Advances in the delivery of cardiopulmonary resuscitation in a diving bell.

This commentary discusses the provision of cardiopulmonary resuscitation to casualties in a diving bell. This single resource consolidates recent advances in the field, published in different medical journals, to support dissemination across the wider diving industry. It summarises the evaluation of techniques for the provision of manual cardiopulmonary resuscitation (CPR) to a seated casualty, including head-to-chest, knee-to-chest, and prone knee-to-chest compression delivery, and concludes that the only safe and potentially effective approach in a diving bell setting without room for a supine casualty is knee-to-chest CPR. The evaluation of a mechanical CPR device is discussed; it is found to be as effective as existing devices and manual CPR in terms of compression efficacy and is well-suited to the setting. The development of a bespoke resuscitation algorithm, together with deviations from accepted advanced life support algorithm principles, is presented. A novel 'upright CPR' technique for the provision of CPR to a seated casualty, developed during the algorithm evaluation process, is described. Finally, areas where evidence is still lacking, and research priorities for the future, are discussed; a key area for future work is the development and testing of a defibrillator suited to a diving bell setting, where space constraints, a heliox atmosphere, and the risk of both fire and rescuer injury are ever-present.