ContentslistsavailableatScienceDirect
Resuscitation
j o ur na l h o me p a g e:ww w . e l s e v i er . c o m / l o c a t e / r e s u s c i t a t i o n
European
Resuscitation
Council
Guidelines
for
Resuscitation
2015
Section
9.
First
aid
David
A.
Zideman
a,∗,
Emmy
D.J.
De
Buck
b,
Eunice
M.
Singletary
c,
Pascal
Cassan
d,
Athanasios
F.
Chalkias
e,f,
Thomas
R.
Evans
g,
Christina
M.
Hafner
h,
Anthony
J.
Handley
i,
Daniel
Meyran
j,
Susanne
Schunder-Tatzber
k,
Philippe
G.
Vandekerckhove
l,m,n aImperialCollegeHealthcareNHSTrust,London,UKbCentreforEvidence-BasedPractice,BelgianRedCross-Flanders,Mechelen,Belgium cDepartmentofEmergencyMedicine,UniversityofVirginia,Charlottesville,VA,USA
dGlobalFirstAidReferenceCentre,InternationalFederationofRedCrossandRedCrescentSocieties,Paris,France eNationalandKapodistrianUniversityofAthens,MedicalSchool,MSc“CardiopulmonaryResuscitation”,Athens,Greece fHellenicSocietyofCardiopulmonaryResuscitation,Athens,Greece
gWellingtonHospital,WellingtonPlace,London,UK
hDepartmentofGeneralAnaesthesiaandIntensiveCareMedicine,MedicalUniversityofVienna,Vienna,Austria iColchesterUniversityHospitalsNHSFoundationTrust,Colchester,UK
jFrenchRed-Cross,Paris,France
kAustrianRedCross,NationalTrainingCenter,Vienna,Austria lBelgianRedCross-Flanders,Mechelen,Belgium
mDepartmentofPublicHealthandPrimaryCare,FacultyofMedicine,CatholicUniversityofLeuven,Leuven,Belgium nFacultyofMedicine,UniversityofGhent,Ghent,Belgium
Introduction
In2005,theAmericanHeartAssociation(AHA)togetherwith theAmericanRedCross(ARC)formedtheNationalFirstAid Sci-enceAdvisoryBoardtoevaluatethescienceassociatedwiththe practiceofFirstAidandpublishedthe2005AHAandARC Guide-linesforFirstAid.Thisadvisoryboardwassubsequentlyexpanded toincluderepresentativesfromseveralinternationalfirstaid orga-nizationstobecometheInternationalFirstAidScienceAdvisory Board(IFASAB).IFASABevaluatedthescientificliteratureoffirstaid andpublishedthetreatmentrecommendationsfor2010in associ-ationwiththeInternationalLiaisonCommitteeonResuscitation (ILCOR)resuscitationrecommendations.1,2
Itwasnotuntil2012thatILCORconvenedafullinternational FirstAidTaskForcewithrepresentationfromallconstituent Inter-national Councils together with the ARC. The ERC contributed directlytotheTaskForceasindividualmembers,questionowners andbyprovidingexpertevidencereviewers. BytheILCOR Con-sensusConference in early2015theTaskForcehad completed comprehensivereviewsoftwenty-twoquestionsusingthe Grad-ingofRecommendationsAssessment,DevelopmentandEvaluation (GRADE)methodologyincombinationwithILCOR’sScientific Evi-denceEvaluationandReviewsystem(SEERS).Seventeenofthese questionswerederivedfromthe2010AHAandARCconsensus doc-ument,theremainingfivequestionswerenewtopicsselectedby
∗ Correspondingauthor.
E-mailaddress:david.zideman@gmail.com(D.A.Zideman).
theFirstAidTaskForceandbasedoncurrentmedicalrequirements. All22questionsweredevisedinaPopulationIntervention Compar-isonOutcome(PICO)formatandlibrariansassistedindeveloping thesearchstrategiessothatthesciencecouldbereassessedat reg-ularintervalsthroughouttheprocessandintothefutureusingthe samesearchcriteria.
Inpublishingtheseguidelines basedonthe2015Consensus onScienceandTreatmentRecommendationstheERCrecognises thatthisisnotacomprehensivereviewofallFirstAidtopics.The twenty-twoquestionsreviewedinthissectionprovideimportant evidence-basedsupportforcurrentfirstaidpracticeorchanges fromcurrentpractice.Itishopedthatthesearchstrategiesthathave beendevelopedwillbeusedtoaccessnewlypublishedresearch. TheTaskForcewillcontinuebyre-examiningtheremaining30 top-icsreviewedin2010anddevelopnewquestionsbasedoncurrent andevolvingmedicalpractice.
GRADEandFirstAid
GRADEisastandardisedandtransparentprocessforthe eval-uationofscientificdata.Forthe2015ConsensusonScienceILCOR combinedGRADEwith thedevelopmentof PICO searchstrings anditsownSEERSsystem.Theprocesscontainedover50planned stepsandinvolvedtheselectionofaPICOquestion,the develop-mentofanappropriatesearchstringforinterrogatingthescience databases,theanalysisofthesearchedpublicationstoselectthose relevant to the PICOs,the analysis of the individually selected papersforriskofbiasandqualityindicatorsacrossselected out-comes, analysis of the results of the science, and insertion of http://dx.doi.org/10.1016/j.resuscitation.2015.07.031
thisinformation intoSummaryofFindingstablesandtheninto aGRADEevidenceprofile.ForeachPICOquestion,twoevidence reviewerscarriedoutstudyselectionandriskofbiasassessment independently.Adraftrecommendationwasformulated,involving abalancebetweenthequalityoftheevidenceidentified,benefits andharms.Thefinalresultswerepresentedinastandardised for-mattotheILCORFirstAidTaskForceanddiscussed.Theresulting treatmentrecommendationswerepresentedtoILCORatthe2015 ConsensusonScienceconferenceandthefinalrecommendations formulated.3
CertainaspectsofFirstAidhavelittleornopublisheddatato supporttheirpracticeand much hasbeenbuiltonexpert con-sensusopinion,traditionandcommonsense.TheGRADEprocess underlinedthelackoftruesciencebehindmany ofthecurrent practicesandinsomecasestheTaskForcewasunabletomake atreatmentrecommendationfoundedonevidence-basedscience. ForeachtreatmentrecommendationtheTaskForceaddeda ‘val-uesandpreferences’statementasadescriptionoflimitationsor qualifiersforthetreatmentrecommendationsandthe‘knowledge gaps’toguidefutureinvestigationandresearch.
InwritingtheseguidelinestheWritingGroupwereconscious thattheconsensusonsciencehadledtoatreatment recommenda-tionthatrequiredqualificationintermsofsafeclinicalpractice. TheWriting Grouphave addedtheseadditional clinical recom-mendationsas expertconsensual opinion and labelledthem as GoodPracticePointstodifferentiatethemfromguidelinesderived directlyfromscientificreview.
The2015definitionofFirstAid
FirstAidisdefinedasthehelpingbehavioursandinitialcare pro-videdfor anacuteillnessorinjury.First Aidcanbeinitiatedby anyoneinanysituation.AFirstAidProviderisdefinedassomeone trainedinFirstAidwhoshould:
• recognise,assessandprioritisetheneedforfirstaid; • providecareusingappropriatecompetencies;
• recogniselimitationsandseekadditionalcarewhenneeded. Thegoalsof FirstAidaretopreservelife,alleviatesuffering, preventfurtherillnessorinjury,andpromoterecovery.
This2015definitionforFirstAid,ascreatedbytheILCORFirst AidTaskForce,addressestheneedtorecogniseinjuryandillness, therequirementtodevelopaspecificskillbaseandtheneedforfirst aidproviderstosimultaneouslyprovideimmediatecareandto acti-vateEmergencyMedicalServicesorothermedicalcareasrequired. Firstaidassessmentsandinterventionsshouldbemedicallysound andbasedonscientificevidence-basedmedicineor,intheabsence ofsuchevidence,onexpertmedicalconsensus.Thescopeoffirst aidisnotpurelyscientific,asbothtrainingandregulatory require-mentswillinfluenceit.Becausethescopeoffirstaidvariesbetween countries,states and provinces,theguidelinescontainedherein mayneedtoberefinedaccordingtocircumstances,need,and reg-ulatoryconstraints.DispatcherassistedFirstAidwasnotevaluated intheGuidelineprocess2015andhasnotbeenincludedinthese guidelines.
Summaryofthe2015FirstAidGuidelines
FirstAidformedicalemergencies
Positioningofabreathingbutunresponsivevictim
Positionindividualswhoareunresponsivebutbreathing nor-mally intoa lateral, side-lying recoveryposition asopposed to leavingthemsupine(lyingonback).Incertainsituationssuchas
resuscitationrelatedagonalrespirationsortrauma,itmaynotbe appropriatetomovetheindividualintoarecoveryposition. Optimalpositionforashockvictim
Placeindividualswithshockintothesupine(lyingonback) posi-tion.Wherethereisnoevidenceoftraumausepassivelegraising toprovideafurthertransient(<7min)improvementinvitalsigns; theclinicalsignificanceofthistransientimprovementisuncertain. Oxygenadministrationforfirstaid
Therearenodirectindicationsfortheuseofsupplemental oxy-genbyfirstaidproviders.
Bronchodilatoradministration
Assistindividualswithasthmawhoareexperiencingdifficulty in breathing with theirbronchodilator administration. First aid providersmustbetrainedinthevariousmethodsofadministering abronchodilator.
Strokerecognition
Useastrokeassessmentsystemtodecreasethetimeto recogni-tionanddefinitivetreatmentforindividualswithsuspectedacute stroke.FirstAidprovidersmustbetrainedintheuseofFAST(Face, Arm,SpeechTool)orCPSS(CincinnatiPre-hospitalStrokeScale)to assistintheearlyrecognitionofstroke.
Aspirinadministrationforchestpain
Inthepre-hospitalenvironment,administer150–300mg chew-able aspirin early to adults with chest pain due to suspected myocardialinfarction(ACS/AMI).Thereisarelativelylowriskof complications particularlyanaphylaxisand seriousbleeding.Do notadministeraspirintoadultswithchestpainofunclearaetiology. Seconddoseofadrenalineforanaphylaxis
Administerasecondintramusculardoseofadrenalineto indi-vidualsinthepre-hospitalenvironmentwithanaphylaxisthathas notbeenrelievedwithin5to15minbyaninitialintramuscular auto-injectordoseofadrenaline.Asecondintramusculardoseof adrenalinemayalsoberequiredifsymptomsre-occur.
Hypoglycaemiatreatment
Treatconsciouspatientswithsymptomatichypoglycaemiawith glucosetabletsequatingtoglucose15–20g.Ifglucosetabletsare notavailable,useotherdietaryformsofsugar.
Exertion-relateddehydrationandrehydrationtherapy
Use3–8%oralcarbohydrate–electrolyte(CE)beveragesfor rehy-drationofindividualswithsimpleexercise-induceddehydration. Alternativeacceptable beveragesfor rehydrationinclude water, 12%CEsolution,coconutwater,2%milk,orteawithorwithout carbohydrateelectrolytesolutionadded.
Eyeinjuryfromchemicalexposure
Foraneyeinjuryduetoexposuretoachemicalsubstance,take immediateactionbyirrigatingtheeyeusingcontinuous,large vol-umesofcleanwater.Refertheindividualforemergencyhealthcare professionalreview.
FirstAidfortraumaemergencies Controlofbleeding
Applydirectpressure,withorwithouta dressing,tocontrol externalbleedingwherepossible.Donottrytocontrolmajor exter-nalbleedingbytheuseofproximalpressurepointsorelevationof anextremity.Howeveritmaybebeneficialtoapplylocalisedcold
therapy,withorwithoutpressure,forminororclosedextremity bleeding.
Haemostaticdressings
Useahaemostaticdressingwhendirectpressurecannotcontrol severeexternalbleedingorthewoundisinapositionwheredirect pressureisnotpossible.Trainingisrequiredtoensurethesafeand effectiveapplicationofthesedressings.
Useofatourniquet
Useatourniquetwhendirectwoundpressurecannotcontrol severeexternalbleedinginalimb.Trainingisrequiredtoensure thesafeandeffectiveapplicationofatourniquet.
Straighteninganangulatedfracture
Donotstraightenanangulatedlongbonefracture.
Protecttheinjuredlimbbysplintingthefracture.Realignment offracturesshouldonlybeundertakenbythosespecificallytrained toperformthisprocedure.
Firstaidtreatmentforanopenchestwound
Leaveanopenchestwoundexposedtofreelycommunicatewith theexternalenvironmentwithoutapplyingadressing,orcoverthe woundwithanon-occlusivedressingifnecessary.Controllocalised bleedingwithdirectpressure.
Spinalmotionrestriction
Theroutineapplicationofacervicalcollarbyafirstaidprovider isnotrecommended.Insuspectedcervicalspineinjury,manually supporttheheadinpositionlimitingangularmovementuntil expe-riencedhealthcareprovisionisavailable.
Recognitionofconcussion
Althoughaconcussionscoringsystemwouldgreatlyassistfirst aidprovidersintherecognitionofconcussion,thereisnosimple validatedscoringsysteminuseincurrentpractice.Anindividual withasuspectedconcussionshouldbeevaluatedbyahealthcare professional.
Coolingofburns
Activelycoolthermalburnsassoonaspossibleforaminimum of10mindurationusingwater.
Burndressings
Subsequenttocooling,burnsshouldbedressedwithaloose steriledressing.
Dentalavulsion
Ifatoothcannotbeimmediatelyre-implanted,storeitinHank’s BalancedSalt Solution.Ifthis is not availableusepropolis, egg white,coconut water, ricetral,whole milk,salineor Phosphate BufferedSaline(inorderofpreference)andrefertheindividual toadentistassoonaspossible.
Education
Firstaideducationprogrammes,publichealthcampaignsand formalfirstaidtrainingarerecommendedinordertoimprove pre-vention,recognitionandmanagementofinjuryandillness.
FirstAidformedicalemergencies
Positioningofthebreathingbutunresponsivevictim
Theprioritymanagementofabreathingbutunresponsive vic-tim,includingonewhosecirculationhasbeensuccessfullyrestored
followingcardiacarrest,isthemaintenanceofanopenairway. Vic-timswithagonalbreathingshouldnotbeplacedintherecovery position.TheERC2015GuidelinesforBasicLifeSupportinclude theuseofarecoverypositionaimedatachievingthis.4
Althoughtheavailableevidenceisweak,theusearecovery posi-tionplacesahighvalueontheimportanceofdecreasingtherisk ofaspirationortheneedformoreadvancedairwaymanagement. Giventheabsenceofhighqualityevidence,therecoveryposition isrecommendedduetothelackofdemonstratedassociatedrisk.
Anumberofdifferentside-lyingrecoverypositionshavebeen compared(leftlateralversusrightlateralversuspronepositions,5
ERCversusResuscitationCouncil(UK)positions,6andAHAversus
ERCversusRautekversusMorrison,Mirakhurand Craig(MMC) positions.7Thequalityofevidenceislow,butoverallnosignificant
differencesbetweenthepositionshavebeenidentified.
Incertainsituationssuchastrauma,itmaynotbeappropriateto movetheindividualintoarecoveryposition.TheHAINESposition hasbeenreportedtoreducethelikelihoodofcausingcervicalspinal injurycomparedwiththeside-lyingpositions.8Theevidencefor
thisisofverylowqualitywithlittleifanydifferencebetweenthe positionsbeingdemonstrated.9
2015FirstAidGuideline
Positionindividualswhoareunresponsivebutbreathing nor-mally intoa lateral, side-lying recoveryposition asopposed to leavingthemsupine(lyingonback).Incertainsituationssuchas resuscitationrelatedagonalrespirationsortrauma,itmaynotbe appropriatetomovetheindividualintoarecoveryposition.
Overall,there islittle evidencetosuggest anoptimal recov-eryposition,buttheERCrecommendsthefollowingsequenceof actions:
• kneelbesidethevictimandmakesurethatbothlegsarestraight, • placethearmnearesttoyououtatrightanglestothebody,elbow
bentwiththehandpalmuppermost;
• bringthefararmacrossthechest,andholdthebackofthehand againstthevictim’scheeknearesttoyou;
• withyourotherhand,graspthefarlegjustabovethekneeand pullitup,keepingthefootontheground;
• keepingthehandpressedagainstthecheek,pullonthefarlegto rollthevictimtowardsyouontohisorherside;
• adjusttheupperlegsothatbothhipandkneearebentatright angles;
• tilttheheadbacktomakesuretheairwayremainsopen; • adjustthehandunderthecheekifnecessary,tokeepthehead
tiltedand facingdownwardstoallowliquidmaterialtodrain fromthemouth;
• checkbreathingregularly.
Ifthevictimhastobekeptintherecoverypositionformorethan 30minturnhimorhertotheoppositesidetorelievethepressure onthelowerarm.
Optimalpositionforshockvictim
Shockisaconditioninwhichthereisfailureoftheperipheral circulation.Itmaybecausedbysuddenlossofbodyfluids(such asinbleeding),seriousinjury,myocardialinfarction(heartattack), pulmonaryembolism,andothersimilarconditions.Whilethe pri-marytreatmentisusuallydirectedatthecauseofshock,supportof thecirculationisimportant.Althoughtheevidenceisweak,thereis potentialclinicalbenefitofimprovedvitalsignsandcardiac func-tionbyplacingindividualswithshockintothesupine(lyingon back)position,ratherthanbymovingavictimwithshockintoan alternativeposition.
Theuseofpassive legraising(PLR)mayprovide atransient (<7min)improvementinheartrate,meanarterialpressure,cardiac index,orstrokevolume;10–12forthosewithnoevidenceoftrauma.
Theclinicalsignificanceofthistransientimprovementisuncertain. Theoptimaldegreeofelevationhasnot beendetermined,with studiesofPLRrangingbetween30and60degreeselevation.No studyhowever,hasreportedadverseeffectsduetoPLR.
Theserecommendationsplaceanincreasedvalueonthe poten-tial, but uncertain, clinical benefit of improved vital signs and cardiacfunction,bypositioningavictimwithshockinthesupine position(withorwithoutPLR),overtheriskofmovingthevictim. The Trendelenburg position (legs raised–head down) was excludedfromevaluationinthisreviewandisnotrecommended duetotheinabilityorimpracticalityoffirstaidprovidersplacinga victimintothispositioninanout-of-hospitalsetting.
2015FirstAidGuideline
Placeindividualswithshockintothesupine(lyingonback) posi-tion.Wherethereisnoevidenceoftraumausepassivelegraisingto provideafurthertransient(<7min)improvementinvitalsignsbut theclinicalsignificanceofthistransientimprovementisuncertain. Oxygenadministrationforfirstaid
Oxygen is probably one of the mostcommonly used drugs inmedicine.Administrationofoxygeninthepre-hospital envi-ronmenthastraditionallybeenconsideredcrucialinthecareof patientswithanacuteillnessorinjury,aimingattreatingor pre-ventinghypoxaemia.However,thereisnoevidencefororagainst theroutine administration of supplementaloxygenby first aid providers.13–16Further,supplementaloxygenmighthavepotential
adverseeffectsthatcomplicatethediseasecourseorevenworsen clinicaloutcomesandthereforeitsusefulnessis notuniversally proved.Ifused,supplementaloxygenshouldonlybeadministered byfirstaidproviderswhohavebeenproperlytrainedinitsuseand iftheycanmonitoritseffects.
2015FirstAidGuideline
Therearenodirectindicationsfortheuseofsupplemental oxy-genbyfirstaidproviders:
Bronchodilatoradministration
Asthma is a common chronic disease affecting millions of people worldwide, while its incidence continues to increase, especially in urban and industrialised areas. Bronchodilators are integral to asthma management and work by relaxing the bronchial smooth muscles, thereby improving respiratory function and reducing respiratory distress. The administra-tion of a bronchodilator decreased the time to resolution of symptoms in children and reduced the time for the sub-jective improvement of dyspnoea in young adult asthma sufferers.17,18 Bronchodilator administration can be achieved
via different methods ranging from assisting the individual with their bronchodilator to administering a bronchodilator as part of an organised response team with medical over-sight.
Individualswithasthmawhoexperiencebreathingdifficulties maybeseverelyincapacitatedandnotbeabletoadministera bron-chodilatorthemselvesduetotheseverityoftheattackordueto poorinhalationtechnique.Althoughfirstaidproviderscannot rou-tinelybeexpectedtomake adiagnosisofasthma,theymaybe abletoaidanindividualexperiencingdifficultyinbreathingdue toasthmabyhelpingthemtositupright,andthenassistingthe patientwiththeadministrationofaprescribedbronchodilator.
Administrationofbronchodilatorsoruseofinhalersrequires competencyinbronchoconstrictionrecognitionandnebuliseruse andfirstaidprovidersshouldbetrained inthesemethods.19–21
Nationalorganisationsmustassurethequalityoftrainingintheir local setting. If thepatient hasno bronchodilator or the bron-chodilatorishavingnoeffect,activateEMSandcontinuetoobserve andassistthepatientuntilhelparrives.
2015FirstAidGuideline
Assistindividualswithasthmawhoareexperiencingdifficulty in breathing with theirbronchodilator administration. First aid providersmustbetrainedinthevariousmethodsofadministering abronchodilator.
Strokerecognition
Strokeisanon-traumatic,focalvascular-inducedinjuryofthe centralnervoussystemandtypicallyresultsinpermanentdamage intheformofcerebralinfarction,intracerebralhaemorrhageand/or subarachnoidhaemorrhage.22Everyyear,15millionpeople
world-widesufferastroke,nearlysixmilliondieandanotherfivemillion areleftpermanentlydisabled.Strokeisthesecondleadingcause ofdeathabovetheageof60yearsandthesecondleadingcauseof disability(lossofvision,speechorpartialorcompleteparalysis).23
Earlyadmissiontoastrokecentreandearlytreatmentgreatly improves stroke outcome and highlights the need for first aid providerstoquicklyrecognizestrokesymptoms.24,25 Thestroke
management goalis toadministerdefinitivetreatmentearlyin thecourseof thestrokeand tobenefit fromthebesttherapies, e.g.receivingclot-bustingtreatmentwithinthefirsthoursofthe onset of strokesymptoms or in thecase of intra-cerebral hae-morrhage,asurgicalintervention.26Thereisgoodevidencethat
theuseofastroke-screeningtoolimprovesthetimetodefinitive treatment.27–30
First aid providers should be trained to utilize a simple strokeassessmenttoolsuchastheFace,Arm,Speech,Testscale (FAST)31–35ortheCincinnatiPrehospitalStrokeScale(CPSS)31,36,37
toidentifyindividualswithsuspectedacutestroke.Thespecificity ofstrokerecognitioncanbeimprovedbyusinga stroke assess-menttoolthatincludesthemeasurementofbloodglucosesuchas theLosAngelesPrehospitalStrokeScale(LAPSS),28,31,36,38–40 the
OntarioPrehospitalStrokeScale(OPSS),41RecognitionofStrokein
theEmergencyRoom(ROSIER)32,34,35,42,43ortheKurashiki
Prehos-pitalStrokeScale(KPSS)44butitisrecognisedthatbloodglucose
measurementmaynotberoutinelyavailabletofirstaidproviders. 2015FirstAidGuideline
Useastrokeassessmentsystemtodecreasethetimeto recogni-tionanddefinitivetreatmentforindividualswithsuspectedacute stroke.FirstaidprovidersmustbetrainedintheuseofFAST(Face, Arm,SpeechTool)orCPSS(CincinnatiPrehospitalStrokeScale)to assistintheearlyrecognitionofstroke.
Aspirinadministrationforchestpain
Thepathogenesisofacutecoronarysyndromes(ACS)including acutemyocardialinfarction(AMI)ismostfrequentlyaruptured plaque in a coronary artery. As the plaque contents leak into theartery,plateletsclumparoundthemandcoronarythrombosis occurscompletelyorpartiallyoccludingthelumenoftheartery, leadingtomyocardialischemiaandpossibleinfarction.
The useofaspirinas anantithrombotic agenttopotentially reducemortalityandmorbidityinACS/AMIisconsideredbeneficial evenwhencomparedwiththelowriskofcomplications, particu-larlyanaphylaxisandseriousbleeding(requiringtransfusion).45–49
withinthefirstfewhoursoftheonsetofsymptoms,alsoreduces cardiovascularmortality,50,51supportingtherecommendationthat
firstaidprovidersshouldadministeraspirintothoseindividuals withchestpainfromsuspectedmyocardialinfarction.
Allpatientswithchestpainduetosuspectedmyocardial infarc-tionshould seekimmediate healthcare professionaladvice and be transferred to hospital for definitive medical care. First aid providersshouldcallforhelpandadministerasingleoraldoseof 150–300mgchewableorsolubleaspirinwhilstwaitingfor health-careprofessionalassistancetoarrive.52Thisearlyadministrationof
aspirinshouldneverdelaythetransferofthepatienttoahospital fordefinitivecare.
Aspirin shouldnot be administered to patientswho have a knownallergyorcontraindicationstoaspirin.
Itisrecognisedthatafirstaidprovidermighthavedifficultyin identifyingchestpainofcardiacoriginandthepre-hospital admin-istrationofaspirinbyfirstaidproviderstoadultswithchestpain ofunclearaetiologyisnotrecommended.Ifthereisanydoubtcall fortheadviceandassistanceofahealthcareprofessional. 2015FirstAidGuidelines
Inthepre-hospitalenvironment,administer150–300mg chew-able aspirin early to adults with chest pain due to suspected myocardialinfarction(ACS/AMI).Thereisarelativelylowriskof complicationsparticularlyanaphylaxisandseriousbleeding. Do notadministeraspirintoadultswithchestpainofunclearaetiology. Seconddoseofadrenalineforanaphylaxis
Anaphylaxisisapotentiallyfatal,allergicreactionthatrequires immediaterecognitionandintervention.Itisarapidmulti-organ systemreaction,affectingthecutaneous,respiratory, cardiovascu-lar,andgastrointestinalsystems,usuallycharacterisedbyswelling, breathing difficulty,shock and even death. Adrenalinereverses thepathophysiologicalmanifestationsofanaphylaxisandremains themostimportantdrug,especiallyifitisgivenwithinthefirst fewminutesofasevereallergicreaction.53–55Althoughadrenaline
shouldbeadministeredassoonasthediagnosisissuspected,the majorityofpatientsdieduetolackofadrenalineordelaysinits administration.54,56
In the pre-hospital setting, adrenaline is administered via prefilled auto-injectors, which contain one doseof 300mcg of adrenalinefor intra-muscularself-administration orassisted by atrainedfirstaidprovider.Ifsymptomsarenotrelievedwithin 5–15minoftheinitialdoseorreoccur,aseconddoseof intramus-cularadrenalineisrecommended.57–66
No absolute contraindications to the use of adrenaline for anaphylaxis have been identified.54,67,68 Adverse effects have
previously been reported in the literature when adrenaline is administeredatanincorrectdoseorviainappropriateroutessuch astheintravenousroute.Useofauto-injectorsbyfirstaidproviders shouldminimizetheopportunityformis-dosingoradministration ofadrenalinebytheintravenousroute.
2015FirstAidGuideline
Administerasecondintramusculardoseofadrenalineto indi-vidualsinthepre-hospitalenvironmentwithanaphylaxisthathas notbeenrelievedwithin5to15minbyaninitialintramuscular auto-injectordoseofadrenaline.Asecondintramusculardoseof adrenalinemayalsoberequiredifsymptomsre-occur.
Hypoglycaemiatreatment
Diabetesisachronicdiseasethatoccurseitherwhenthe pan-creasdoesnotproduceenoughinsulin,ahormonethatregulates
bloodsugar,orwhenthebodycannoteffectivelyusetheinsulinit produces.
Diabetesisfrequentlycomplicatedbyseriouseventssuchas heart attack and stroke but significant or extreme alterations of blood sugar level (hyper- and hypoglycaemia) can present as a medical emergency. Hypoglycaemia is usually a sudden andlife-threateningeventwiththetypicalsymptomsofhunger, headache,agitation,tremor,sweating,psychoticbehaviour (fre-quentlyresemblingdrunkenness)andlossofconsciousness.Itis mostimportantthatthesesymptomsarerecognisedas hypogly-caemiaasthevictimrequiresrapidfirstaidtreatment.
Glucose tabletsequating to glucose 15–20gshould beused by first aidproviders, before dietary forms of sugar for treat-ingsymptomatic hypoglycaemia,inconscious patientswhoare abletofollowcommandsandswallow.Glucosetablets,however, may not alwaysbe immediatelyavailable and various alterna-tiveforms ofdietarysugarssuchasSkittlesTM,MentosTM,sugar
cubes,jellybeansandorangejuicecanbeusedtotreatsymptomatic hypoglycaemia.69–71Glucosegelsandpastearenotdirectly
equiv-alenttooralglucosetabletsintermsofdosingandabsorption. Ifthepatientis unconsciousorunabletoswallowthen oral treatmentshouldbewithhelddue totheriskofaspiration,and theemergencymedicalservicesshouldbecalled.
2015FirstAidGuideline
Treatconsciouspatientswithsymptomatichypoglycaemiawith glucosetabletsequatingtoglucose15–20g.Ifglucosetabletsare notavailable,useotherdietaryformsofsugar.
Exertion-relateddehydrationandrehydrationtherapy
Firstaidprovidersareoften calledupontoassist at “hydra-tion stations” for sporting events suchas bicycle racesor foot races. Failure to hydrate adequately before, during and follow-ingexercisecontributestoexercise-associateddehydration.When vigorousexercisetakesplaceduringperiodsofhighambient tem-peratures,dehydrationmaybeassociatedwithheatcramps,heat exhaustionorheatstroke.
Wateriscommonlyusedforrehydrationfollowingexercise,but newercommercial“sportsdrinks”areoftenpromotedforthis pur-pose.Furthermore,alternativebeverages(tea orcoconutwater) haverecentlybeenpromotedasacceptablefororalrehydration andsomeathletesmayhaveaculturalpreferenceforthese bev-erages. Solutions made from oral rehydration salt packets and homemadesolutions are more commonly usedfor rehydration followinggastrointestinallossesandarenotaspractical foruse followingexercise-associateddehydration.
3–8%oralcarbohydrate–electrolyte(CE)beverageswerefound to be superior to water and are therefore recommended for rehydration of individuals with simple exercise-induced dehydration.72–80Itisrecognisedthatwatermaybethesimplest
and mostreadilyavailable rehydratingsolutionand that palat-abilityandgastro-intestinaltolerancemaybeafactorthatlimits rehydrationwithfluidsotherthanwater.Otheralternative accept-ablebeveragesforrehydrationinclude12%CEsolution,72coconut
water,73,79,802%milk,77orteawithorwithoutcarbohydrate
elec-trolytesolutionadded.74,81
It isknownthat thirstis notan accurateguide for rehydra-tion,andthevolumeoforalfluidsingestedtypicallymustatleast equalthevolumefluidlost.Theexactamountofliquidrequired foradequaterehydrationmaynotbedeterminableinthefirstaid setting.
Oral hydration may not be appropriate for individuals with severedehydrationassociatedwithhypotension,hyperpyrexiaor mentalstatuschanges.Suchindividualsshouldreceivecarebyan
advancedmedicalprovidercapableofadministeringintravenous fluids(GoodPracticePoint).
2015FirstAidGuideline
Use3–8%oralcarbohydrate–electrolyte(CE)beveragesfor rehy-drationofindividualswithsimpleexercise-induceddehydration. Alternativeacceptablebeverages for rehydrationinclude water, 12%CEsolution,coconutwater,2%milk,orteawithorwithout carbohydrateelectrolytesolutionadded.
Eyeinjuryfromchemicalexposure
Accidentalexposureoftheeyetochemicalsubstancesisa com-monprobleminboththehouseholdandindustrialsettingandit isoftendifficulttoidentifypreciselywhatchemicalhasentered theeye.Alkaliinjurytothecorneahasbeenshowntocausesevere cornealinjuryandriskofblindness.Irrigationwithlargevolumes ofwaterwasmoreeffectiveatimprovingcornealpHascompared tousinglowvolumesorsalineirrigation.82
Tryingtoidentifythechemicalsubstancemaydelaytreatment anditisrecommendedthatthefirstaidprovidershouldflushthe eyewithcontinuouslargevolumesofclean water immediately aftertheinjury hasbeensustainedand torefer thepatientfor emergencyhealthcarereview.
Wherethereisaknownhighriskofeyecontaminationby par-ticularchemicals,specificantidotesshouldbereadilyavailable. 2015FirstAidGuideline
Incaseofeyeinjuryduetoexposuretoachemicalsubstance, takeimmediateaction.Putondisposablegloves.Irrigatetheeye usingcontinuous, largevolumesof clean water. Takecare that therinsingwaterdoesnotcomeintocontactwiththeothereye (GoodPracticePoint).Call112andthePoisonControlCentre.Wash yourhandsaftergivingfirstaid.Refertheindividualforemergency healthcareprofessionalreview(GoodPracticePoint).
Firstaidfortraumaemergencies
Controlofbleeding
Thereisapaucityofliteraturecomparingdifferentbleeding con-trolstrategiescommonlyemployedbyfirstaiders.Thebestcontrol ofbleedingistoapplydirectpressuretothewoundwherepossible. Localisedcoldtherapy,withorwithoutpressure,maybebeneficial inhaemostasisforminororclosedbleedinginextremitiesalthough thisisbasedonin-hospitalevidence.83,84Thereisnopublished
evi-dencefortheeffectiveuseofproximalpressurepointstocontrol bleeding.
Wherebleedingcannotbecontrolledbydirectpressureitmay bepossibletocontrolbleedingbytheuseofahaemostaticdressing oratourniquet(seebelow).
2015FirstAidGuideline
Applydirect pressure,withorwithoutadressing,tocontrol externalbleedingwherepossible.Donottrytocontrolmajor exter-nalbleedingbytheuseofproximalpressurepointsorelevationof anextremity.Howeveritmaybebeneficialtoapplylocalisedcold therapy,withorwithoutpressure,forminororclosedextremity bleeding.
Haemostaticdressings
Haemostaticdressingsarecommonlyusedtocontrolbleeding inthesurgicalandmilitarysettingsespeciallywhenthewoundis inanon-compressibleareasuchastheneck,abdomen,orgroin. Earlygenerationhaemostaticagentswerepowderorgranulesthat
werepoureddirectlyintothewound.Someofthesewere associ-atedwithexothermicreactionsthatcouldexacerbatetissueinjury. Majorimprovementshavebeenmadeinthecomposition,texture, andactiveconstituentmaterialsofhaemostaticdressings.85–89In
humanstudiestherewasareportedimprovementin haemosta-sisassociatedwithalowcomplicationrateof3%fromtheuseof haemostaticdressingsandadecreaseinmortality.90–93
2015FirstAidGuideline
Useahaemostaticdressingwhendirectpressurecannotcontrol severeexternalbleedingorthewoundisinapositionwheredirect pressureisnotpossible.Trainingisrequiredtoensurethesafeand effectiveapplicationofthesedressings.
Useofatourniquet
Haemorrhagefromvascularinjuredextremitiesmayresultin life-threateningexsanguinationandisoneoftheleadingcausesof preventabledeathonthebattlefieldandintheciviliansetting.94,95
Initialmanagementofsevereexternallimbbleedingisdirect pres-surebutthis maynotbepossibleandevenatightcompression bandagedirectlyoverthewoundmaynotcompletelycontrolmajor arterialbleeding.
Tourniquets have been used in military settings for severe external limb bleeding for many years.96,97 The application of
a tourniquet has resulted in a decrease in mortality,96,98–106
haemostasisbeingachievedwithanassociatedincidenceof com-plicationsof6%and4.3%.96,97,99,100,103,105–109
2015FirstAidGuideline
Useatourniquetwhendirectwoundpressurecannotcontrol severeexternalbleedinginalimb.Trainingisrequiredtoensure thesafeandeffectiveapplicationofatourniquet.
Straighteninganangulatedfracture
Fractures,dislocations,sprainsandstrainsareextremityinjuries commonlycared forby firstaidproviders.Longbone fractures, particularlyofthelegorforearm,maybeangulatedon presenta-tion.Severeangulationmaylimittheabilitytoproperlysplintthe extremityormovetheinjuredindividual.
Firstaidforfracturesbeginswithmanualstabilisationofthe fracture,followedbysplintinginthepositionfound.Splinting,to include thejointaboveand thejointbelowthebreak, protects theinjuryfromfurthermovementandthuspreventsorreduces painandthepotentialforconvertingaclosedfracturetoanopen fracture.
Althoughtherearenopublishedstudiesthatshowabenefitto stabilisingorsplintingafracturedextremity,commonsenseand expertopinionsupporttheuseofasplinttoimmobilizetheinjured extremityforthepurposeofpreventingfurtherharmandreducing pain.Splintingofanextremityinjurybyfirstaidprovidersshould be“inthepositionfound”,withaslittlemovementaspossibleto applythesplint.Insomecases,anextremityfracturewillpresent withsevereangulation,makingapplicationofasplintand trans-portationextremelydifficultorimpossible.Inthesecases,thefirst aidprovidermaydefertoaproviderwithspecifictrainingto per-formminimalrealignmenttofacilitatesplintingandtransportation toahospital.
2015FirstAidGuideline
Do not straighten an angulated long bone fracture (Good PracticePoint).
Protect theinjured limb by splintingthe fracture toreduce movement,limit pain,reducethechancefor furtherinjury and tofacilitatesafeandprompttransport.Realignmentoffractures
shouldonlybeundertakenbythosespecificallytrainedtoperform thisprocedure.
Firstaidtreatmentforanopenchestwound
Thecorrectmanagement ofan openchest woundis critical, astheinadvertentsealingofthesewoundsbytheincorrectuse ofocclusivedressingsordeviceortheapplicationofa dressing thatbecomesocclusivemayresultinthepotentiallife-threatening complicationofatensionpneumothorax.110Adecreaseinthe
inci-denceofrespiratoryarrestandimprovementsinoxygensaturation, tidalvolume,respiratoryrateandmeanarterialpressurehasbeen shownusinganon-occlusivedeviceinananimalmodel.111 Itis
importantthatanopenchestwound,especiallywithassociated underlyinglungdamage,isnotoccludedandthattheinsideofthe chestisinopencommunicationwiththeexternalenvironment. 2015FirstAidGuideline
Leaveanopenchestwoundexposedtofreelycommunicatewith theexternalenvironmentwithoutapplyingadressing,orcoverthe woundwithanon-occlusivedressingifnecessary.Theuseof occlu-sivedevices ordressingscanbeassociatedwiththepotentially life-threateningcomplicationofatensionpneumothorax.Control localisedbleedingwithdirectpressure.
Cervicalspinalmotionrestriction Definitions
• Spinalimmobilisationisdefinedastheprocessofimmobilising thespineusingacombinationofdevices(e.g.backboardand cer-vicalcollar)intendedtorestrictspinalmotion.
• Cervicalspinalmotionrestrictionisdefinedasthereductionor limitationofcervicalspinemovementusingmechanicalcervical devicesincludingcervicalcollarsandsandbagswithtape. • Spinal stabilisationis defined as physicalmaintenance of the
spineinaneutralpositionpriortoapplyingspinalmotion restric-tiondevices.
Insuspectedcervicalspineinjuryithasbeenroutinetoapply cervicalcollarstotheneck,inordertoavoidfurtherinjuryfrom spinalmovement.However,thisinterventionhasbeenbasedon consensusandopinionrather thanonscientific evidence.112,113
Furthermore,clinicallysignificantadverseeffects,suchasraised intracranial pressure, have been shown to occur following the applicationofacervicalcollar.114–118
2015FirstAidGuideline
Theroutineapplicationofacervicalcollarbyafirstaidprovider isnotrecommended.
Insuspectedcervicalspineinjury,manuallysupporttheheadin apositionlimitingangularmovementuntilexperiencedhealthcare providersareavailable(GoodPracticePoint).
Recognitionofconcussion
Minorheadinjurieswithoutlossofconsciousnessarecommon inadultsandchildren.Thefirstaidprovidersmayfinditdifficult torecogniseconcussion(minortraumaticbraininjury(TBI))due tothecomplexityofthesymptomsandsigns,andthiscanlead toadelayinprovidingproperconcussionmanagementand post-concussionadviceandtreatment.
Insport,theuseofasportconcussionassessmenttool(SCAT3) iswidelyadvocatedand used.119 Thistoolis advocatedforuse
byhealthcareprofessionalsandrequiresatwo-stageassessment,
beforecompetitionandpostconcussion.Itisthereforenot appro-priateasasingleassessmenttoolforfirstaidproviders.Ifanathlete withasuspectedconcussionhashadaninitialSCAT3assessment thentheyshouldbereferredtoahealthcareprofessionalforfurther assessmentandadvice.
2015FirstAidGuideline
Althoughaconcussionscoringsystemwouldgreatlyassistfirst aidprovidersintherecognitionofconcussion,thereisnosimple validatedscoringsysteminuseincurrentpractice.Anindividual withasuspectedconcussionshouldbeevaluatedbyahealthcare professional.
Coolingofburns
Immediate active cooling of thermal burns, defined as any methodundertakentodecreaselocaltissuetemperature,isa com-monfirstaidrecommendationformany years.Cooling thermal burnswillminimisetheresultingdepthoftheburn120,121and
pos-siblydecreasethenumberofpatientsthatwilleventuallyrequire hospitaladmissionfortreatment.122Theotherperceivedbenefits
ofcoolingarepainreliefandreductionofoedema,reduced infec-tionratesandafasterwoundhealingprocess.
Therearenoscientificallysupportedrecommendationsforthe specificcoolingtemperature,themethodofcooling(e.g.gelpads, coldpacks or water)or theduration of cooling.Cleanwater is readilyavailableinmanyareasoftheworldandcanthereforebe usedimmediatelyforcoolingofburns.Coolingofburnsfor10min isthecurrentlyperceivedrecommendedpractice.
Caremustbetakenwhencoolinglargethermalburnsorburns ininfantsandsmallchildrensoasnottoinducehypothermia. 2015FirstAidGuideline
Activelycoolthermalburnsassoonaspossibleforaminimum of10mindurationusingwater.
Wetordryburndressings
Abroadrangeofburnwounddressingsareavailable,ranging fromhydrocolloiddressings,polyurethanefilmdressings, hydro-gel dressings, silicon-coated nylon dressings, biosynthetic skin substitutedressings,antimicrobialdressings,fibredressingsand simplewounddressingpadswithorwithoutmedication.123
Cur-rentburnwounddressingsalsoincludeplasticwrap(clingfilmor medicalcommercialforms)andhastheadvantagethatitis inex-pensive,widelyavailable,non-toxic,non-adherent,impermeable, andtransparentallowingforwoundmonitoringwithouthavingto removethedressing.
No scientific evidence was found to determine which type of dressings, wet or dry, is most effective. The decision about whichtypeofburndressingfirstaidprovidersshoulduse,should thereforebedeterminedbynationalandlocalburnmanagement policies.
2015FirstAidGuideline
Subsequenttocooling,burnsshouldbedressedaccordingto currentpracticewithaloosesteriledressing(GoodPracticePoint). Dentalavulsion
Followingafalloraccidentinvolvingtheface,atoothcanbe injuredoravulsed.Appropriatefirstaidinthecaseofanavulsed permanenttoothincreasesthechanceofrecoveryafter replace-mentofthetooth.Immediatere-implantationistheintervention ofchoicebythedentalcommunity,howeveritisoftennot possi-bleforfirstaidproviderstore-implantthetoothduetoalackof trainingorskillsinthatprocedure.
Ifthetoothisnotimmediatelyre-implanted,thepriorityisto getthepatientandtheavulsedtoothtoadentist,whoiscapable ofre-implantingthetoothassoonaspossible.Inthemeanwhile storethetoothinatemporarystoragesolution.HanksBalanced Saltsolutionistherecommendedmedium,124–127butother
rec-ommendedsolutionsarePropolis,126,128eggwhite,125,126coconut
water,127ricetral124whencomparedwithsurvivalfollowing
stor-ageinwholemilk.Saline129,130andPhosphateBufferedsaline131
werelesseffectiveasstoragesolutionsthanwholemilk.Thechoice ofastoragesolutiondependsontheavailabilityandaccessibility ofthesolution.
2015FirstAidGuideline
Ifatoothcannotbeimmediatelyre-implantedstoreitinHank’s BalancedSaltSolution.IfthisisnotavailableusePropolis,eggwhite, coconutwater,ricetral,wholemilk,salineorPhosphateBuffered Saline(inorderofpreference)andrefertheindividualtoadentist assoonaspossible.
Education
FirstAideducationandtraining
EducationandtraininginFirstAidhasbeenshowntoincrease survivalfromtraumaamongthosepatientscaredforbytrainedfirst aidproviders132 andtoimprovetheresolutionofsymptoms.133
Education in the form of a public health campaign has also improvedtheabilitytorecogniselife-threateningillness,suchas stroke134andfromapreventionperspectiveithasbeenshownto
reducetheincidenceofburninjury.122
2015FirstAidGuideline
Firstaideducationprogrammes,publichealthcampaignsand formalfirstaidtrainingarerecommendedinordertoimprove pre-vention,recognitionandmanagementofinjuryandillness.
Conflictsofinterest
DavidZideman Noconflictofinterestreported
AnthonyJ.Handley MedicaladvisorBA,Virgin,Placesforpeople,Life savingSocieties,TradingCompanySecretaryRCUK ChristinaHafner Noconflictofinterestreported
DanielMeyran FrenchRedCross:Medicaladvisor EmmyDeBuck BelgianRedCross-Flanders:employee EuniceSingletary AmericanRedCrossAdvisoryCouncilmember PascalCassan FrenchRedCrossHeadGlobalFirstAidDefence
Center
PhilippeVandekerckhove RedCrossBelgium:employee
SusanneSchunder-Tatzber OMVAustrianOil&Gascompany:HealthManager ThanosChalkias Noconflictofinterestreported
TomEvans Noconflictofinterestreported
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