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The Divemaster's Quick Accident Response Guide

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First Aid Kit

Oxygen Resuscitation Equipment

Dive Accidents Requiring Immediate Transport to a Chamber Facility
Air Embolism Decompression Sickness

Diving Accidents Requiring Transport to Hospital

Mediastinal Emphysema | Drowning-Near Drowning | Oxygen Toxicity  | Severe Trauma   |  Suspected Heart Attack, Stroke  |  Severe Allergic Reaction Stinging FishesMollusks  |  Sea Snakes  |  Hypothermia | Hyperthermia  |Ingested Marine Toxins 

Diving Accidents Not Requiring Transport to Hospital

| Nitrogen Narcosis  |  Carbon Dioxide Poisoning  |  Ear Disorders 

Hazardous Marine Life Injuries Not Requiring Transport

Diving Emergency Telephone Numbers

DAN America.... 919-684-9111
Latin America +1-267-520-1507
DAN Europe....+39-039-605-7858
DAN Japan....81-3-3812-4999
DAN Southern Africa (Outside South Africa)....27-11-242-0112
DAN Inside South Africa (Toll Free)....0800-020-111
Outside South Africa .... +27-11-254-0112(accepts collect calls)
DAN S.E. Asia-Pacific Region
Diving Emergency Services Australia
Within Australia....1-800-088-200
From Overseas....+61-8-8212-9242
DES New Zealand....+0800-4DES111 (0800 4 337 111)
Singapore Naval Medicine & Hyperbaric Center....+67-58-1733
DAN S.E.A.P.-Philippines....+02-2815-9911
DAN SEAP Malaysia....+05-930-4114


I. First Aid Kit
The following items are offered as an example of a list of first aid supplies which can be modified according to your needs and experience:Gloves
Deodorant cleansing soap (antibacterial)
Household Vinegar solution (neutralize jellyfish stings)
Household ammonia
Antibiotic Ointment
Cortisone Cream 1%
Non-aspirin pain reliever
Hot packs
Cold packs (pain relief)
Denatured alcohol, 12 oz. bottle (sterilizing instruments)
Telfa pads or plastic wrap (cover burns)
Absorbent dressings (control severe bleeding with pressure)
Squeeze bottle of water, 6 oz. (irrigating eyes and wounds)
Squeeze bottle of sterile saline
Sterile cotton, gauze pads, and adhesive tape
Band-Aids and butterfly bandages
Q-TipsTongue depressors
Disposable cups
Razor blades, single edged
Shaving cream
Tweezers or forceps
Needle nosed pliers with wire cutters (to remove fishhooks)
Bandage scissors
Lighter or waterproof matches
Space blankets
Backboard, splints and neckbrace, if space permits
Seasickness medication
Pocket mask (eliminates direct contact while resuscitating a person)

For purposes of hospital and insurance follow-up and to avoid any legal problems, it would be a good idea to record as many of the events as possible during an episode. A pen and small notebook would be good to have in this respect.

None of these items will be of any use at all if there's no one on the boat who knows how to administer first aid. All divemasters and instructors should be fully certified in First Aid and their certification should be up-dated at least yearly.

Oxygen should be an absolute necessity on a dive boat and would certainly be helpful on any boat. Knowledge is needed as the appropriate local emergency information number to call and this information should be readily available in the First Aid kit.. If the kit is used, it should be immediately replenished and should be up dated every 6 months to a year depending on the types of medications it contains.

Oxygen Resuscitation Equipment

The DAN Oxygen System provides an O2 cylinder in a case with appropriate pressure regulator, flow meter, tubing, airways and ventilation devices. Other oxygen sources are available-but the important thing is that the equipment should be up-to-date, readily available and someone should know how to use it properly.

Oxygen is the one first aid treatment that can be used with the full knowledge that it can only help and usually is the one treatment that will turn a serious diving injury around. It is the first thing you should think of in all serious decompression illness and should be used even if you're uncertain of its need.

It probably would be a good idea to have a backup kit-since most dives are 40-60 minutes away from the shore and the O2 tanks hold generally only 20 minutes of oxygen. A larger O2 tank would solve this problem but in most boats the space is limited.

If possible, have your divemasters take a DAN oxygen course or at least have studied their oxygen manual.

DAN now offers 'Remo2', a partial rebreathing apparatus that prolongs the oxygen supply of the O2 bottle.

Diving Accident Management
Model Accident Action Plan


II. First Aid for Diving Accidents
Requiring Immediate Transport to a Chamber Facility

A. Air Embolism

Recognition (This usually occurs during or immediately after surfacing )

Symptoms (one or more of the following)
Chest pain
Paralysis or weakness
Blurred vision
Personality change
Voice change in tonal quality (mediastinal air)

Signs (one or more of the following)
Bloody froth from nose or mouth
Paralysis or weakness
Stopped breathing
Apparent Death

Early Management
CPR, if required
Open airway, prevent aspiration, intubate if trained person available
Give O2, remove only to open airway or if convulsions ensue.
Mask, if available
If conscious, give nonalcoholic liquids
Place in horizontal, neutral position
Restrain convulsing person loosely and resume O2 as soon as airway is open
Protect from excessive cold, heat, water or fumes
Transport to nearest emergency facility closely associated with a recompression chamber.
Do not waste time evaluating and stabilizing at a facility unaccustomed to diving emergencies. This is possibly the most important thing you can do!
Call DAN at 919-684-8111 in the USA, +41-1-383-1111 in Europe, +81-3-3812-4999 in Japan, (800) 088-200 from within Australia, +61-8-373-5312 when calling Australia from overseas, 
0800 4 DES 111 (0800 4 337 111). in New Zealand and +65-750-5546 to get the Singapore Naval Medicine & Hyperbaric Center. or your own preferred emergency number.
Air evacuation should be at sea level pressure or as low as possible in unpressurized aircraft
Contact hyperbaric chamber, send diver's profile with the diver, and send all diving equipment for examination or have it examined locally.

B.Decompression Sickness

Recognition (Symptoms usually appear 15 minutes to 12 hours after surfacing)

Blotchy rash
Paralysis or weakness anywhere in the body
Coughing spasms
Staggering or instability
Personality change

Tired feeling
Pain, arms, legs or trunk
Numbness, tingling or paralysis
Chest compression or shortness of breath
Anything unusual after the dive

Early Management
Stabilize patient the same way as for Air Embolism
Urgent recompression after stabilization in trauma facility closely associated with a recompression chamber
Immediate oxygen breathing, continue even if person improves markedly
Mask, if available)
Early recompression treatment for all forms of decompression sickness
See Decompression Accident Management


III. First Aid for Diving Accidents
Requiring Transport to a Hospital Facility



Pain in the chest
Shortness of breath

Shallow, rapid breathing
Cyanosis (blue skin, lips, fingernails)
Possible crackling under the skin of the neck
Possible mediastinal shift (Heart sounds not in the usual place)

No recompression necessary, if there is no arterial gas embolism associated
A physician needs to insert a chest tube, withdraw air so that the lung can reinflate
If recompression therapy is required because of AGE or DCS, a chest tube is a must to prevent "Tension pneumothorax"

Mediastinal Emphysema (Lung over pressure accident)

Recognition (Always associated with pneumothorax)

Pain in the chest (beneath the breastbone)
Shortness of breath

Obvious difficulty breathing
Brassy change in voice

Should be seen by physician and observed for 24 hours.
No chamber recompression needed unless associated with air embolism or DCS

Drowning-Near Drowning

Lack of respirations
Cyanosis (bluish pallor, face lips, nailbeds)

Try to identify the time the victim was last seen breathing
Free entanglements if present
Maintain control of victim
Positive buoyancy of the victim, drop victims weight belt, inflate victims BC
Rescuer maintains dive status
Controlled ascent
On surface - open airway
Rescue breathing if necessary
Signal for help
Start CPR , removal of gear and in water transport to the boat or shore
In dive boat, horizontal position
Immediate call for help and transport to a facility
Assess ABC's-airway, breathing and circulation
Clear airway
Chest compression if no carotid pulse felt
Continue rescue breathing begun in the water
Consider the possibility of concurrent hypothermia (low body core temperature)
Do not use Entonox (Nitrous oxide/oxygen)
Do not use PASG (MAST) trousers

Oxygen Toxicity (with convulsions)



  • Decreased or loss of consciousness followed by
  • Convulsions

  • Symptoms
  • Nausea
  • Dizziness
  • Ringing in the ears
  • Abnormal vision
  • Confusion

  • Symptoms are usually too late to be helpful.

    Avoidance of gases with high O2 concentrations (as in Nitrox at inappropriate depth)
    Avoid CO2 retention which can precipitate O2 convulsions at any depth
    If convulsions occur at depth, be prepared to treat near drowning and /or air embolism

    Severe Trauma or Large Predator Injury
    (head injury, limb injury due to falls, equipment crush, prop injuries)
    Call for help and immediate transport
    Open airway
    Treat for shock on site and stabilize before evacuation
    Face up neutral position
    Direct pressure over bleeding wounds
    CPR if no pulse or respirations
    Keep warm
    Be aware of the possibility of neck injury
    O2 if any question of hypoxemia (Low oxygen in the blood)
    Splint limb injuries

    Suspected Heart Attack, Stroke
    Call for help and immediate transport
    Treat for shock
    CPR if no pulse or respirations
    Keep warm
    Pain relief, if available

    Severe Allergic Reaction
    Remove any remnant of allergen (i.e., jellyfish tentacles, foreign material)
    Epinephrine injection, if available
    Decadron injection or tablets
    Antihistamine, if available
    Wash out wounds or injury with alcohol, vinegar or sea water
    Call for help and immediate transport
    Treat for shock
    CPR if no pulse or respirations
    Keep warm
    Pain relief, if available

    Stinging Fishes (Stingrays, Scorpionfish)
    Remove spine and debride (scrub) the wound
    Irrigate wound
    Soak in hot water (thermolabile toxin) 50 degree C. for 30 to 90 minutes
    Tetanus treatment
    Treat for shock, hydrate
    Topical antibiotics
    Local injection Emetine 50 mg if available
    Stonefish antivenin (Australia Commonwealth Serum Lab.)
    Heat for pain

    Mollusks (Cone shells, Blue-ringed Octupus)
    Pressure dressing
    Cleanse puncture site
    Topical antibiotics
    CPR, if necessary, to treat possible respiratory distressor paralysis
    To a facility as soon as possible

    Sea Snakes
    Recognize that there are few symptoms early on
    Immobilize site
    Hospitalize immediately because of possible need for respiratory support
    Give sea snake antivenin
    Polyvalent land snake antivenin can be used
    Hemodialysis useful if no antivenin available
    CPR, if needed

    Keep core temperature above 95 degrees F.
    Keep airway open
    Wrap in blankets, preferably next to another person
    Basic life support, CPR, if needed
    Warm liquids, if alert, unless very cold—then avoid due to possibility of ventricular fibrillation (rapid, useless fluttering of the heart)
    Avoid O2 due to the cooling effect, unless the O2 is humidified and warm. (Nemiroff coffee jug technique)

    Heat Exhaustion (due to excessive fluid loss)
    Remove from source of heat
    Lower temperature
    Keep calm
    Keep airway open
    Give salt (1tsp/8ounces water)

    Heat Stroke
    Remove all clothing
    Cover with cool wet sheet
    Place in air-conditioned area
    Cold packs to neck, scalp, groin and armpits
    Treat convulsions if they occur

    Ingested Marine Toxins (liveaboards)

    Paralytic shellfish poisoning

  • Notify all who may have eaten the same food
  • Induce vomiting, if they haven't already done so
  • Respiratory paralysis can be fatal
  • O2 if short of breath
  • Life support and CPR
  • Hospitalize immediately

  • Scombroid
    (Similar to paralytic shellfish poisoning except due to severe allergic reaction.)
  • Ventilation and CPR
  • Hospitalize

  • Elasmobranch Poisoning , Tetrodotoxin, Clupeotoxin Poisoning
  • Treat the same as paralytic shellfish poisoning

  • Ciguatera
    (Treat as paralytic shellfish poisoning)
  • Oral fluids
  • Diphenhydramine, if itching
  • R/O diving illness
  • Transport to a medical facility


    IV. First Aid For Injuries
    That Can be Treated On Board

    Nitrogen Narcosis


    Inappropriate behavior at depth
    Ignoring hand signals and instructions
    Stupor or coma

    Inflexible mentation (thinking
    )Decrease or loss of judgment
    False sense of security
    Lack of concern for safety
    Inability to think through problems
    Near unconsciousness or loss of consciousness at depth

    Ascend until free of symptoms
    Surface with controlled ascent
    Intense counseling session!
    Carbon Dioxide Poisoning

    Rapid breathing
    Feeling of suffocation, shortness of breath, impending doom and panic
    Headache, nausea , dizziness
    Rapid heartbeat
    Confusion and unclear thinking

    Slowed responses
    Muscle irritability (twitching)
    Loss of consciousness

    Remove the cause ( skip breathing, over-exertion, equipment failure, rebreathers, etc.)
    Stop and rest during early symptoms to avoid loss of consciousness
    Consider O2 toxicity if diving with EAN.

    Ear Disorders

    Middle ear barotrauma

  • Keep quiet and calm
  • Without DCS or rupture of the round or oval windows, give
  • Benadryl 25 mg po, Claritin po or Sudafed.
  • Antibiotics po if marked fluid accumulation in middle ear.
  • Get ENT evaluation
  • Discontinue diving until cleared by ENT

  • Inner Ear Barotrauma
  • Recognize round or oval window damage( loss balance, ataxia, tinnitus, deafness)
  • Headup and affected ear elevated
  • Discourage straining
  • ENT evaluation, no more diving until cleared by ENT

  • Sea Sickness
  • The best medications have been found to be "Meclizine", "Bonine", Dramamine and Trans-derm Scop.
  • Keep your eyes on the horizon
  • Stay on deck
  • Keep yourself well hydrated with non-alcoholic beverages
  • Try antacid tablets or lemon drops. If diving, try to be the first diver in from a heaving boat.
  • Check our web site at http://www.scuba-doc.com/seask.html


    V. Hazardous Marine Life Injuries
    Not Requiring Transport

    Coral and Barnacle Cuts

  • Stop bleeding
  • Clean well with a brush, soap and water
  • Alcohol or vinegar flush
  • Scrub and debride foreign particles
  • Bed rest, elevation, antibiotics for severe cuts
  • Be aware of danger of anaerobic infection and clostridial infection
  • Topical antibiotics

  • Coelenterate Injury
    (fire coral, hydroids, Jellyfish, sea wasps, sea anemones)
  • Injury all caused by nematocysts
  • Flush with alcohol or vinegar or dilute household ammonia (1:3 water)
  • Flush with saline or sea water, no fresh water
  • Meat tenderizer
  • Non-steroidal anti-inflammatory cream (where available, Not in USA)
  • Pain relief, sedation, diphenhydramine
  • Be aware of possible severe systemic reactions
  • Shaving cream, shave or flush

  • Sea Lice
  • Caused by nematocysts in Thimble jellyfish larvae
  • Remove clothing
  • They should be flushed off with sea water-not rubbed off
  • or washed off with fresh water or they will fire off
  • Spraying on shaving cream and washing the cream off along with the nematocysts

  • Echinoderms (Sea Urchins)
  • The small black dots may not be the tips of the spines

  • but dye and will be eventually absorbed by the body
  • Hot water 30 minutes
  • Do not beat or pound the part to "crush" the spines
  • Surgical removal is indicated only if a granuloma

  • (hard knot) is formed or if it gets infected
    and needs pus to be drained
  • NSAID for anti inflammatory effect and pain relief
  • Topical antibiotics

  • Sponges
  • Deactivate toxins, acetic acid 5%, 10-15 minutes

  • or isopropyl alcohol soaks for 10 minutes
  • Sticky side of adhesive tape
  • Repeat soaks and tape
  • Steroid cream

  • Segmented Worms, Bristle Worms
  • Acetic acid (Vinegar) to bites of blood worms
  • Remove bristles with forceps or adhesive tape

  • several times, ammonia 3:1, isopropyl alcohol
    Batfish Punctures
  • Remove any residue
  • Hot water immersion 30 minutes

  • Starfish Injuries
  • Hot water immersion 30 minutes
  • Debride
  • Soap and water scrub and rinse
  • Monitor for infection

  • Catfish Injuries
  • Hot water immersion 30 minutes
  • Debride
  • Rinse with soap and water

  • Stress, Anxiety and Hyperventilation Reassure
  • Reassure
  • Slow down respiratory rate
  • 02
  • Rebreathe in a paper bag
  • Do not encourage further diving

    Information in this guide is derived from major searches of the literature, courses and lectures presented by Medical Seminars and DAN and lectures given by Jeff Davis, M.D., David Elliott, M.D., Paul Cianci, M.D., Paul Sheffield, Ph.D., Martin Nemiroff, M.D. and Glen Egstrom, Ph.D. and my personal observations and experiences over thirty years of diving. Many thanks to David Elliott for his review and critique.

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     Ernest Campbell, MD, FACS All Rights Reserved.

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