Performing an on-site neurological assessment

3



14

?


Section 2

REVIEW QUESTIONS

1. You should perform neurological assessment if you suspect that the diver have DCI. a. True b. False

2. The On-Site Neurological Assessment for Divers can help to establish:a. if there are neurological signs of DCIb. proper treatment by physicianc. CNS toxicityd. is the O2 first aid necessary

3. When you are managing a dive-related injury, you should: a. initiate basic life support procedures b. provide oxygen first aidc. activate your emergency pland. never record vital signs



Section 3 | The five areas evaluated as part of an On-Site Neurological Assessment

3.1

The five areas evaluated as part of an On-Site

Neurological AssessmentAlthough there are multiple tests in the On-Site Neurological Assess-ment, five general areas of concern are evaluated. These include:• Mental Function• Cranial Nerves• Motor Function (Strength)• Sensory Function• Balance and Coordination

While it is impossible to divide the nervous system into independent parts, this artificial division allows the examiner to focus on functional units within the nervous system, and simplifies documentation of ab-normal findings. The actual tests for each of these areas will be detailed later in the section entitled Performing the On-Site Neurological As-sessment.

Mental FunctionIn the Mental Function portion of the exam, you will examine the diver’s level of con-sciousness. This entails determining wheth-er he knows where he is as well as knowing the date and time. You will also evaluate his memory, speech, arithmetic skills and his ability to comprehend language.

Many of these tests can be performed dur-ing your initial conversation with the diver. Fortunately, most injured divers exhibit nor-mal mental function.

Fig. 4: Table used to evaluate the Mental Function

4



3.3

3.2 Cranial NervesThere are 12 pairs of nerves emanating from the skull that control the various senses and muscles of the face such as the eyes, ears, mouth, tongue, throat and neck.

A series of simple tests allow you to evaluate if these nerves have been affected.

Motor Function (Strength)When examining the diver’s motor strength, remember that these symptoms usually present themselves in one of two ways: weakness or paralysis.

Such abnormalities can often be detected or confirmed by comparing one side of the body with the other. Decompression illness rarely affect both sides of the body simultaneously. When it does, the abnormality is usually obvious.

Any sign of weakness or paralysis, no matter how slight the abnormal-ity, should prompt you to seek immediate emergency medical assist-ance and professional medical evaluation.

Areas to be evaluated in the motor strength por-tion of the assessment in-clude the shoulder, biceps, triceps, hands, hips, legs and feet.

Fig. 5: Controling the senses and muscles of the face

5

Fig. 6: Evaluating strength

6



3.5

3.4Sensory FunctionThree of the more common warning signs of DCI are:• Pain, defined as perception without stimulus;• Numbness that can be confirmed during the examination; and• Tingling (a "pins-and-needles" feeling with a decrease in normal

sensation).

The sensory function portion of the exam attempts to define areas with altered sensitivity, using light touch and the touch of a sharp object.

Balance and CoordinationThe final section of the On-Site Neurological Exam evaluates the diver’s balance and coordination. You will evaluate the diver’s balance while walking. Coordination is evaluated using the finger-nose-finger test. This will be discussed in detail later

Fig. 7: Evaluating the sensory function

7

Fig. 8: Evaluating balance and coordination

8



18

?


Section 3

REVIEW QUESTIONS

1. Which areas are evaluated during neurological assessment:a. Mental Function d. Motor Function (strength) b. Balance and Coordination e. Sensory Functionc. Cranial Nerves

2. Mental Function portion of the exam, you will examine the diver’s level of consciousness.a. True b. False

3. Cranial Nerves control the various senses and muscles of the face such as: a. eyes d. mouth b. ears e. tongue c. throat f. neck

4. Symptoms of DCI referring to Motor Function usually present themselves in one of two ways:a. burning and skin rash c. headache and dizzinessb. weakness and paralysis d. bladder and bowel problems

5. The sensory function portion of the exam attempts to define areas with altered sensitivity, using both light touch and the touch of a sharp object.a. True b. False

6. You will evaluate the diver’s balance while _______. Coordination is evaluated using the ____-____-____ test. a. walking, head-finger-footb. walking, finger-nose-fingerc. standing on one leg, finger-nose-fingerd. standing on one leg, head-finger-foot




On-Site Neuro Provider Skills Development

Skills Overview:1. Taking a History2. Performing an On-Site Neurological Examination

a. Taking Vital Signsb. Mental Functionc. Cranial Nervesd. Motor Function (Strength)e. Sensory Functionf. Balance and Coordination



The most important step to performing an on-site neurological assess-ment understands exactly what happened and what medical condi-tions the diver had before making the dive. Without this, you’ll never be able to fully understand the dive injury itself.

It is extremely important to take a thorough history prior to perform-ing the examination portion of the assessment. By doing this, you might determine that there is a weakness in one arm or leg that is related to a previous injury rather than the dive.

If possible, you need to obtain and document a description of all dives for 48 hours before the injury. This information should include depths, times, ascent rates, surface intervals, breathing gases and any problems or symptoms. The On-Site Neurological Assessment for Divers slate includes an area to record your findings from the history-taking portion of the assessment.

4.1 Taking a History

9 10

Fig. 9 - 10: Taking a history



If the problem is restricted to pain, have the injured diver describe the pain. Is it sharp, dull or throbbing? Is it localized or hard to pinpoint? Does the pain sen-sation change when the diver moves the extremity, such as when he stands up?

The diver should also attempt to rate the pain on a scale of 0 to 10, with 10 being the worst imaginable.

You should document symptom onset times and their progression, along with a description of all first aid measures. This includes time span and the meth-od of 100 percent oxygen delivery. You should also document any effect the first aid treatment had on the symptoms.

As part of a thorough assessment, you will also want to discuss the possible dive injury with the diver’s buddy or with another observer who may be able to indicate what happened to cause the injury

Remember:denial is common with divers. The simple act of the diver volunteering that there may be a problem should cause you to examine the situation further.

Fig. 11: Have the diver rate the pain

11



A neurological exam involves questioning the injured diver, observ-ing responses, testing for reactions and having the diver perform basic movements. You should record your findings from each step of the ex-amination, and each successive examination, on the DAN On-Site Neu-rological Assessment for Divers slate.

You should perform an on-site neurological assessment only on a con-scious, breathing diver, and you should always ask permission prior to touching the diver or beginning to provide care. It is a good idea to have a third party present during the examination to help eliminate concerns over improper contact.

Taking Vital SignsTo begin the actual On-Site Neurological Assessment, you should es-tablish some basic vital signs.

You should also collect the diver’s pulse and respiration rates. Count both for 30 seconds and multiply by two.

PulseTo take a pulse, apply gentle pressure with two or three fingers along the thumb side of the diver’s arm, just inside the bone (called the radi-us), 6-7 cm up from the inside wrist. Do not use your thumb to find the pulse. This may take some practice and is a skill you should regularly practice.

4.2 Performing an On-Site Neurological Examination

Fig. 12: Taking a pulse

12

Fig. 13: Taking the blood pressure

13



RespirationsWhen counting respirations, do not let the diver know you are monitor-ing breathing, as people tend to become more self-conscious, focusing on their own breathing and may alter their breathing patterns. It may be helpful to have a bystander count respirations.

Normal pulse rates are between 60 and 80 beats per minute. Normal respiration rates are between 12 and 20 breaths a minute.

If you have been trained to do so, it is helpful to determine the injured diver’s blood pressure. For the purpose of this exam, you are concerned with the possibility of the diver going into shock. If you haven’t been trained to determine blood pressure, record whether the diver exhibits any of the warning signs of shock.

Several conditions can cause shock: internal or external bleeding, heart failure, neurological injury and system wide infection. Regardless of the cause, shock can lead to death if it is not treated promptly.

Signs of Shock include: • Uneasiness• Restlessness, worry or an aggressive manner• Shallow or gasping breathing• Accelerated heartbeat (more than 100 may indicate shock)• Weak pulse• Moist and cool skin• Heavy sweating• Pale or bluish tissue colour• Shivering• Intense thirst• Nausea• Vomiting

A drop in blood pressure happens very late in the progression of shock and indicates an extremely critical condition.

If the diver shows the signs of entering shock, immediately begin treat-ing the diver for shock and postpone the neurological assessment.



Treat for Shock• Open the airway.• Anticipate vomiting.• Provide oxygen.

– Assist with ventilation if the diver is not breathing.• Control external bleeding.• Maintain a normal body temperature. Keep the injured diver warm.• Elevate the feet if there is no indication of head trauma.• Don’t give drinks.

Mental FunctionBegin your mental function assessment by simply talking to the diver. You’ve already been doing this while taking the history and you can form an opinion on the diver’s men-tal status based on the responses to these basic questions. However, even though a diver appears alert, the answers to the fol-lowing questions may reveal confusion. Do not omit them.

Consciousness

Begin by recording if the diver is alert. If not, you will need to record if he:• Responds to verbal stimulus, such as

questions or shouts;• Responds to pain only, such as a sternal

rub; or• Is unresponsive.

If the diver is unresponsive, immediately check ABC and start basic life support.

Mark the diver’s level of consciousness on your slate using the acronym• A lert• V erbal stimulus• P ainful stimulus (Fig. 15)• U nresponsive

Fig. 14: Mental function assessment

14

Fig. 15: Checking level of consciousness

15



Speech and LanguageYour next step is to make a judgment call as to the diver’s use of speech and language. You’ll need to determine whether he can understand you and follow directions, as well as determining whether he can com-municate effectively with you.• Have the diver close his eyes and stick out his tongue (Fig. 16).• To test the diver’s ability to express himself, have him say a simple

phrase like "red, white and blue" or "no ifs, ands or buts." A thor-ough medical history is important when making judgments like this in order to understand if the diver had a speech impediment prior to the dive accident.

• Point out several objects around the examination area and have the diver tell you what three of these are. Ex-amples of objects to have identified include dive mask, pen, watch; or light, scuba cylinder, snorkel. Any eas-ily recognizable combination of three should suffice (Fig. 17).

• Have the diver read and interpret a sentence for you. For example: "The small boy walked to the lake with a large dog."

Orientation to a Person, Time and Place The next step is to ask the injured diver if he knows what time it is and what day it is. You can ask if the diver knows who he is and who you are:

►► Ask the diver where he is. Ask him if he knows what state or province he is in.

►► Also, ask the time, date and year.

16

17



JudgmentTo test the diver’s judgment, ask the diver if he knows what is happen-ing or why he is here. The diver should be able to explain that he was diving; or he should be able to identify that you are performing the exam because you are concerned about a dive injury.

Short-Term Memory Have him repeat back to you the three objects he previously identified during speech and language examination.

Abstract Reasoning Test the diver’s abstract reasoning by telling him a proverb and ask-ing him to interpret it for you. Examples include: "A stitch in time saves nine," and "A bird in the hand is worth two in the bush."

Use proverbs that are locally or regionally appropriate.

Calculations

Assess the injured diver’s ability to handle arithmetic by asking him to count backwards from 100 by sevens.

While it is important to evaluate a diver’s mental function, most injured divers will be able to answer these questions and will have a normal status.

18

Fig. 18: Table used to

evaluate the mental function

(Calculations)



Cranial NervesThe next section of the exam will focus on the injured diver’s face. You will be testing the diver’s eyes, face, hearing and tongue during this portion of the exam.

Eye ControlThe first exam of the cranial nerves will test whether the diver can fol-low movement with his eyes. Hold your finger about 1 meter away, di-rectly in front of the diver. Then, move your finger to the diver’s right and then left, up and then down. Record any direction the diver cannot follow your finger. Be sure to have the diver hold his head still, using only his eyes to follow your finger (Fig. 19).

Also, record if there is any fine twitching present in the eyes. The pupils may appear to jerk to one side. This is called nystagmus and can be present when the diver is looking forward or when he is looking in one of the four directions (up, down, right, left).

Facial Control

The next area you will evaluate is facial control. Have the diver close his eyes and smile (Fig. 20).

The face should appear the same on both sides. You should indicate any weaknesses or droopiness in the face.

19 20



HearingTest the diver’s hearing by holding your hand about 30 centimetres from the diver’s ear and rubbing your thumb and finger together. Check both ears (Fig. 21).

Attempt to determine if the diver’s hearing is the same on both sides. Do not attempt to determine hearing loss; rather, determine whether hearing is symmetrical on both sides or if one side is reduced.

If the surroundings are noisy, this test is difficult to evaluate. Ask by-standers to be quiet and turn off unneeded equipment.

Facial SensationTo check for facial sensation, instruct the diver to close his eyes while you lightly touch your fingertips across the forehead and face (Fig. 22).

To be sure he can feel your touch, and that it is the same all over the face, ask the diver to confirm where you are touching by identifying where he feels the sensation.

21 22



Motor Function (Strength)The next portion of the exam will be focusing on the diver’s motor func-tion and his ability to control his body. You will be evaluating the diver to see whether you consider his strength to be normal, whether weak-ness is present or if there is paralysis. You need to record any weak-nesses to report to the dive physician or EMS personnel.

You will test the diver’s deltoids, biceps, triceps, finger spread, grip strength, hip flexors, quadriceps, hamstrings and feet, moving them both up and down. For each test, have the diver push against resist-ance you provide. To test hand strength, have the diver squeeze your fingers.

For each test, the diver’s strength should be the same on both sides. Record any instance where one side is noticeably weaker than the oth-er. However, confirm with the diver there isn’t a pre-existing condition that may have caused the weakness.• Check the diver’s shoulders (deltoids) by bringing the elbows up

level with the shoulders, hands level with the arms and touching the chest. Instruct the diver to resist while you push down and then pull up. Check each muscle group independently by providing re-sistance (Fig. 23).

• Do this with the biceps while you pull down on the hand and on the triceps as the diver attempts to push you away (Fig. 24).

23 24



• Test the diver’s ability to spread his hands by providing resistance against the side of his index finger as he attempts to spread his fin-gers (Fig. 25).

• Test the diver’s grip strength by having him grip one or two of your fingers in each hand and squeeze (Fig. 26).

• To test the hip flexors, pull down on the diver’s bent leg so he is resisting at the hip (Fig. 27).

• Test the diver’s quadriceps (Fig. 28) and ham-string (Fig. 29) the same way you did the bi-ceps and triceps on the arm.

• To test the diver’s foot strength, have him flex his foot at the ankle, both upwards and down-wards, against your resistance (Fig. 30 - 31).

• Record all of your findings on your slate. You will record your findings from these motor strength tests as normal strength (5), weak-ness (3) or paralysis (0).

25

26

28 3127 29 30



Sensory FunctionFollowing the tests for muscle strength, you will exam-ine the entire body to see if the injured diver has any areas of abnormal sensitivity on his body.

Some of the common symptoms of DCI include pain, numbness or tingling. A dermatomal map allows phy-sicians to determine which area of the spinal cord may be affected if there are areas on the body that demon-strate these symptoms.

Using a light touch first, as you did on the face, and then touching with a sharp object, slowly scan the body to determine if there are any areas where the diver’s sensitivity is altered.

Have the diver close his eyes during this procedure. You will test several specific areas on both sides of the diver’s body.

Shade in any areas on the figure at right with decreased sensation level using the symbols below.

LIGHT TOUCH: XPIN: PBOTH: B

Fig. 32: Dermatomal map

32

34

33



• Touch the upper arms along the biceps and then the forearms (Fig. 35 - 36).

• Then test both hands, on the back of the hand and the palm (Fig. 37).• Scan the diver’s torso from his collarbone to his hips to determine

whether there are any areas with altered sensitivity (Fig. 38).• From there, move to the front of the diver’s thighs and then down

to the inside of his calves.• Lastly, check the top of the diver’s feet.• As you move down the body, have the diver confirm each area by

identifying the area you are touching. The diver should confirm the sensation, or lack of it, in each area before you move to another area.

• Repeat the same examinations using a sharp object, such as a pin or a broken tongue depressor.

35 36 37 38



Balance and Coordination

WalkingTo test the diver’s balance, have the diver walk forward about 3 meters while looking straight ahead (Fig. 39).

Note whether movements are smooth and if the diver can maintain balance without looking down or holding on. You should be prepared to catch the diver if he starts to fall. Performing this test may be difficult on a moving vessel.

You will record on the slate whether the diver can walk unassisted, walk with assistance, stand unassisted or is unable to stand.

Finger-Nose-FingerTo test coordination, hold your finger approximately 50 centimetres from the diver’s face; then have him move his index finger back and forth rapidly between his nose and your finger (Fig. 40).

Have him attempt to repeat this exercise with his eyes closed (Fig. 41).

39 40

41


Section 5 | Summary


Section 5 | Summary

Summary

Performing this examination soon after an accident may provide valu-able information to the physician responsible for treatment.

If the results of any of these tests are not nor-mal, you should suspect injury to the central nervous system.

Once you have completed the on-site neuro-logical assessment and determined that it is likely the diver has a dive-related injury, you should immediately begin first aid treatment, including oxygen first aid. Also, begin the ef-fort to obtain recompression therapy for the

injured diver by calling DAN. Remember, you will not harm the diver by providing oxygen first aid in the event the problem does not turn out to be dive-related.

Repeat this examination in 60- minute intervals while awaiting assist-ance. This is helpful in determining any change in the diver’s condition. Report the results to the emergency medical personnel who respond to the call.

In this course, you have learned about:• The purpose of an on-site neurological assessment• You also learned about the five areas evaluated during

the examination, including:• Mental Function• Cranial Nerves• Motor Function• Sensory Function• Balance and Coordination

• Taking a History• How to Perform an On-Site Neurological Assessment

Remember, good diving safety habits include practicing this examination on normal divers to become proficient in the test.

Note:however, that the diver’s condition may prevent the performance of one or more of these tests. Record any omitted test and the reason.

Fig. 42: Providing Oxygen First Aid

42


DAN Shop

www.dansa.org

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 in-jured divers. DAN also offers training pro-grammes for physicians and emergency medical services personnel.

DAN provides these valuable services to the entire dive community because of the support of the world's largest as-sociation 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

DAN Shop

www.dansa.org

A sea of products is only a click away...


Review Questions Answers

Section I:1. A2. Numbness, Pain, dizziness, unusual fatigue, headache, weakness, nausea,

difficulty in walking, difficulty in breathing, itching, rash, paralysis, bladder or bowel problems, decreased skin sensation, unconsciousness, hearing loss / ringing ears

3. B4. A

Section 2: Section 3:1. A2. A, B, D3. A, B, C.

1. A, B, C, D, E2. A3. A, B, C, D, E, F4. B5. A6. B


On-Site Neurological Assessment for Divers course evaluation

Congratulations on completing your DAN On-Site Neuro Provider!To help us improve this programme, please complete and return this questionnaire.Safe Diving!

Sincerely,Guy ThomasDAN Europe Director of Training

Strongly 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 emergency oxygen. 5 4 3 2 16. Did you learn and practise these skills? 5 4 3 2 1

Taking a History Yes / No / UnsureTaking Vital Signs Yes / No / UnsureMental Function Yes / No / UnsureCranial Nerves Yes / No / UnsureMotor Function Yes / No / UnsureSensory Function Yes / No / UnsureBalance and Coordination Yes / No / UnsureFull On-Site Neuro Exam 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 or to DAN


Notes:

On Site NeurologicalAssessment for Divers

On Site N

eurological Assessm

ent for Divers

on site neurological assessment for divers · 4 dan on-site neurological assessment for divers...

Documents