Rules and Regulations pertaining to emergency procedures must be available and immediately accessible in the hyperbaric unit. 

CARDIO-PULMONARY ARREST

1. Activate Hospital/Emergency Room code system – page the HBO physician STAT to the hyperbaric department
2. Note the time of occurrence
3. Confirm DNR status
4. Turn set pressure to zero
5. (Sechrist) Turn the master valve to “Emergency Vent”.
6. (Perry) Turn the On/Off selector to the “Off” position
7. Press the emergency decompression button intermittently, 3 seconds on, 3 seconds off.
8. Observe patient continually.
9. Open door when pressure indicator shows black
10. Remove patient from chamber.
11. Initiate CPR
12. As Code team arrives, HBO staff will disconnect all through-chamber cables and tubing to facilitate moving patient away from chamber and onto the emergency department stretcher.
13. If emergency stretcher is not available, remove stretcher mattress, sheets, blankets and linen from patient and stretcher.
14. Assist Code team as required.
15. Complete documentation

Note: Defibrillation and/or Cardioversion should be held until the patient is clear of the chamber entrance and all linens and the mattress is removed

COMMUNICATION FAILURE

To ensure communication between the clinical staff and patient if presented with a communication system failure.

Action

1. Use cue cards to advise patient of a communication failure (see attached sample Communication Cue Cards in English and in Spanish)
2. Assess patient level of comfort/anxiety
3. Inform the hyperbaric physician for determination to continue treatment.
4. If treatment is to be aborted, begin ascent to surface pressure – continue to communicate with the patient via cue cards.
5. Note this in the chamber inspection log and inform the Safety Officer.

CONFINEMENT ANXIETY AND CLAUSTROPHOBIA 

Action

1. Consider the possibility of oxygen toxicity
2. Staff identifies signs and symptoms of confinement anxiety (hyperventilation, clenching fists, sudden complaint of discomfort, feelings of being smothered, flushed face, profuse diaphoresis
3. Let the patient know you are beginning to decompress the chamber and that it will take time to ascend
4. Let the patient know that you will not leave the chamber side
5. Coach the patient to breathe slowly using abdominal muscles and to focus on a pleasant thought
6. Stay with the patient at all times and maintain communication (visual and audio)
7. Direct the patient to perform some distracting tasks such as counting, reciting his/her address etc.
8. Inform the patient of the approximate time the chamber door will open
9. At surface, after opening the door and removing the patient, offer support and understanding of the patient's reaction
10. Encourage the patient to discuss their feelings

DOOR SAFETY PIN JAM

To release the safety lock pin:

1. Insert a blunt instrument (screwdriver, ballpoint pen) into the hole
2. Push safety lock pin into the retracted position
3. Note this in the chamber inspection log, and inform Safety Officer

EMERGENCY DECOMPRESSION

1. Activate Hospital/Rapid Response Code System – page the HBO physician STAT to the hyperbaric department
2. Reduce set pressure to slightly below zero.
3. Inform the patient of your actions without causing undue alarm, if possible.
4. (Sechrist) Turn the on/off selector to the "emergency vent” position.
5. (Perry) Turn the On/Off selector to the Off position
6. Depress the "emergency vent" button (Sechrist) or “Exhaust Bypass” (Perry). Ascent will commence at approximately 0.5-1.5 psi/second while the button is depressed. Ideally, the "emergency vent” button should be depressed on an intermittent basis for a more controlled (reduced risk of devastating barotrauma) fast vent rate (e.g. three seconds on then three seconds off).
7. Continue to follow the orders of the hyperbaric physician. Open door when pressure indicator shows black.
8. Remove patient, proceed as ordered and patient's condition dictates.
9. Consider STAT chest x-ray to rule out pulmonary barotrauma.

FIRE

1. Key Terms:

Fire Marshal – Security Director or Security Supervisor responsible for overall fire fighting activities until relieved by the Fire Department.

2. In the event of a fire remember:

R – RESCUE – Remove patient and area personnel in immediate danger.

A – ALARM – No delay, activate alarm by pulling fire alarm box.

C – CONFINE – Close doors, windows, to prevent fire/smoke spread.

E – EXTINGUISH – Know location of fire extinguishers, and how to use them.

3. Fire Extinguishers usage:

P – Pull the pin.

A – Aim the nozzle.

S – Squeeze the handle.

S – Sweep back and forth.

    In the event of a fire remember:

        RACE – Rescue, Alarm, Confine, Evacuate/Extinguish

        PASS – Pull, Aim, Squeeze, Sweep

Fire in Hyperbaric Facility

1. Remove anyone in immediate danger.
2. Staff to Don Smoke Hoods if warranted.
3. Inform the patient without causing undue alarm, that he/she is being returned to normal pressure;
4. Set pressure gauge to zero.
5. The rate of decompression will be determined by the degree of immediate danger.
6. Either begin decompression at a rate of 5psi/min or if imminent danger exists, start emergency decompression
7. (Sechrist) Turn the master valve to “Emergency Vent”
8. (Perry) Turn the On/Off selector to the “Off” position
9. Activate the fire signaling device.
10. Ensure all doors to the hyperbaric facility are closed.
11. Use fire extinguisher to fight fire if possible
12. Remain by the control panel and communicate as often as necessary.
13. Once the pressure indicator shows all black, turn the master valve to off.
14. Turn off the chamber oxygen supply wall valve.
15. When all immediate flames are contained, open door and remove patient.
16. Evacuate all staff and patients from the hyperbaric facility/room and close doors.
17. Turn off Oxygen Main Zone valve located outside of the hyperbaric unit as you are exiting the unit.

Fire In Chamber

1. Set pressure to zero
2. (Sechrist) Turn master valve to emergency vent
3. (Perry) Turn the On/Off selector to the off Position
4. Start Emergency Decompression at a rate of 3 seconds on 3 seconds off. In cases of eminent danger, depress and hold down button until chamber reaches 1 ATA or flip the Emergency shut down vent toggle.
5. Do NOT remain at either end of the chamber.
6. Activate hospital fire signaling device.
7. Notify hyperbaric physician and Safety Officer.
8. Unplug and/or turn off all electrical connections (IV pumps, TCOM, EKG monitor, TV)
9. Ensure all doors to the facility are closed.
10. When the patient is at 1ATA, turn off the chamber oxygen supply wall valve.
11. Staff to don smoke hoods; have fire extinguisher ready prior to opening the chamber door.
12. Evacuate all staff and patients from the hyperbaric facility/room and close doors.
13. Turn off oxygen Main Zone valve located outside of the hyperbaric unit as you are exiting the unit.

Fire in the Adjacent Area: (example – hallway, other treatment areas)

1. Be sure the doors to the hyperbaric facility are closed.
2. Determine proximity and degree of immediate danger
3. Inform Safety Officer and hyperbaric physician to make determination for evacuation.
4. Explain the situation to the patient, without unduly alarming them.
5. Decompress patients at 5 psi/min if warranted.
6. If not already occurring, activate fire-signaling device.
7. Staff to don smoke hoods, ensure the safety of all patients and occupants within the
   hyperbaric facility.
8. Proceed to the “point of egress”.
9. Treatment may resume when the responsible hospital personnel have given “all clear”.

Fire off-unit / other area of hospital

1. The staff will direct and instruct visitors to stay in the designated waiting areas until instructed to do otherwise.
2. Close all doors.
3. Administrative Assistant or Unit Secretary will obtain a list of patients on the unit at that time, either by computer print out or hand written.
4. Note location of fire as announced overhead.
5. Await further orders from the designated hospital personnel. (Is this a drill?)
6. IF all clear has not been given with 2 minutes, consider initiating ascent at 2 psi/ minute.
7. Document all steps as indicated on the Code Red Documentation form.

HYPOGLYCEMIA IN THE CHAMBER

1. Identify signs of hypoglycemia in the patient e.g., confusion, dizziness, feeling shaky, hunger, headaches, sweating, pale skin
2. Note the time of occurrence of the symptoms
3. Ask the patient to place the air mask to their face to be worn during ascent
4. Report the action to the hyperbaric physician and proceed as ordered
5. Reduce the chamber pressure to zero psi. If signs of seizure activity occur, halt decompression immediately. (Wait until seizure activity has ceased and adequate ventilation is observed)
6. At surface, check blood sugar
7. Treat per physician order and institutional policy

OXYGEN SUPPLY FAILURE

Local Failure

1. Inform patient, without causing undue alarm, that pressure will be decreasing.
2. Set pressure gauge to zero and ascend to surface (chamber will automatically depressurize at a linear rate of approximately 7 psi per minute)
3. Investigate source of failure and inform the designated hospital personnel.
4. Stabilize pressure if failure is rectified before patient arrives at surface pressure.
5. At surface pressure, turn master valve to the off position and remove the patient from the chamber.
6. If cause of failure is not determined, remove patient from chamber once at surface pressure and pressure indicator is black.
7. Inform hyperbaric physician, Nurse Manager and Safety Officer of failure.

Hospital Wide

1. Inform patient without causing undue alarm, that ascent to surface pressure will begin.
2. Return pressure set gauge to zero and ascend to surface (chamber will automatically depressurize at a linear rate of approximately 7 psi per minute)
3. At surface pressure, turn the master valve to off position, open door and remove patient.
4. Inform Safety Officer immediately of occurrence.
5. Inform engineering services that HBO chambers are now off.

OXYGEN TOXICITY

Premonitory Signs-absence of seizure activity

Action

1. Instruct the patient to begin air breathing (Note the time of occurrence).
2. Within 1-2 minutes of the patient breathing air, ask the patient if complaint has resolved, improved, remained the same or worsened.
1. If the patient complaint has resolved or improved, the patient should complete the entire 10-minute air break. The decision to continue or abort the treatment will rest with the hyperbaric physician. It is important that the staff maintain direct visual observation of the patient throughout the ascent.
2. If the patient complaint is unresolved, then return the patient immediately to surface pressure while continuing to breathe air via mask.

NOTE: If the patient is actively seizing the chamber pressure must not be altered!

In the “Emergently” referred patient-actively seizing

Action

1. Hold at stable pressure until adequate ventilation is observed
2. Note time of occurrence and length of seizure activity.
3. Report the reaction to the hyperbaric physician
4. Reduce chamber pressure to 1.5 ATA (while continually assessing airway patency.)
5. Reassure patient.
6. Proceed as ordered.

In the “Electively” referred patient-Actively seizing

Action

1. Hold at stable pressure until seizure has ceased adequate ventilation is observed.
2. Note time of occurrence and length of seizure activity.
3. Report the reaction to the Hyperbaric Physician Proceed as ordered.
4. Reduce chamber pressure to zero (while continually assessing airway patency.)
5. Reassure patient.
6. Proceed as ordered.

SUSPECTED PNEUMOTHORAX

If during ascent to surface pressure the patient complains of or is noted to be suffering from any of the following:

• Sudden, stabbing chest pain.
• Sudden, shortness of breath.
• Uneven chest excursion during respirations.
• Increasing respiratory distress.
• Deviated trachea.
• Distended neck veins.
• Cardiovascular changes.

Action

1. Halt further pressure reduction immediately.
2. Note time and complaint
3. Notify hyperbaric physician.
4. Increase pressure slightly to relieve symptoms.
5. Prepare chest tube tray or needle thoracentesis.
6. Once all necessary thoracentesis equipment is assembled and physician is present, decompress patient at rate per physician's order.
7. Inform patient of what is suspected and the necessary management.
8. Call for stat chest x-ray.
9. At surface, turn Maser Valve to OFF. Once pressure indicator shows black open chamber door and remove patient.
10. Proceed as ordered.

The Safety Director will review these procedures with staff during the schedule (monthly) emergency procedure drill.