2024 AHA_ARC指南：急救

AHA/AMERICAN RED CROSS GUIDELINE

2024 American Heart Association and American Red Cross Guidelines for First Aid

Elizabeth K.Hewett Brumberg, MD, Co-Chair\*; Matthew J.Douma, MN, RN, Co-Chair\*; KostasAlibertis NR-P; Nathan P.Charlton, MD; Michael P.Goldman, MD, MHS-Med Ed; KatrinaHarper-Kirksey, MD; Seth C.Hawkins, MD, NREMT; Amber V.Hoover, MSN, RN; AmyKule, MD; StefanLeichtle, MD, MBA; Sarah FrancesMcClure, DO, NR-P; George SamWang, MD; MarkWhelchel, DNP, ACNP-BC; LynnWhite, MS; Eric J.Lavonas, MD, MS; on behalf of the American Heart Association and American Red Cross

ABSTRACT: Codeveloped by the American Heart Association and the American Red Cross, these guidelines represent the first comprehensive update of first aid treatment recommendations since 2010. Incorporating the results of structured evidence reviews from the International Liaison Committee on Resuscitation, these guidelines cover first aid treatment for critical and common medical, traumatic, environmental, and toxicological conditions. This update emphasizes the continuous evolution of evidence evaluation and the necessity of adapting educational strategies to local needs and diverse community demographics. Existing guidelines remain relevant unless specifically updated in this publication. Key topics that are new, are substantially revised, or have significant new literature include opioid overdose, bleeding control, open chest wounds, spinal motion restriction, hypothermia, frostbite, presyncope, anaphylaxis, snakebite, oxygen administration, and the use of pulse oximetry in first aid, with the inclusion of pediatric-specific guidance as warranted.

Key Words:

AHA Scientific Statements ◼ American Heart Association ◼ emergencies ◼ first aid ◼ Red Cross ◼ wounds and injuries

## TOP 10 TAKE-HOME MESSAGES FOR FIRST AID

1. General care and safety: The first aid provider should provide care within their skill and knowledge set, seeking further medical care as needed, and be mindful of their own safety. 2. First aid for bleeding: When faced with life-threatening bleeding, the first aid provider should apply direct pressure followed by application of a tourniquet or wound packing if the location of the wound is amenable. 3. First aid for chest pain: In adults with acute chest pain, it is recommended that emergency medical services be activated to initiate transport to the closest emergency department. While awaiting the arrival of emergency medical services, first aid providers may encourage alert adults experiencing nontraumatic chest pain to chew and swallow

aspirin (162–325 mg) unless the person experiencing pain has a known aspirin allergy or has been advised by a health care professional not to take aspirin.

4. First aid for stroke: The use of a stroke recognition scale such as Face, Arms, Speech, Time is recommended to aid in the recognition of acute stroke in adults and may also be used as an adjunct in pediatrics, although it is not validated in that setting and should not solely be used to identify the broad presentation of stroke in children.

5. First aid for opioid overdose: A first aid provider who encounters a person with suspected opioid overdose who is unresponsive and not breathing normally should activate the emergency response system, provide high-quality cardiopulmonary resuscitation (compressions plus ventilation), and administer naloxone.

## Nonstandard Abbreviations and Acronyms

AHA American Heart Association COR Class of Recommendation CPR cardiopulmonary resuscitation ED emergency department EMS emergency medical services FAST Face, Arm, Speech, Time ILCOR International Liaison Committee on Resuscitation LOE Level of Evidence NSAID nonsteroidal anti-inflammatory drug PCM physical counterpressure maneuver PPE personal protective equipment RCT randomized controlled trial 6. Assistance with administration of prescribed medications: The first aid provider should help a person self-administer prescribed lifesaving medications as needed such as inhaled bronchodilators for asthma and intramuscular epinephrine for anaphylaxis. 7. First aid for open chest wounds: In the first aid setting, it is reasonable to leave an open chest wound exposed to ambient air; to place a clean, nonocclusive, dry dressing such as gauze or a clean piece of cloth; or to place a specialized dressing such as a vented chest seal. 8. First aid for tick bites: First aid providers should remove an attached tick as soon as possible by grasping the head of the tick as close to the skin as possible with tweezers or a commercial tick removal device and pulling upward with steady, even pressure. 9. First aid for seizure: First aid providers should activate emergency medical services for first-time seizures; seizures lasting ${\tt>}5$ minutes; multiple seizures without return to normal; seizures in water; seizures with injuries, breathing difficulty, or choking; seizures in infants ${<}6$ months of age; and seizures in pregnant individuals or if the person does not return to baseline mental status within 5 to 10 minutes after seizure activity stops. 10. Oxygen and pulse oximetry use in first aid: It is reasonable for first aid providers to use pulse oximetry results as part of a complete assessment of an ill or injured person and in consideration of the many limitations of pulse oximeters. First aid providers should be aware of the potential harms of administration of supplemental oxygen in individuals with known chronic obstructive pulmonary disease and should not provide oxygen over an oxygen saturation of $92\%$ .

INTRODUCTION

Although battlefield first aid training has been documented for centuries, the concept of training members of the lay public is more recent. 1 In 1878, 2 British army officers, Surgeon-Major Peter Shepherd and Colonel Francis Duncan, established the concept of teaching first aid skills to civilians by using a comprehensive first aid curriculum. 2 In the United States, organized training in first aid started in 1903, when Clara Barton, president of the American Red Cross (Red Cross), formed a committee to establish instruction in first aid among industrial workers. 1 In 1911, Red Cross first aid training was expanded to include home nursing and first aid instruction taught by physicians. 3 The first Red Cross textbook on first aid for the general public was published in 1913. 4

Working in partnership with the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the Red Cross regularly provide evidence-based treatment recommendations for first aid topics. The last comprehensive review of AHA/ Red Cross first aid recommendations was published in 2010, 2 with updates focused on specific topics published in 2015, 1 2019, 5 and 2020. 6 The recommendations in this document are derived from that work, evidence evaluations from the ILCOR First Aid Task Force, 7–11 and structured evidence evaluations performed by the writing group.

## Scope of the Guidelines

First aid is defined as “helping behaviors and initial care provided for an acute illness or injury.” 1 First aid can be provided by anyone, including the ill or injured person (self-care), nearby individuals, and trained rescuers with a duty to respond (eg, lifeguards). The scope of first aid provided is based on the first aid provider’s level of training, available equipment and resources, overall scenario, and need. First aid competencies include, at any level of training, the following:

• Recognizing, assessing, and prioritizing the need for first aid; • Providing care by using appropriate knowledge, skills, and behaviors; and • Recognizing limitations and seeking additional care when needed. 1

These guidelines are intended to apply to common residential, workplace, and recreational settings. In general, first aid care begins when the first aid provider begins to assess and assist the ill or injured person and continues until the condition no longer requires urgent intervention, emergency medical services (EMS) professionals arrive, or the person arrives at definitive health care (eg, a hospital, urgent care facility, or doctor’s office).

## Organization of the Writing Group

The writing group included a diverse group of experts with backgrounds in critical care nursing, emergency medicine, pediatrics, pediatric emergency medicine, critical care, medical toxicology, pharmacology, critical care, trauma, EMS, wilderness medicine, education, research, and nursing. Group members were appointed by the AHA Emergency Cardiovascular Care Science Subcommittee and the Red Cross Scientific Advisory Council, and evidence reviews and knowledge syntheses were reviewed and approved by the AHA Emergency Cardiovascular Care Science Subcommittee and the Red Cross Scientific Advisory Council.

The AHA and the Red Cross have rigorous conflictof-interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Before appointment, writing group members disclosed all relevant commercial relationships and other potential (including intellectual) conflicts. These procedures are described more fully in “Part 2: Evidence Evaluation and Guidelines Development” in the “2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” 12 The Writing Group Disclosure Table in this document lists the writing group members’ relevant relationships with industry.

## METHODOLOGY AND EVIDENCE REVIEW

The writing group members first created and approved a list of first aid topics, drawing on the scope of prior guidelines and new topics that have gained prominence since the 2015 publication. A population, intervention, comparison, and outcome question was created for each topic. Guided by the chairs and with assistance from a professional medical librarian as needed, the writing group performed a structured evidence evaluation for each topic, which was internally peer reviewed. These searches were executed in Medline and the Excerpta Medica Database (Embase) using the Ovid search interface and the Cochrane Central Register of Controlled Trials. ILCOR evidence reviews published since 2015 were reviewed, and the dates of updated searches were harmonized with these reviews to avoid search overlap. Search results were not limited by language or year as long as an English language abstract was available. Final searches were executed in February through December 2023. Structured searches were supplemented by bibliography review and ad hoc searches when needed. Search results were imported into Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia; https://covidence.org). At least 2 writing

group members performed dual screening of the titles and abstracts of all articles identified from each search and identified articles for full-text review. Screening conflicts were resolved between the 2 writing group members and writing group leadership before full-text review. Two writing group members reviewed the full text of all selected articles and applied the information contained to develop treatment recommendations appropriate for each clinical question.

The opioid overdose first aid recommendations are based on guidelines provided by the AHA in 2020, 13,14 which were reaffirmed with additional evidence in 2023, 15 adapted for the first aid provider and setting.

Each draft recommendation was created by a group of 2 writing group members and then reviewed and refined by all writing group members during regular virtual meetings and 2 in-person meetings. Completed draft recommendations were reviewed by organizational leaders in the AHA and the Red Cross, with recommendations incorporated as draft revisions. Final draft recommendations were then externally peer reviewed.

## Class of Recommendation and Level of Evidence

Each recommendation was assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence, alternative treatment options, and impact on patients and society (Table1). Recommendation wording flows in a structured manner based on the COR determination. The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. In determining the COR, the writing group considered the LOE and other factors, including systems issues, economic factors, and ethical factors such as equity, acceptability, feasibility, and risk of harm. These evidencereview methods, including specific criteria used to determine COR and LOE, are described more fully in “Part 2: Evidence Evaluation and Guidelines Development” of the 2020 guidelines. 12 The writing group members had final authority over and formally approved these recommendations.

Unfortunately, despite improvements in the design and funding support for emergency care research, the overall certainty of the evidence base for first aid science is low. None of the 179 recommendations in these guidelines are supported by Level A evidence (high-quality evidence from >1 randomized controlled trial [RCT] or $\geq1$ RCTs corroborated by high-quality registry studies). Thirteen recommendations are supported by Level B randomized evidence (moderate evidence from $\geq1$ RCTs) and 23 by

 Table 1. Applying COR and LOE to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care\* (Updated May 2019)

Level B nonrandomized evidence. The majority of recommendations are based on Level C evidence, including those based on limited data (65 recommendations) and expert opinion (78 recommendations). Accordingly, the strength of recommendations is weaker than optimal: 82 recommendations are Class 1 (strong) recommendations; many of these are about calling for help. Forty-five Class 2a (moderate) recommendations and 31 Class 2b (weak) recommendations are included in these guidelines. In addition, 8 recommendations are designated Class 3: No Benefit, and 13 recommendations are Class 3: Harm. Clinical trials, thoughtfully designed intervention studies with real-world applicability, and well-controlled

observational studies in first aid science are clearly needed.

Guideline Structure

These guidelines are organized into modular knowledge chunks, grouped into discrete modules of information on specific topics or management issues. 16 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. A brief introduction is provided to put the recommendations into context with important background information and overarching management or treatment concepts.

Recommendation-specific supportive text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references facilitate quick access and review.

Document Review and Approval

These guidelines were submitted for blinded peer review to subject-matter experts nominated by the AHA and the Red Cross. Before appointment, all peer reviewers were required to disclose relationships with industry and any other conflicts of interest, and all disclosures were reviewed by AHA journal staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Emergency Cardiovascular Care Science Advisory Committee, the Red Cross Scientific Advisory Council, the AHA Scientific Advisory and Coordinating Committee, and the AHA Executive Committee. Comprehensive disclosure information for peer reviewers is listed in the Reviewer Disclosure Table.

These recommendations supersede the last full set of AHA/Red Cross first aid guidelines, published in 2015, and recommendations in the 2019 and 2020 focused updates.

REFERENCES

1. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation . 2015;132(suppl 2):S574– S589. doi: 10.1161/CIR.0000000000000269 2. Markenson D, Ferguson JD, Chameides L, Cassan P, Chung K-L, Epstein J, Gonzales L, Herrington RA, Pellegrino JL, Ratcliff N, Singer A. Part 17: first aid: 2010 American Heart Association and American Red Cross Guidelines for First Aid. Circulation . 2010;122(suppl 3):S934045. doi: 10.1161/CIRCULATIONAHA.110.971150 3. Dock LL, Pickett SE, Noyes CD, Clement FF, Fox EG, Van Meter AR. History of American Red Cross Nursing . The Macmillan Company; 1922. 4. Delano JA. Red Cross Textbook on Elementary Hygiene and Home Care of the Sick . Blakiston’s Son & Co; 1913. 5. Charlton NP, Pellegrino JL, Kule A, Slater TM, Epstein JL, Flores GE, Goolsby CA, Orkin AM, Singletary EM, Swain JM. 2019 American Heart Association and American Red Cross focused update for first aid: presyncope: an update to the American Heart Association and American Red Cross guidelines for first aid. Circulation . 2019;140:e931–e938. doi: 10.1161/CIR.0000000000000730 6. Pellegrino JL, Charlton NP, Carlson JN, Flores GE, Goolsby CA, Hoover AV, Kule A, Magid DJ, Orkin AM, Singletary EM, et al. 2020 American Heart Association and American Red Cross focused update for first aid. Circulation . 2020;142:e287–e303. doi: 10.1161/CIR.0000000000000900 7. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, Aickin R, Bhanji F, Donnino MW, Mancini ME, et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation . 2019;140:e826–e880. doi: 10.1161/CIR.0000000000000734 8. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S2–S27. doi: 10.1161/CIR.0000000000000890 9. Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, et al; COVID-19 Working Group. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group [published correction appears in Circulation . 2022;145:e760]. Circulation . 2022;145:e645–e721. doi: 10.1161/CIR.0000000000001017 10. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al; Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published correction appears in Circulation . 2024;149:e1218]. Circulation . 2022;146:e483–e557. doi: 10.1161/CIR.0000000000001095 11. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al; Collaborators. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published corrections appear in Circulation . 2024;149:e1128 and Circulation . 2024;149:e1411]. Circulation . 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179 12. Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, et al. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S358–S365. doi: 10.1161/CIR.0000000000000898 13. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al; on behalf of the Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S366–S468. doi: 10.1161/CIR.0000000000000916 14. Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, et al; on behalf of the Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S469–S523. doi: 10.1161/CIR.0000000000000901 15. Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, et al; American Heart Association. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2023;148:e149–e184. doi: 10.1161/CIR.0000000000001161 16. Levine GN, O’Gara PT, Beckman JA, Al-Khatib SM, Birtcher KK, Cigarroa JE, de Las Fuentes L, Deswal A, Fleisher LA, Gentile F, et al. Recent innovations, modifications, and evolution of ACC/AHA clinical practice guidelines: an update for our constituencies: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation . 2020;141:e34]. Circulation . 2019;139:e879–e886. doi: 10.1161/CIR.0000000000000651

MAJOR CONCEPTS

Overview

First aid scenarios vary widely, from minor illness and injuries to immediately life-threatening conditions such as heart attack, stroke, major trauma, or overdose. People may require first aid care for a few minutes or many hours, and not all scenes are safe. First aid providers vary in age, physical ability, level of acquired and retained skill, and willingness and ability to act. No single set of guidelines can encompass all scenarios. The philosophical principles

of beneficence, nonmaleficence, and autonomy are applicable: The first aid provider should assist the ill or injured person as much as possible, avoid causing harm, and respect the right of a person who is alert and capable of decision-making to accept or refuse care. 1

First aid recommendations do not include actions that legally can be performed only by a health care professional or those actions that require specialized training or equipment. In some cases, a first aid provider may have specialized training and a duty to respond; common examples include lifeguards and members of industrial emergency response teams. Local and institutional protocols and the tenets of advanced training supersede general first aid recommendations.

These guidelines assume that a first aid provider has access to common household items and nonprescription medications but does not have access to specialized medical equipment or monitoring tools. In addition, they are assumed to apply to settings where access to EMS and higher levels of medical care are readily available. Recommendations may need to be altered or amended in rural, wilderness, and other low-resource settings.

General Approach

The first aid provider can improve and empower their response through training and preparation, including maintaining a first aid kit and preparing for setting and activityrelated responses such as in the home, at the beach, or while backcountry skiing. The Red Cross’ recommended first aid kit content list is detailed in Tables2 and 3. The first step in the first aid response is to assess the scene for hazards and threats and to take actions to protect oneself, such as using personal protective equipment (PPE). There can be ambiguity in emergencies, and it can be difficult to determine whether help is needed. Deciding to act is the most important first step in the provision of first aid.

The person who may be ill or injured should be assessed with the standard systematic approach taught in a first aid course. First aid providers should assess the ill or injured person by checking for responsiveness, breathing, and potential injuries. Any abnormalities in responsiveness or breathing and any major injuries should be viewed as an emergency and should prompt activation of EMS.

Signs of a first aid emergency requiring professional assistance include (but are not limited to) the following:

• Unresponsiveness or new confusion • Breathing that is absent, abnormal sounding, too fast, or too slow • Severe or life-threatening bleeding • Persistent vomiting or diarrhea • Pallor, weakness, lethargy, diaphoresis, weak or absent peripheral pulses • Evidence of allergic reaction such as hives, facial swelling, difficulty breathing, or vomiting

Table 2. Minimum Contents for American Red Cross First Aid Kit

|Item*|Quantity+|Minimum size| |---|---|---| |Medical examination gloves|2pairs|| |Adhesive bandage| 3 each (4 each [16 total]) | 1×3in 3/4×3in Large fingertip Knuckle | |Adhesive tape||3/8 inx2.5 yd| | Topical wound gel or ointment (topical antibiotic) |10| 1/57 oz (0.5 g) application | |Alcohol-based hand sanitizer|10|1/32oz| | Eye/skin wash, saline solution||10z| |First aid guidebook||| | Supplies to secure dressing, roller bandage |A|2,3, or 4 inx4 yd| |Utility shears/scissors||7in| | Splint (compact, moldable splitting device with securing mechanism; eg, roller bandage, elastic bandage, triangular bandage, tape) ||4.0x24 in| | Supplies to control bleeding, sterile pad ||4x4in| | Tourniquet, manufactured, windless ||| | Triangular bandages||40x40x56 in| | Plastic bag, application of ice, storage of amputations orwaste (or instant cold pack) ||1 qt or 1 gal (4x5 in)| |Aspirin| 81mgx4 or 325mgx1 | Low-dose tablet or adult aspirin, chewable | |Oral glucose tablet |1tablet|200| | Splinter forceps/tweezers|||

Quantities and sizes in red differ from American Red Cross Advisory Council recommendations but are needed if the kit is to meet current American National Standards Institute compliance. Items in red are new additions based on the American National Standards Institute standards for Class A first aid kits or language tidying to maintain consistency with the institute’s 2021 standards. NA indicates not applicable.

\*All items should be latex free.

†Because of the high probability of specific injuries and illnesses based on occupational data, first aid kits should be provided for a single individual.

• Loss of vision, hearing, speech, movement, or balance • Severe pain, including chest and abdominal pain • Unusual behavior, especially actions that may cause harm (eg, walking into traffic) • Bites and stings from venomous snakes, scorpions, spiders, and certain insects • Exposure to toxins and poisons • Broken and dislocated limbs and joints

Whenever possible, first aid providers should approach from the direction that the person who needs help is facing, so as not to surprise or startle them and cause unnecessary movement. First aid providers should always begin by introducing themselves and their intention and obtaining

Table 3. Optional Items for American Red Cross First Aid Kit

|Item*|Quantity|Minimum size| |---|---|---| | Breathing barrier, latex-free face shield ||7A| |Foil blanket||52x84in| |Antiseptic|10|1/57 oz (0.5 g)| |Trauma pad||5×9in| |Topical antibiotic application|10|1/57 oz (0.5 g)| | Eye covering with means of attachment |1(2)| 2x9 sq in| |Burn dressing (gel soaked)||4x4in| |Burn treatment|10|1/32 oz (0.9 g)| |Hemostatic agent||2| |Epinephrine autoinjector| Minimum 1， recommended 2 doses |7| |Hanks Balanced Salt Solution||1fl oz|

The table lists optional items to be considered for a first aid kit. Red type indicates the optional items that will allow the kit to meet the 2021 recommendations for an American National Standards Institute Class A first aid kit. NA indicates not applicable. \*All items should be latex free.

the consent of the person or their parent or guardian. If the person is unresponsive or the parent or guardian of a minor is not present, consent to treatment is implied. A calm voice and approach can reduce the person’s fear and anxiety. This also allows the first aid provider to determine whether the person is awake and responsive to voice and verbal commands. If the ill or injured person can talk or cry normally, it may be assumed that their airway is open and their breathing is adequate. The first aid provider should communicate with the ill or injured person, explaining what they are doing to help and acting with respect and empathy. Many people with underlying health conditions will wear medical alert jewelry (typically a bracelet or pendant). The first aid provider should quickly look for this to help guide initial evaluation and treatment.

In many cases, an ill or injured person with a normal alertness and responsiveness may be left in the position in which they are most comfortable (usually the position in which they are found) unless there is a need to move them to a different location or position for safety reasons or to facilitate treatment. First aid providers may assess an ill or injured person by asking them questions to determine their mental status or medical history or by more closely examining part of their body (after obtaining consent). The first aid provider should activate EMS as soon as they determine that help is needed. Emergency telecommunicators (911 dispatchers or 911 call takers) can be a valuable source of help in directing first aid actions. If first aid provider is using a mobile phone, they should provide care to the ill or injured person while talking to the emergency dispatcher by activating the phone’s speaker function.

Not having first aid equipment is not a barrier to providing first aid. First aid providers may use whatever resources are available to them, and improvised equipment such as dressings and splints may be found among common items. Moreover, the simple act of attending to a frightened person is a compassionate act of first aid in and of itself.

Calling for Help

A crucial early step of first aid intervention is to recognize when help is needed and how to get it. First aid providers should know how to activate an on-site emergency response plan, how and when to access the EMS system, and how to contact the regional poison center (Table4).

Providing care for someone who is ill or injured should not delay calling for more advanced care if it is needed. However, if the first aid provider is alone with an injured or ill person and there are imminent threats to life involving the ABCs (airway, breathing, circulation), it may be necessary to perform lifesaving emergency interventions such as opening the airway or controlling life-threatening hemorrhage before leaving the person to activate the emergency response system.

Hand Hygiene and PPE

Proper hand hygiene prevents the spread of infections to the first aid provider and the ill or injured person. Hands should be cleaned with soap and water before and after first aid is provided and after contact with bodily fluids and surfaces around the person and handling medical equipment. An alcohol-based hand sanitizer may be used if soap and water are unavailable and the hands are not visibly soiled. If using soap and water, the first aid provider should wash hands for at least 20 seconds, scrubbing all surfaces of the fingers, hands, and wrists. Alcoholbased sanitizers should contain at least $60\%$ ethanol or isopropyl alcohol and should be rubbed over all surfaces of the fingers, hands, and wrists until the sanitizer has dried, ${\approx}30$ seconds.

Provider Safety

First aid should not be delayed or deferred because of concerns about disease transmission. However, the use

Table 4. Universal Emergency Telephone Numbers in the United States and Canada

|Location|EMS|Poison center| |---|---|---| |United States|911|1-800-222-1222| |Canada|911| 1-844-764-7669 (1-844-POISON-X) |

EMS indicates emergency medical services.

of PPE may help protect the first aid provider, the ill or injured person, and any bystanders. PPE minimizes exposure to hazards that cause injuries or illnesses and includes items such as gloves, masks, eye shields, gowns, and aprons. Education on and demonstration of how to perform hand hygiene and to safely put on, take off, and dispose of PPE are integral parts of risk reduction and should be included in all first aid education programs.

Special Populations

Providing first aid requires special consideration of the unique cultures, experiences, and characteristics of people and communities. Special consideration may be beneficial for the following groups.

Various Age Groups

Neonates $\langle\<<30$ days of age) and infants (between 30 days and 1 year of age): Care must be gentle and specialized, with attention to the fragility of their small size. Techniques such as infant cardiopulmonary resuscitation (CPR) require specific knowledge and handling.

Children (1 year of age–beginning of puberty): Communication might be challenging; attempt to calm them and possibly engage their caregiver. Age-appropriate techniques and equipment are essential. Beginning of puberty is defined by appearance of breast buds in girls and axillary hair in boys.

Adolescents: Consider their privacy and emotional concerns, and be sensitive to their potential fear or embarrassment.

Adults: Approach with standard procedures, adjusting for any preexisting conditions or other special needs.

Older people: Be aware of possible preexisting medical conditions, medications, or frailty. Ensure comfort, and take extra time if needed to communicate effectively.

Gender Identity

Respectful language: Use the person’s preferred pronouns and name if known.

Consider privacy and sensitivities: Recognize and respect potential sensitivities related to the person’s gender identity, especially if their clothing needs to be removed for treatment.

Different Cultures, Religions, and Languages

Cultural sensitivity: Recognize that cultural beliefs and practices may influence how a person reacts to illness or injury.

Religious considerations: Respect religious restrictions or requirements such as modesty, and seek guidance from family or community members if needed.

Language considerations: With appropriate privacy considerations, use translation assistance from bystanders or technology as appropriate.

People Experiencing Homelessness and People Who Use Drugs

Nonjudgmental approach: Approach with compassion and without judgment, focusing on the immediate medical needs.

Cognitively Diverse People

Respect for personal space: Maintain a respectful distance whenever possible because some individuals may have sensory sensitivities. Work with caregivers if possible.

Clear communication: Use simple, clear language and be patient, allowing extra time for responses.

Engage caregivers: If present, caregivers or family members may help with communication or care.

People Who Have Physical Disabilities

Understanding the differences and limitations: Be aware of the specific disability if possible, and adjust your approach accordingly.

Communication aids: Use aids or assistance from caregivers if needed for effective communication.

Victims of Physical or Sexual Violence

Injury and treatment may cause or exacerbate psychological trauma. A sensitive approach using the principles of trauma-informed care may be helpful. 2–4

First Aid Education

The primary goal of first aid education is to enhance layperson response to emergencies, aiming to increase both the quantity and quality of engagement in treating ill or injured people. This increase in layperson intervention is essential for reducing morbidity and saving lives. 5 Universal access to first aid education is strongly recommended, and its integration into everyday activities is advocated to achieve this goal. 5

Teaching Methodology

Although there is a lack of extensive RCTs, the combination of health science educational best practices and observational and quasi-experimental studies in first aid education provides a solid foundation for these recommendations. The teaching methodology of first aid is crucial. The “Learn, See, Practice, Prove, Do, Maintain” framework proposed by Sawyer et $a^{6}$ incorporates various educational concepts from procedural learning, 6 simulation, 7 and resuscitation science. 8 This model begins with learning, ideally through multimedia resources, followed by real-life demonstrations (seeing). These steps represent a “flipped classroom” model, enhancing advanced learning tasks in the presence of a teacher and peers. 9 Deliberate practice combines appropriate training frequency, 10 low-risk practice environments, 11 and direct observation for feedback. 12,13 Proving involves using valid and reliable assessments to ensure effective learning outcomes. 14 For instance, a first aid provider certificate

should indicate a learner’s ability to positively affect patient outcomes. 15 Maintaining the ability to perform first aid skill sets independently requires intermittent skill refreshers, also called spaced learning. 16,17,18 No educational effort perfectly integrates all aspects of the Learn, See, Practice, Prove, Do, Maintain framework, but it serves as a comprehensive guide for educators planning first aid training, covering content, teaching methods, and evaluation strategies. 19,20

Local Context

A crucial aspect of education delivery is understanding local needs before implementing an intervention. 20 Community engagement helps tailor the content such as prioritizing anaphylaxis education in schools that have a history of related emergencies or focusing on naloxone administration training for people who are most likely to witness an opioid emergency. 21–25 Programs like Stop the Bleed have gained traction partly because of their relevance to societal issues like mass shootings in America. 26 First aid educators should also focus on communities with historically poor medical outcomes attributable to lack of prior efforts for dedicated first aid education. 5

After the appropriate first aid topics are selected, decisions on the target audience, educators, additional teaching strategies, and evaluation methods are made. 20 Schools and other community institutions are key venues for universal first aid education. Even young children in schools should be included because they are capable of performing essential first aid tasks. 27 A collaborative approach in which first aid experts and community leaders work together in a train-the-trainer model is ideal. 28 This approach not only facilitates initial learning but also supports ongoing training refreshers. 17 Various methods, including discussions, simulations, and technological innovations such as CPR feedback devices 29 and potential future use of virtual/augmented reality platforms, 30 enhance the learning experience.

Evaluation

Evaluating the impact of first aid education involves aligning learning objectives with appropriate evaluation techniques, considering the constraints of time and resources. 20,31 Educational evaluations should focus on the effects of a course on first aid providers’ willingness and ability to provide appropriate first aid rather than just on course enjoyment. 19 Integrating educational efforts with implementation science, quality improvement science, and human factors principles can further enhance education and lead to better patient and provider outcomes. 32

REFERENCES

1. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract . 2021;30:17–28. doi: 10.1159/000509119 2. Fischer KR, Bakes KM, Corbin TJ, Fein JA, Harris EJ, James TL, Melzer-Lange MD. Trauma-informed care for violently injured patients in the emergency department. Ann Emerg Med . 2019;73:193–202. doi: 10.1016/j.annemergmed.2018.10.018 3. Wathen CN, Mantler T. Trauma- and violence-informed care: orienting intimate partner violence interventions to equity. Curr Epidemiol Rep . 2022;9:233–244. doi: 10.1007/s40471-022-00307-7 4. Wilson C, Pence DM, Conradi L. Trauma-informed care. In: Encyclopedia of Social Work . Oxford Research Encyclopedias; 2013. 5. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation . 2015;132(suppl 2):S574– S589. doi: 10.1161/CIR.0000000000000269 6. Sawyer T, White M, Zaveri P, Chang T, Ades A, French H, Anderson J, Auerbach M, Johnston L, Kessler D. Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad Med . 2015;90:1025–1033. doi: 10.1097/ACM.0000000000000734 7. Cheng A, Lang TR, Starr SR, Pusic M, Cook DA. Technology-enhanced simulation and pediatric education: a meta-analysis. Pediatrics . 2014;133:e1313–e1323. doi: 10.1542/peds.2013-2139 8. Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dainty KN, Diederich E, Lin Y, Leary M, et al. Part 6: resuscitation education science: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S551–S579. doi: 10.1161/CIR.0000000000000903 9. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ . 2018;18:38. doi: 10.1186/s12909-018-1144-z 10. Howard NM, Cook DA, Hatala R, Pusic MV. Learning curves in health professions education simulation research: a systematic review. Simul Healthc . 2021;16:128–135. doi: 10.1097/SIH.0000000000000477 11. Pusic MV, Triola MM. Determining the optimal place and time for procedural education. BMJ Qual Saf . 2017;26:863–865. doi: 10.1136/bmjqs-2017-007120 12. Swanberg M, Woodson-Smith S, Pangaro L, Torre D, Maggio L. Factors and interactions influencing direct observation: a literature review guided by activity theory. Teach Learn Med . 2022;34:155–166. doi: 10.1080/10401334.2021.1931871 13. Rushton A. Formative assessment: a key to deep learning? Med Teach . 2005;27:509–513. doi: 10.1080/01421590500129159 14. Cook DA, Hatala R. Validation of educational assessments: a primer for simulation and beyond. Adv Simul (Lond) . 2016;1:31. doi: 10.1186/s41077-016-0033-y 15. Murad MK, Husum H. Trained lay first responders reduce trauma mortality: a controlled study of rural trauma in Iraq. Prehosp Disaster Med . 2010;25:533–539. doi: 10.1017/s1049023x00008724 16. Yeung J, Djarv T, Hsieh MJ, Sawyer T, Lockey A, Finn J, Greif R; Education, Implementation and Team Task Force and Neonatal Life Support Task Force of the International Liaison Committee on Resuscitation (ILCOR). Spaced learning versus massed learning in resuscitation: a systematic review. Resuscitation . 2020;156:61–71. doi: 10.1016/j.resuscitation.2020.08.132 17. Patocka C, Cheng A, Sibbald M, Duff JP, Lai A, Lee-Nobbee P, Levin H, Varshney T, Weber B, Bhanji F. A randomized education trial of spaced versus massed instruction to improve acquisition and retention of paediatric resuscitation skills in emergency medical service (EMS) providers. Resuscitation . 2019;141:73–80. doi: 10.1016/j.resuscitation.2019.06.010 18. Pusic MV, Kessler D, Szyld D, Kalet A, Pecaric M, Boutis K. Experience curves as an organizing framework for deliberate practice in emergency medicine learning. Acad Emerg Med . 2012;19:1476–1480. doi: 10.1111/acem.12043 19. Praslova L. Adaptation of Kirkpatrick’s four level model of training criteria to assessment of learning outcomes and program evaluation in higher education. Educ Assess Eval Accountability . 2010;22:215–225. doi: 10.1007/s11092-010-9098-7 20. Thomas PA, Kern DE, Hughes MT, Tackett SA, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach . 4th ed. Johns Hopkins University Press; 2022. 21. Razaghizad A, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E,

Kimmelman J, Martel MO, Eisenberg MJ. The effect of overdose education and naloxone distribution: an umbrella review of systematic reviews. Am J Public Health . 2021;111:e1–e12. doi: 10.2105/AJPH.2021.306306

22. Polloni L, Baldi I, Lazzarotto F, Bonaguro R, Toniolo A, Gregori D,

Muraro A. Multidisciplinary education improves school personnel’s self-efficacy in managing food allergy and anaphylaxis. Pediatr Allergy Immunol .

2020;31:380–387. doi: 10.1111/pai.13212

23. Meyran D, Cassan P, Nemeth M, Singletary E, Raitt J, Djarv T, Carlson JN. The ability of first aid providers to recognize anaphylaxis: a scoping review. Cureus . 2023;15:e41547. doi: 10.7759/cureus.41547 24. Kobayashi L, Green TC, Bowman SE, Ray MC, McKenzie MS, Rich JD. Patient simulation for assessment of layperson management of opioid overdose with intranasal naloxone in a recently released prisoner cohort. Simul Healthc . 2017;12:22–27. doi: 10.1097/SIH.0000000000000182 25. Whittall JP, Orkin AM, Handford C, Klaiman M, Leece P, Charles M, Wright A, Turner S, Morrison LJ, Strike C, et al. Resuscitation simulation among people who are likely to witness opioid overdose: experiences from the SOONER trial. PLoS One . 2022;17:e0270829. doi: 10.1371/journal.pone.0270829 26. Ross EM, Redman TT, Mapp JG, Brown DJ, Tanaka K, Cooley CW, Kharod CU, Wampler DA. Stop the Bleed: the effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency. Prehosp Disaster Med . 2018;33:127–132. doi: 10.1017/S1049023X18000055 27. Bollig G, Wahl HA, Svendsen MV. Primary school children are able to perform basic life-saving first aid measures. Resuscitation . 2009;80:689–692. doi: 10.1016/j.resuscitation.2009.03.012 28. Madah-Amiri D, Clausen T, Lobmaier P. Utilizing a train-the-trainer model for multi-site naloxone distribution programs. Drug Alcohol Depend . 2016;163:153–156. doi: 10.1016/j.drugalcdep.2016.04.007 29. Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedback/prompt devices during training and CPR performance: a systematic review. Resuscitation . 2009;80:743–751. doi: 10.1016/j.resuscitation.2009.04.012 30. Ricci S, Calandrino A, Borgonovo G, Chirico M, Casadio M. Viewpoint: virtual and augmented reality in basic and advanced life support training. JMIR Serious Games . 2022;10:e28595. doi: 10.2196/28595 31. De Buck E, Van Remoortel H, Dieltjens T, Verstraeten H, Clarysse M, Moens O, Vandekerckhove P. Evidence-based educational pathway for the integration of first aid training in school curricula. Resuscitation . 2015;94:8–22. doi: 10.1016/j.resuscitation.2015.06.008 32. Cafazzo JA, St-Cyr O. From discovery to design: the evolution of human factors in healthcare. Healthc Q . 2012;15 Spec No:24–29. doi: 10.12927/hcq.2012.22845

GENERAL FIRST AID

Positioning of the Ill or Injured Person

Background

The positioning of the ill or injured person is an important first aid intervention that may affect their safety, airway patency, and sustained injuries. The recovery position, also described as semiprone, lateral recumbent, side lying, and three-quarters prone (Figure1), has long been recommended for individuals with decreased level of consciousness. Although the recovery position has been the subject of little formal study, its anticipated benefits are to maintain an open airway, prevent aspiration, and provide stability and comfort. 1 However, the recovery position may not be ideal if there are injuries to the spine, hip, or pelvis; if breathing is abnormal; or if CPR is needed.

This topic was the subject of a 2022 ILCOR systematic review. 1 An updated literature search was performed by the writing group in 2023.

| Positioning of the Ill or Injured Person for First Aid||||| |---|---|---|---|---| |COR|LOE||Recommendations|| ||C-LD|| 1. If a person requires CPR or rescue breathing (ie, is unresponsive with absent or abnormal breathing), the first aid provider should position the person supine and follow the CPR algorithm. || ||C-EO|| 2. A first aid provider who is assisting a person with a potentially serious illness or injury should immediately activate the emergency response system. || |||| 3. A first aid provider who is assisting a person with a potentialy serious illness or injury should remain with the person until trained rescuers arrive as long as it is safe to do so. || || C-EO C-EO || 4. If the area is unsafe, the first aid provider should move an ill or injured person to a safe location if possible and safe for the first aid provider to do so. || |||||| ||C-EO|| 5. If a person has been injured, is responsive, and is breathing normally and the nature of the injury suggests a neck, back, hip, or pelvic injury, thesuggests a neck, back, hip, or pelvic injury, the person should be left in the position in which theyperson should be left in the position in which they were found to avoid potential further injury unlesswere found to avoid potential further injury unless the area is unsafe. || ||C-EO|| 6. An awake and alert person who is having difficulty breathing should be allowed to assume a position most comfortable for breathing, which will be sitting up in most situations. || ||C-EO|| Individuals who are il or injured should be protected from hyperthermia or hypothermia dueto exposure. || |2a|C-LD|| 8. It is reasonable to position a person with decreased alertness of nontraumatic cause who is breathing normally in a recovery (side-lying) position. ||

Recommendation-Specific Supportive Text

1. The AHA and the Red Cross provide basic life support algorithms for lay rescuers and health care professionals to perform the initial steps of resuscitation for adults and children, with single rescuer and multiple rescuer procedures. 2,3 These algorithms include checking for responsiveness, shouting for nearby help, activating the emergency response system, assessing respirations, applying an automatic external defibrillator, and initiating

 Figure 1. The recovery position.

CPR or rescue breathing as appropriate. Chest compressions and rescue breathing are performed with the person being assisted in the supine position. 2. Activation of the emergency response system leads to the arrival of rescuers who are trained and equipped to manage medical emergencies, facilitates rapid transport to a health care facility, and may shorten time to definitive treatment. 4–7 3. Remaining with an ill or injured person enables the first aid provider to assist the person, provide reassurance, and monitor for changes in the person’s condition. 1 In some cases, it may be necessary to leave the person briefly to summon help, including activating the emergency response system. 4. To provide effective first aid care, a provider needs to recognize whether the setting is safe to assess or deliver medical assistance. 3 5. Although studies about moving an injured person in the first aid setting could not be identified, prior first aid guidelines have recommended that a person with suspected injuries to the neck, back, hip, or pelvis remain in their original position to avoid worsening the injury (eg, worsening hemorrhage or neurological injury). 8,9 6. It is presumed that a person who is alert will choose a position that optimizes their ability to breathe and avoids airway obstruction. No studies were identified that directly address this. A systematic review evaluated the effect of lateral position compared with other body positions on mortality, morbidity, and clinical adverse events in critically ill adults. The review authors could not identify one best position because of the lack of evidence in the included studies. 10 Encouraging individuals with difficulty breathing to assume a position of comfort is widely recommended. 11–15 Studies of adults with heart failure or chronic obstructive pulmonary disease found improved respiratory mechanics when patients were allowed to assume a sitting-up position. 16,17 A systematic review on the influence of body position on lung function in healthy individuals and specific patient groups found that in healthy individuals and patients with lung, heart, or neuromuscular diseases or obesity, lung function parameters such as forced expiratory volume and vital capacity were generally higher in more erect positions. 18

7. There is a well-documented association between both hyperthermia and hypothermia and adverse outcomes in patients who are ill or injured. In environments that are warm or hot, it is crucial to implement measures to prevent overheating. This can be achieved through the use of shade

and promoting evaporative and convective heat loss. Conversely, in cold settings, it is essential to prevent the loss of body heat to the environment and the ground. This can be accomplished by using insulating materials such as blankets and foam pads to maintain the patient’s normal body temperature. 19–23

8. The recovery position may reduce the risk for airway obstruction, facilitate drainage of airway secretions, and reduce the risk of aspiration in a person with a decreased level of responsiveness, particularly if the airway cannot be closely monitored by a first aid provider. In addition, a sidelying position may be preferred for comfort over the supine position by individuals in certain circumstances such as pregnant individuals, those with respiratory difficulties, or those with a greater or smaller body habitus. 1 A left-side lying position improves blood circulation for people in the later stages of pregnancy. 24,25 However, the recovery position is associated with delayed recognition of respiratory arrest and delayed initiation of chest compressions. 26

REFERENCES

1. Douma MJ, Handley AJ, MacKenzie E, Raitt J, Orkin A, Berry D, Bendall J, O’Dochartaigh D, Picard C, Carlson JN, et al. The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest: a systematic review. Resusc Plus . 2022;10:100236. doi: 10.1016/j.resplu.2022.100236 2. Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, et al; on behalf of the Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S469–S523. doi: 10.1161/CIR.0000000000000901 3. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al; on behalf of the Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S366–S468. doi: 10.1161/CIR.0000000000000916 4. Loh JP, Satler LF, Pendyala LK, Minha S, Frohna WJ, Torguson R, Chen F, Suddath WO, Pichard AD, Waksman R. Use of emergency medical services expedites in-hospital care processes in patients presenting with STsegment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Cardiovasc Revasc Med . 2014;15:219–225. doi: 10.1016/j.carrev.2014.03.011 5. Chiang D, Ade JM, Liu XW, Bellolio F, Lohse CM, Sandefur BJ, Campbell RL. Assessment of ED triage of anaphylaxis patients based on the Emergency Severity Index. Am J Emerg Med . 2021;46:449–455. doi: 10.1016/j.ajem.2020.10.057 6. Chen H, Wang J, Pan X, Zhang M. Effects of emergency medical services on timely treatment and outcome in stroke patients with intravenous thrombolysis among the severity of neurologic deficits: a retrospective observational study. Medicine (Baltimore) . 2023;102:e35053. doi: 10.1097/MD.0000000000035053 7. Wein TH, Staub L, Felberg R, Hickenbottom SL, Chan W, Grotta JC, Demchuk AM, Groff J, Bartholomew LK, Morgenstern LB. Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project. Stroke . 2000;31:1925–1928. doi: 10.1161/01.str.31.8.1925 8. Zarisfi F, Pek JH, Oh JHH, Loke JH, Lim SH. Singapore first aid guidelines 2021. Singapore Med J . 2021;62:427–432. doi: 10.11622/smedj.2021112 9. Christie RJ. Therapeutic positioning of the multiply-injured trauma patient in ICU. Br J Nurs . 2008;17:638–642. doi: 10.12968/bjon.2008.17.10.29477 10. Hewitt N, Bucknall T, Faraone NM. Lateral positioning for critically ill adult patients. Cochrane Database Syst Rev . 2016;2016:CD007205. doi: 10.1002/14651858.CD007205.pub2 11. Guerra AM, Waseem M. Epiglottitis. StatPearls . StatPearls Publishing; 2023. 12. Dubois G, Vasseur-Binachon B, Yoshimoto C. Clinical Guidelines – Diagnosis and Treatment Manual: Epiglottitis . MSF Medical Guidelines; 2023. Accessed December 31, 2023. https://medicalguidelines.msf.org/en/ viewport/CG/english/epiglottitis-16689226.html 13. American Academy of Pediatrics. Croup in young children. AAP Parenting Website. 2022. Accessed January 19, 2023. https://publications.aap.org/ patiented/article-abstract/doi/10.1542/peo_document381/82003/Crou p?redirectedFrom=fulltext 14. Sinha V, Dua A, Singh K, Alvarado AC, Skibiski J. Supraglottic airway obstruction. StatPearls . StatPearls Publishing; 2023. 15. Perth Children’s Hospital. Inhaled foreign body: emergency department guidelines. 2022. Accessed December 31, 2023. https://pch.health.wa.gov. au/For-health-professionals/Emergency-Department-Guidelines/Inhaledforeign-body 16. Elbehairy AF, Faisal A, McIsaac H, Domnik NJ, Milne KM, James MD, Neder JA, O’Donnell DE; Canadian Respiratory Research Network. Mechanisms of orthopnoea in patients with advanced COPD. Eur Respir J . 2021;57:2000754. doi: 10.1183/13993003.00754-2020 17. Nava S, Larovere MT, Fanfulla F, Navalesi P, Delmastro M, Mortara A. Orthopnea and inspiratory effort in chronic heart failure patients. Respir Med . 2003;97:647–653. doi: 10.1053/rmed.2003.1495 18. Katz S, Arish N, Rokach A, Zaltzman Y, Marcus EL. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med . 2018;18:159. doi: 10.1186/s12890-018-0723-4 19. Thomas-Ruddel DO, Hoffmann P, Schwarzkopf D, Scheer C, Bach F, Komann M, Gerlach H, Weiss M, Lindner M, Ruddel H, et al; MEDUSA Study Group. Fever and hypothermia represent two populations of sepsis patients and are associated with outside temperature. Crit Care . 2021;25:368. doi: 10.1186/s13054-021-03776-2 20. Schauer SG, April MD, Fisher AD, Weymouth WL, Maddry JK, Gillespie KR, Salinas J, Cap AP. Hypothermia in the combat trauma population. Prehosp Emerg Care . 2023;27:934–940. doi: 10.1080/10903127.2022.2119315 21. Rösli D, Schnüriger B, Candinas D, Haltmeier T. The impact of accidental hypothermia on mortality in trauma patients overall and patients with traumatic brain injury specifically: a systematic review and meta-analysis. World J Surg . 2020;44:4106–4117. doi: 10.1007/s00268-020-05750-5 22. Hopp S, Dominici F, Bobb JF. Medical diagnoses of heat wave-related hospital admissions in older adults. Prev Med . 2018;110:81–85. doi: 10.1016/j.ypmed.2018.02.001 23. Green H, Bailey J, Schwarz L, Vanos J, Ebi K, Benmarhnia T. Impact of heat on mortality and morbidity in low and middle income countries: a review of the epidemiological evidence and considerations for future research. Environ Res . 2019;171:80–91. doi: 10.1016/j.envres.2019.01.010 24. Hankins GD, Harvey CJ, Clark SL, Uckan EM, Van Hook JW. The effects of maternal position and cardiac output on intrapulmonary shunt in normal third-trimester pregnancy. Obstet Gynecol . 1996;88:327–330. doi: 10.1016/0029-7844(96)00212-8 25. Summers RL, Harrison JM, Thompson JR, Porter J, Coleman TG. Theoretical analysis of the effect of positioning on hemodynamic stability during pregnancy. Acad Emerg Med . 2011;18:1094–1098. doi: 10.1111/j.1553-2712.2011.01166.x 26. Freire-Tellado M, Navarro-Paton R, Pavon-Prieto MDP, Fernandez-Lopez M, Mateos-Lorenzo J, Lopez-Forneas I. Does lying in the recovery position increase the likelihood of not delivering cardiopulmonary resuscitation? Resuscitation . 2017;115:173–177. doi: 10.1016/j.resuscitation.2017.03.008

Position for Shock

Background

A person presenting with shock, including cardiogenic, hypovolemic, or hemorrhagic shock, may experience dizziness, difficulty breathing, chest pain, or skin mottling.

While waiting for EMS, the first aid provider can position the person in a way to optimize circulation to vital organs such as the brain and to avoid decompensation. Various studies have evaluated how body positioning such as standing, being supine, or elevating the legs potentially affects vital signs and cardiac function.

This topic was the subject of a 2022 ILCOR systematic review. 1 An updated literature search was performed by the writing group in 2023.

|First Aid Positioning of the Person in Shock|||| |---|---|---|---| |COR|LOE|Recommendations|| |2a|C-LD|1. If a person shows evidence of shock with a|| |2a|C-LD|2a| normal level of alertness, it is reasonable to place or maintain the person in a supine position. | |2a|C-LD|2a|| | 2. If a person showing signs of shock is at risk for airway obstruction (decreased alertness,airway obstruction (decreased alertness, active vomiting) or cannot be continuouslyactive vomiting) or cannot be continuously watched, it is reasonable to place the person in the recovery position. |C-LD|2a|| ||C-LD|2a|| |C-LD|C-LD|2a| 3. If there is no evidence of trauma or injury (eg,| |C-LD|simple fainting, shock from nontraumatic bleeding,||| |C-LD| sepsis, dehydration), raising the feet about 6 to 12 in (≈30°-45%) from supine position may be ||| |C-LD|reasonable while awaiting the arrival of EMS.||| |2b|C-EO| 4. If a person is placed in a leg-raised position that results in pain, discomfort, or worsened || |2b|C-EO| 4. If a person is placed in a leg-raised position that results in pain, discomfort, or worsened | results in pain, discomfort, or worsened symptoms, returning the person to a supine position may be considered. |

Recommendation-Specific Supportive Text

1. An observational study found that in individuals undergoing phlebotomy, a supine position resulted in greater cardiac index and lower heart rate compared with a standing position. 2 2. The recovery position may reduce the risk for airway obstruction, facilitate drainage of airway secretions, and reduce the risk of aspiration in individuals with a decreased level of responsiveness, particularly if the airway cannot be closely monitored by a first aid provider. In addition, a side-lying position may be preferred for comfort over the supine position by individuals in certain circumstances such pregnant individuals, people with respiratory difficulties, or those with a greater or smaller body habitus. 1 3. The beneficial evidence for feet elevation is extrapolated from an RCT and observational studies performed in non–first aid settings, demonstrating an effect of the passive leg raise on vital signs and indicators of cardiac output. Observed improvements with passive leg raise compared with the supine position in hypotensive subjects were temporary, and not all studies show this effect. 3–7 4. Complications such as arrhythmias and hypoxia have developed in hemodynamically unstable

patients who have been moved into the elevatedfeet position. Although these were detected with the use of in-hospital monitors, the development of new symptoms may indicate condition decompensation. 8

REFERENCES

1. Douma MJ, Handley AJ, MacKenzie E, Raitt J, Orkin A, Berry D, Bendall J, O’Dochartaigh D, Picard C, Carlson JN, et al. The recovery position for maintenance of adequate ventilation and the prevention of cardiac arrest: a systematic review. Resusc Plus . 2022;10:100236. doi: 10.1016/j.resplu.2022.100236 2. Wong DH, O’Connor D, Tremper KK, Zaccari J, Thompson P, Hill D. Changes in cardiac output after acute blood loss and position change in man. Crit Care Med . 1989;17:979–983. doi: 10.1097/00003246-198910000-00002 3. Kyriakides ZS, Koukoulas A, Paraskevaidis IA, Chrysos D, Tsiapras D, Galiotos C, Kremastinos DT. Does passive leg raising increase cardiac performance? A study using Doppler echocardiography. Int J Cardiol . 1994;44:288–293. doi: 10.1016/0167-5273(94)90294-1 4. Kamran H, Salciccioli L, Kumar P, Pushilin S, Namana V, Trotman S, Lazar J. The relation between blood pressure changes induced by passive leg raising and arterial stiffness. J Am Soc Hypertens . 2010;4:284–289. doi: 10.1016/j.jash.2010.09.002 5. Jabot J, Teboul JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change. Intensive Care Med . 2009;35:85–90. doi: 10.1007/s00134-008-1293-3 6. Gaffney FA, Bastian BC, Thal ER, Atkins JM, Blomqvist CG. Passive leg raising does not produce a significant or sustained autotransfusion effect. J Trauma . 1982;22:190–193. doi: 10.1097/00005373-198203000-00003 7. Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest . 2002;121:1245–1252. doi: 10.1378/chest.121.4.1245 8. Toppen W, Aquije Montoya E, Ong S, Markovic D, Kao Y, Xu X, Chiem A, Cannesson M, Berlin D, Barjaktarevic I. Passive leg raise: feasibility and safety of the maneuver in patients with undifferentiated shock. J Intensive Care Med . 2020;35:1123–1128. doi: 10.1177/0885066618820492

Administration of Oxygen

Background

The administration of oxygen for injured or ill individuals in the prehospital setting has been a mainstay of EMS care for nearly 50 years. Historical indications have included breathing problems, chest pain, traumatic injury, and stroke. Oxygen therapy plays a vital role in stabilizing patients experiencing inadequate tissue oxygenation, thereby averting or mitigating hypoxiainduced cellular damage. Although oxygen is generally safe and straightforward to administer, its use is not without controversy. Recent studies have demonstrated worse outcomes for some conditions when oxygen is administered. Moreover, the availability and suitability for lay first aid providers of oxygen therapy have been questioned.

ILCOR completed a scoping review on the use of oxygen for first aid in 2022 1 and a systematic review on the use of oxygen for acute stroke in 2020. 2 An updated literature search was performed by the writing group in 2023.

| Administration of Oxygen in First Aid||| |---|---|---| |COR|C-LD|Recommendations| |2b|C-LD| tered in the first aid setting foradults or children exhibiting signs or symptoms of shortness of breath, dificulty breathing, or hypoxia is unknown. | |2b|C-LD| tered in the first aid setting foradults or children exhibiting signs or symptoms of shortness of breath, dificulty breathing, or hypoxia is unknown. | ||C-LD|B-R| | 3:NO Benefit | It is not beneficial to administer oxygen over room air in the first aid setting for adults experiencing acute stroke. |B-R| | 3:NO Benefit | It is potentially harmful for first aid providers to administer supplementary oxygen to a person with known chronic obstructive pulmonary disease to |B-R| ||||

Recommendation-Specific Supportive Text

1. A 2022 ILCOR scoping review did not identify any studies on the effectiveness of oxygen therapy in the first aid setting. 1 The ILCOR First Aid Task Force concluded that there is no direct evidence to support or not support the use of oxygen by first aid providers in the first aid setting. No evidence was found about whether people with specific conditions such as drowning, carbon monoxide poisoning, decompression illness, or pneumonia would benefit from oxygen administration in the first aid setting. Although there are specific conditions for which oxygen administration by health care professionals or specially trained rescuers has been proven beneficial, particularly when guided by reliable pulse oximetry, the overarching message is that a role for oxygen administration in general first aid has not been established.

2. An ILCOR 2020 systematic review on oxygen for acute stroke did not identify a benefit of oxygen over room air for survival or neurological outcome. 2 A single observational study in the prehospital setting 3 provided direct evidence from the prehospital setting, supported by 8 RCTs from the in-hospital setting. These studies compare the use of supplementary oxygen with varying flow rates and delivery methods with no use of supplementary oxygen (ie, room air) in individuals with acute stroke. These studies failed to find a benefit for critical outcomes such as survival, favorable neurological outcomes, and quality of life.

3. One study and a Cochrane systematic review identified by the task force enrolled 214 adults with chronic obstructive pulmonary disease receiving treatment by paramedics en route to the hospital. The study observed a reduction in mortality in favor of the group in whom oxygen was titrated to maintain pulse oximetry of $92\%$ compared with the group receiving high-flow oxygen (2 deaths in the titrated oxygen group compared with 11 deaths in the high-flow control arm; risk ratio, 0.22 $[95\%$ CI, 0.05–0.97]; 214 participants). 4,5

REFERENCES

1. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al; Collaborators. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published corrections appear in Circulation . 2024;149:e1128 and Circulation . 2024;149:e1411]. Circulation . 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179 2. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 3. Dylla L, Adler DH, Abar B, Benesch C, Jones CMC, Kerry O’Banion M, Cushman JT. Prehospital supplemental oxygen for acute stroke: a retrospective analysis. Am J Emerg Med . 2020;38:2324–2328. doi: 10.1016/j.ajem.2019.11.002 4. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ . 2010;341:c5462. doi: 10.1136/bmj.c5462 5. Kopsaftis Z, Carson-Chahhoud KV, Austin MA, Wood-Baker R. Oxygen therapy in the pre-hospital setting for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev . 2020;1:CD005534. doi: 10.1002/14651858.CD005534.pub3

Pulse Oximetry

Background

Pulse oximetry is a simple, noninvasive test for assessing health conditions in both health care facilities and outof-hospital settings. Recently, this technology has also found its way into home first aid kits and wearable devices such as watches and fitness bands. By using these devices, first aid providers may be able to measure the level of oxygen bound to hemoglobin in the blood. This information is valuable for evaluating both respiratory and circulatory health, particularly in urgent situations. During the COVID-19 pandemic, pulse oximetry was used by infected individuals at home as a tool to detect silent hypoxia and to determine whether they needed to present for care in a clinic or emergency department (ED). 1,2

Table 5. Limitations of Pulse Oximeters

|Patient factors|Device factors|Environmental factors| |---|---|---| | Chronic respiratory disease |Battery level/charge|Extremes of temperature| | Nail thickness and nail paint or polish | Device condition such as being dusty, dirty, or damaged | Movement or vibration such as transportation | | Heart rhythm and cardiac output | Size and orientation of light and sensor | Moisture and humidity| | Skin thickness, perfusion, pigmentation, and temperature | Device accuracy and calibration (FDA categories): 1.Consumer product 2.Home-use medical devices 3.Medical device | Interference from direct external light sources, including sunlight |

FDA indicates US Food and Drug Administration.

Patients and health care professionals highly value the use of pulse oximeters for home management of different conditions. 3 Of concern, however, are the numerous limitations pulse oximeters, including their systematic overestimation of oxygen saturation in individuals with darker skin pigmentation 4–6 (Table5). Moreover, pulse oximeters sold over the counter may not be approved or cleared by the US Food and Drug Administration or other regulatory agencies. 7

This topic was the subject of a 2022 ILCOR scoping review. 8 An updated literature search was performed by the writing group in 2023.

|Use of Pulse Oximetry in First Aid||| |---|---|---| |COR|LOE|Recommendations| ||C-EO| 1.A physical examination and history should be the primary assessment methods for first aid provid- ers to evaluate an ill or injured person. | ||C-EO| 1.A physical examination and history should be the primary assessment methods for first aid provid- ers to evaluate an ill or injured person. | |2a|C-EO| 2.1It isreasonableforfirst aid providers to usepulse oximetry results in the context of a complete assessment and to be aware of the limitations of | |2a|C-EO| 2.1It isreasonableforfirst aid providers to usepulse oximetry results in the context of a complete assessment and to be aware of the limitations of |

Recommendation-Specific Supportive Text

1. The primary survey, physical examination, and SAMPLE history (signs/symptoms, allergies, medications, past medical history, last oral intake, events leading up to present illness/injury) are essential components of the first aid assessment, which is structured to rapidly detect life-threatening conditions. Skipping these essential assessment components may result in delays in the detection and resolution of life-threatening conditions. Assessment of respiratory status includes observing for bluish discoloration of the face, lips, or nails; abnormal respiratory rate and effort; cough; a sensation of dyspnea; restlessness and discomfort; chest pain or tightness; and increased heart rate. Interpretation of any numerical value provided by a pulse oximeter must include considering these and other potential assessment findings.

2. Pulse oximeters have numerous limitations. Pulse oximeter accuracy can be affected by many patient, device, and environmental factors. In 2 large hospital-based cohort studies that compared oxygen saturation measured by pulse oximetry with the gold standard of arterial blood gas analysis, Black patients had almost 3 times the frequency of hypoxemia that was missed by pulse oximetry compared with White patients. 4 A systematic review and meta-analysis concluded that pulse oximetry may overestimate oxygen saturation in people with high levels of skin pigmentation and people whose ethnicity is reported as Black/African American compared with oxygen saturation measured from a blood sample. 5 Many environmental factors,

including ambient lighting, temperature, and movement, can also interfere with pulse oximeter accuracy. 7 Devices that have not been approved by the US Food and Drug Administration may be even less accurate.

REFERENCES

1. Wilkerson RG, Annous Y, Farhy E, Hurst J, Smedley AD. Home pulse oximetry monitoring during the COVID-19 pandemic: an assessment of patient engagement and compliance [published online June 26, 2023]. Health Policy Technol . doi: 10.1016/j.hlpt.2023.100776. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC10291857/ 2. Luks AM, Swenson ER. Pulse oximetry for monitoring patients with COVID-19 at home: potential pitfalls and practical guidance. Ann Am Thorac Soc . 2020;17:1040–1046. doi: 10.1513/AnnalsATS.202005-418FR 3. Shah S, Majmudar K, Stein A, Gupta N, Suppes S, Karamanis M, Capannari J, Sethi S, Patte C. Novel use of home pulse oximetry monitoring in COVID-19 patients discharged from the emergency department identifies need for hospitalization. Acad Emerg Med . 2020;27:681–692. doi: 10.1111/acem.14053 4. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med . 2020;383:2477–2478. doi: 10.1056/NEJMc2029240 5. Shi C, Goodall M, Dumville J, Hill J, Norman G, Hamer O, Clegg A, Watkins CL, Georgiou G, Hodkinson A, et al. The accuracy of pulse oximetry in measuring oxygen saturation by levels of skin pigmentation: a systematic review and meta-analysis. BMC Med . 2022;20:267. doi: 10.1186/s12916-022-02452-8 6. Jamali H, Castillo LT, Morgan CC, Coult J, Muhammad JL, Osobamiro OO, Parsons EC, Adamson R. Racial disparity in oxygen saturation measurements by pulse oximetry: evidence and implications. Ann Am Thorac Soc . 2022;19:1951–1964. doi: 10.1513/AnnalsATS.202203-270CME 7. US Food and Drug Administration. Pulse Oximeter Accuracy and Limitations: FDA Safety Communication. 2023. Accessed October 30, 2023. https://public4.pagefreezer.com/content/FDA/20-02-2024T15:13/ https://www.fda.gov/medical-devices/safety-communications/pulse-oximeter-accuracy-and-limitations-fda-safety-communication 8. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al; Collaborators. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published corrections appear in Circulation . 2024;149:e1128 and Circulation . 2024;149:e1411]. Circulation . 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179

MEDICAL EMERGENCIES

Bronchodilators for Asthma With Shortness of Breath

Background

There are many causes of shortness of breath. First aid providers may encounter a person with a previous diagnosis of asthma who has acute difficulty breathing or is wheezing. Many will carry prescribed inhaled medication with them to use when they are experiencing an asthma exacerbation. Some people, because of severity of illness or other factors, may require assistance to self-administer bronchodilator medication.

The ILCOR performed a scoping review on potential harms from bronchodilator administration in 2022. 1 An updated literature search was performed by the writing group in 2023.

| First Aid Recommendations for Assisting a Person Experiencing an Asthma Attack With Using Their Own Inhaled Bronchodilator Medication ||| |---|---|---| |COR|LOE|| |||1. First aid providers should assist a person with| ||B-R|| ||B-R| asthma who is having difficulty breathing with the administration of their own prescribed bronchodilators as needed. | ||B-R|| |2a|B-R|2.It is reasonable to use either an inhaler with a| |2a|B-R| spacer or a nebulizer when assisting a person with asthma to use their own inhaled bronchodilator | ||B-R|medication, in preference to using aninhaler alone.| |2a|B-R| 3. If a commercially available spacer is not available, it isreasonabletouseanimprovisedspacerwhen | |2a|B-R|| |2a|B-R|assisting a person who is having an asthma attack| |||to use theirowninhaledbronchodilatormedication.|

Recommendation-Specific Supportive Text

1. Inhaled bronchodilators are effective in patients with asthma and acute shortness of breath. 2–12 Evidence from included studies was extrapolated from the EMS and ED settings to the first aid setting. No new studies specifically examining the first aid setting have been published since the prior guidelines in 2015. 13 Bronchodilator administration is safe; treatment with albuterol/salbutamol causes no clinically significant change in heart rate, 5–7,12 blood pressure, 5 serum potassium, tremor, headache, nervousness, weakness, palpitation, or dry mouth. 12

2. When used with a metered dose inhaler, spacer devices improve the delivery of bronchodilator medications to the lungs. 14 Inhalers with spacer devices provide clinical effectiveness equal to that of nebulizer machines, including in community settings. 15

3. Improvised spacers made with a 500-mL $\langle\approx\!16$ oz) plastic cold drink bottle 16–19 or a 150-mL ( ≈ 5 oz) disposable paper cup 20 appear to provide drug delivery similar to that achieved with commercial spacer devices (Figure2).

 Figure 2. Use of an improvised spacer with a metered dose inhaler.

REFERENCES 1. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al; Collaborators. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published corrections appear in Circulation . 2024;149:e1128 and Circulation . 2024;149:e1411]. Circulation . 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179 2. van der Woude HJ, Postma DS, Politiek MJ, Winter TH, Aalbers R. Relief of dyspnoea by beta2-agonists after methacholine-induced bronchoconstriction. Respir Med . 2004;98:816–820. doi: 10.1016/j.rmed.2004.03.001 3. Politiek MJ, Boorsma M, Aalbers R. Comparison of formoterol, salbutamol and salmeterol in methacholine-induced severe bronchoconstriction. Eur Respir J . 1999;13:988–992. doi: 10.1034/j.1399-3003.1999.13e10.x 4. Berger WE, Milgrom H, Skoner DP, Tripp K, Parsey MV, Baumgartner RA; Xopenex Pediatric Asthma Group. Evaluation of levalbuterol metered dose inhaler in pediatric patients with asthma: a double-blind, randomized, placebo- and active-controlled trial. Curr Med Res Opin . 2006;22:1217– 1226. doi: 10.1185/030079906X112534 5. Littner MR, Tashkin DP, Siegel SC, Katz R. Double-blind comparison of acute effects of inhaled albuterol, isoproterenol and placebo on cardiopulmonary function and gas exchange in asthmatic children. Ann Allergy . 1983;50:309–316. 6. Emerman CL, Shade B, Kubincanek J. A controlled trial of nebulized isoetharine in the prehospital treatment of acute asthma. Am J Emerg Med . 1990;8:512–514. doi: 10.1016/0735-6757(90)90153-q 7. Bentur L, Canny GJ, Shields MD, Kerem E, Schuh S, Reisman JJ, Fakhoury K, Pedder L, Levison H. Controlled trial of nebulized albuterol in children younger than 2 years of age with acute asthma. Pediatrics . 1992;89:133–137. 8. Amirav I, Yacobov R, Luder AS. Formoterol Turbuhaler is as effective as Salbutamol Diskus in relieving adenosine-induced bronchoconstriction in children. J Aerosol Med . 2007;20:1–6. doi: 10.1089/jam.2006.0561 9. Hermansen MN, Nielsen KG, Buchvald F, Jespersen JJ, Bengtsson T, Bisgaard H. Acute relief of exercise-induced bronchoconstriction by inhaled formoterol in children with persistent asthma. Chest . 2006;129:1203– 1209. doi: 10.1378/chest.129.5.1203 10. Osmond MH, Klassen TP. Efficacy of ipratropium bromide in acute childhood asthma: a meta-analysis. Acad Emerg Med . 1995;2:651–656. doi: 10.1111/j.1553-2712.1995.tb03607.x 11. Weiss SJ, Anand P, Ernst AA, Orgeron D, May WL. Effect of out-of-hospital albuterol inhalation treatments on patient comfort and morbidity. Ann Emerg Med . 1994;24:873–878. doi: 10.1016/s0196-0644(94)70205-5 12. Karpel JP, Aldrich TK, Prezant DJ, Guguchev K, Gaitan-Salas A, Pathiparti R. Emergency treatment of acute asthma with albuterol metered-dose inhaler plus holding chamber: how often should treatments be administered? Chest . 1997;112:348–356. doi: 10.1378/chest.112.2.348 13. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation . 2015;132(suppl 2):S574– S589. doi: 10.1161/CIR.0000000000000269 14. Newman SP. Spacer devices for metered dose inhalers. Clin Pharmacokinet . 2004;43:349–360. doi: 10.2165/00003088-200443060-00001 15. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev . 2013;2013:CD000052. doi: 10.1002/14651858.CD000052.pub3 16. Rodriguez C, Sossa M, Lozano JM. Commercial versus home-made spacers in delivering bronchodilator therapy for acute therapy in children. Cochrane Database Syst Rev . 2008;2008:CD005536. doi: 10.1002/14651858.CD005536.pub2 17. Schor D, Rizzo JA, Medeiros D, Dela Bianca AC, Silva AR, Nunes C, Morais-Almeida M, Sarinho E. Home-made spacer as an auxiliary device in administration of beclomethasone via pressurized metered dose inhaler for asthma control: a randomized controlled pragmatic trial. Respir Med . 2017;126:52–58. doi: 10.1016/j.rmed.2017.03.017 18. Zar HJ, Streun S, Levin M, Weinberg EG, Swingler GH. Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction. Arch Dis Child . 2007;92:142–146. doi: 10.1136/adc.2006.101642 19. Zar HJ, Weinberg EG, Binns HJ, Gallie F, Mann MD. Lung deposition of aerosol: a comparison of different spacers. Arch Dis Child . 2000;82:495– 498. doi: 10.1136/adc.82.6.495 20. Willemse BW, Toelle BG, Li JS, Shah S, Peat JK. Use of a paper disposable cup as a spacer is effective for the first-aid management of asthma. Respir Med . 2003;97:86–89. doi: 10.1053/rmed.2002.1407

Recognition of Stroke in Adults

Background

Stroke is a leading cause of death and disability worldwide. Each year, nearly 800000 people in the United States experience a new or recurrent stroke. 1 Projections show that between 2012 and 2030, ${\approx}3.4$ million US adults, representing $3.9\%$ of the adult population, will have had a stroke. 1,2

Various stroke recognition instruments have been developed for both in-hospital and prehospital use. Compared with stroke scales intended for in-hospital use, stroke scales designed for the first aid setting have fewer diagnostic criteria, easily identified clinical signs, and simple implementation.

The ILCOR published a systematic review on stroke recognition in 2020. 3,4 An updated literature search was performed by the writing group in 2023.

|| Recognition of Stroke in the First Aid Setting-Adults||| |---|---|---|---| |COR|LOE|Recommendations|| ||B-NR| 1. If stroke is suspected, the EMS system should be activated immediately. || ||B-NR| The use of a stroke recognition scale such as the Face, Arms, Speech, Time (FAST) or Cincinnati || ||B-NR| Face, Arms, Speech, Time (FAST) or Cincinnati Prehospital Stroke Scale is recommended to aid in || ||B-NR|the recognition of acute stroke in adults.|| |2a|C-EO||| |2a|C-EO| capilary blood glucose in adults with suspected stroke if it is available and does not delay activating EMS. ||

Recommendation-Specific Supportive Text

1. Stroke is a serious and time-sensitive medical emergency. Emergency interventions are most effective when delivered promptly. Use of EMS by patients with stroke has been associated with earlier ED arrival, quicker ED evaluation, more rapid treatment, and more eligible patients receiving intervention. 5,6 For the best outcomes possible, recognition and activation of the stroke care system should occur as quickly as possible.

2. A 2020 ILCOR systematic review 3 evaluated 9 different screening tools reported in 19 observational studies. The FAST, 7 which is essentially identical to the Cincinnati Prehospital Stroke Scale, was the only tool intended for administration by laypeople (Figure3). The FAST and the Cincinnati Prehospital Stroke Scale have the same 3 physical examination items (face, arms, and speech), which the review authors identified as appropriate

 Figure 3. The FAST (Face, Arms, Speech, Time) stroke recognition tool.

Reproduced with permission from the American Stroke Association. 8 Copyright $\copyright$ 2020, American Heart Association, Inc.

for use by first aid providers. Although data specific to first aid providers are lacking, the use of stroke scales coached by EMS dispatchers and by EMS personnel improves early recognition of stroke. 9,10

3. If a first aid provider has the necessary knowledge and equipment to perform capillary blood glucose measurement, the measurement of blood glucose may aid in ruling out hypoglycemia, a common stroke mimic.

2. Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, Lackland DT, Lichtman JH, Mohl S, Sacco RL, et al; on behalf of the American Heart Association Advocacy Coordinating Committee and Stroke Council. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association [published correction appears in Stroke . 2015;46:e179]. Stroke . 2013;44:2361–2375. doi: 10.1161/STR.0b013e31829734f2 3. Meyran D, Cassan P, Avau B, Singletary E, Zideman DA. Stroke recognition for first aid providers: a systematic review and meta-analysis. Cureus . 2020;12:e11386. doi: 10.7759/cureus.11386 4. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 5. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke . 2019;50:e440–e441]. Stroke . 2018;49:e46–e110. doi: 10.1161/STR.0000000000000158 6. Ekundayo OJ, Saver JL, Fonarow GC, Schwamm LH, Xian Y, Zhao X, Hernandez AF, Peterson ED, Cheng EM. Patterns of emergency medical services use and its association with timely stroke treatment: findings

REFERENCES

1. Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, et al; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2023 update: a report from the American Heart Association [published corrections appear in Circulation . 2023;147:e622 and Circulation . 2023;148:e4]. Circulation . 2023;147:e93–e621. doi: 10.1161/CIR.0000000000001123

from Get With The Guidelines–Stroke. Circ Cardiovasc Qual Outcomes . 2013;6:262–269. doi: 10.1161/CIRCOUTCOMES.113.000089 7. Wall HK, Beagan BM, O’Neill J, Foell KM, Boddie-Willis CL. Addressing stroke signs and symptoms through public education: the Stroke Heroes Act FAST campaign. Prev Chronic Dis . 2008;5:A49. 8. American Stroke Association. Spot a stroke F.A.S.T. poster. Accessed April 25, 2024. https://stroke.org/en/help-and-support/resource-library/fastmaterials/fast-poster-2020 9. De Luca A, Giorgi Rossi P, Villa GF; Stroke group Italian Society pre hospital emergency Services. The use of Cincinnati Prehospital Stroke Scale during telephone dispatch interview increases the accuracy in identifying stroke and transient ischemic attack symptoms. BMC Health Serv Res . 2013;13:513. doi: 10.1186/1472-6963-13-513 10. Berglund A, Svensson L, Wahlgren N, von Euler M; HASTA Collaborators. Face Arm Speech Time Test use in the prehospital setting, better in the ambulance than in the emergency medical communication center. Cerebrovasc Dis . 2014;37:212–216. doi: 10.1159/000358116

Recognition of Stroke in Children

Background

Approximately 40000 children worldwide experience stroke each year. 1 Pediatric stroke incidence peaks at 3 time points: in the perinatal period, before 5 years of age, and in adolescence. Whereas perinatal strokes typically occur when the neonate is in the hospital, strokes affecting older children and adolescents may first be noted by a first aid provider. Although pediatric stroke can present in similar ways to adult stroke, it can also present in nonspecific ways and mimic other childhood diseases. Table6 lists the most common signs and symptoms of pediatric stroke.

The ILCOR published a systematic review on stroke recognition in 2020. 2,3 An updated literature search was performed by the writing group in 2023.

|| Recognition of Stroke in the First Aid Setting-Children||| |---|---|---|---| |COR|LOE|Recommendations|| ||B-NR| 1. If pediatric stroke is suspected, EMS should be activated, and the person should be transported to an ED. || |2a|C-EO| 2.It is reasonable to consider stroke when common pediatric symptoms are present in association with other neurological signs and symptoms. || | 3:NO Benefit |C-EO| 3.AAdult strokescores arenotvalidated inthe pediatric population and should not solely bepediatric population and should not solely be used to identify the broad presentation of strokeused to identify the broad presentation of stroke in children. ||

Recommendation-Specific Supportive Text

1. Early identification of stroke in children is important because a shorter time to definitive therapy decreases the risk of death and permanent disability from stroke. 4–8 Shortening the time from presentation in the first aid setting to an ED, preferably with pediatric neurology and stroke expertise, is an important component of this timeline.

2. Stroke in children can present in nonspecific ways and mimic other childhood diseases. Symptoms can present suddenly or come on more gradually, making identification difficult. 9

Table 6. Common Signs and Symptoms of Stroke in Children

| Focal signs and symptoms| |---| |Hemiparesis| |Limb weakness| |Facial droop| |Altered sensation| |Visual disturbance| |Speech disturbance| |General signs and symptoms| |Altered mental status| |Seizure| |Headache| |Ataxia| |Vertigo/dizziness| |Nausea/vomiting|

Symptoms can be nonspecific such as sudden or severe headache, altered mental status, and sudden onset vomiting, or they can be more localized such as focal numbness or weakness, ataxia, and speech and visual disturbances. 5,7–9 Although headache and vomiting can be symptoms of other common childhood diseases, their presence in association with other neurological symptoms should raise concern for stroke. Some strokes can also present as either generalized or focal seizures, which is especially common in children ${<}1$ year of age. 5,9,10

3. Stroke scales and recognition tools used in adult patients such as the FAST have not been validated for use in children. Pediatric stroke scales such as the Pediatric National Institutes of Health Stroke Scale are complex and have been validated only for administration by health care professionals. 8 We were unable to identify a pediatric stroke recognition rubric that is validated in the first aid setting.

REFERENCES

1. Oleske DM, Cheng X, Jeong A, Arndt TJ. Pediatric acute ischemic stroke by age-group: a systematic review and meta-analysis of published studies and hospitalization records. Neuroepidemiology . 2021;55:331–341. doi: 10.1159/000518281 2. Meyran D, Cassan P, Avau B, Singletary E, Zideman DA. Stroke recognition for first aid providers: a systematic review and meta-analysis. Cureus . 2020;12:e11386. doi: 10.7759/cureus.11386 3. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 4. Olivieri M, Sorg AL, Weinberger R, Kurnik K, Bidlingmaier C, Juranek S, Hoffmann F, Reiter K, Bonfert M, Tacke M, et al. Recanalization strategies in childhood stroke in Germany. Sci Rep . 2021;11:13314. doi: 10.1038/s41598-021-92533-0 5. Mastrangelo M, Giordo L, Ricciardi G, De Michele M, Toni D, Leuzzi V. Acute ischemic stroke in childhood: a comprehensive review. Eur J Pediatr . 2022;181:45–58. doi: 10.1007/s00431-021-04212-x 6. Hollist M, Au K, Morgan L, Shetty PA, Rane R, Hollist A, Amaniampong A, Kirmani BF. Pediatric stroke: overview and recent updates. Aging Dis . 2021;12:1043–1055. doi: 10.14336/AD.2021.0219 7. Harrar DB, Salussolia CL, Kapur K, Danehy A, Kleinman ME, Mannix R, Rivkin MJ. A stroke alert protocol decreases the time to diagnosis of brain attack symptoms in a pediatric emergency department. J Pediatr . 2020;216:136–141.e6. doi: 10.1016/j.jpeds.2019.09.027 8. Oborska Z, Urban P, Wychowaniec K, Jozwiak S. Paediatric stroke: a review of current guidelines for diagnosis and treatment. Neurol Neurochir Pol . 2020;54:116–124. doi: 10.5603/PJNNS.a2020.0010 9. Gerstl L, Weinberger R, von Kries R, Heinen F, Schroeder AS, Bonfert MV, Borggrafe I, Tacke M, Vill K, Landgraf M, et al. Symptom patterns in childhood arterial ischemic stroke: analysis of a population-based study in Germany. Klin Padiatr . 2018;230:319–325. doi: 10.1055/a-0684-9794 10. Mallick AA, Ganesan V, Kirkham FJ, Fallon P, Hedderly T, McShane T, Parker AP, Wassmer E, Wraige E, Amin S, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg Psychiatry . 2015;86:917–921. doi: 10.1136/jnnp-2014-309188

Chest Pain in Adults

Background

More than 7.8 million people are evaluated in US EDs each year for chest pain. Chest pain is a common health problem with multiple causes, ranging from minor chest wall strains to pneumonia or myocardial infarction (heart attack). It can be difficult to differentiate chest pain of cardiac origin such as a heart attack from chest pain of other origins. 1 The prevalence of myocardial infarction in patients presenting to the ED with nontraumatic chest pain varies by age, ranging from $\approx\!1\%$ in patients 18 to 44 years of age to $4\%$ in patients ${\ge}80$ years of age. 2 Individuals with chest pain often delay seeking care, leading to poor outcomes. 3,4 Common signs and symptoms associated with a heart attack include chest pain or pressure, shortness of breath, nausea, sweating, or pain in the jaw, arm(s), or back.

The most important action for a person experiencing chest pain or other symptoms that might indicate a myocardial infarction is to activate EMS. Aspirin in the dose of 162 to 324 mg improves survival in patients with myocardial infarction. 5,6 A 2020 systematic review found that early or first aid administration of aspirin to adults with nontraumatic chest pain was associated with reduced mortality. 7 The rate of major complications associated with administration of a single dose of aspirin to an individual experiencing chest pain appears to be low, but certain individuals may have an allergy to aspirin or a bleeding risk, or they may have been advised by a health care professional not to take aspirin. 8

The AHA does not recommend administration of oxygen in health care settings for people with acute coronary syndromes who are not hypoxic. 9,10

In 2020, the ILCOR performed a systematic review on administration of aspirin for people with chest pain. 11 An updated literature search was performed by the writing group in 2023.

| First Aid for Adults Experiencing Chest Pain||| |---|---|---| |COR|LOE|| ||C-LD|1. In adults with acute chest pain, the emergency| ||C-LD|response system should be activated to initiate| ||C-LD|transport to the closest ED by EMS.| |20|B-NR| 2. While awaiting the arrival of EMS, first aid provid ers may encourage alert adults experiencing non- | |20|B-NR| 2. While awaiting the arrival of EMS, first aid provid ers may encourage alert adults experiencing non- | |20|B-NR| traumatic chest pain to chew and swallow aspirin (162-325 mg), unless the person experiencing pain | |20|B-NR| traumatic chest pain to chew and swallow aspirin (162-325 mg), unless the person experiencing pain | |20||a health care professional not to take aspirin.| |20|C-EO| 3. If there is any uncertainty that aspirin should be| |20|C-EO| taken, it is reasonable to wait for EMS arrival without administration of aspirin. | |20|C-EO||

Recommendation-Specific Supportive Text

1. Although chest pain is a common sign of a heart attack, some people such as women, people who have diabetes, and older people may experience other symptoms, including dyspnea; pain or discomfort in the back, neck, jaw, or stomach; sweating; nausea; or lightheadedness. 1,12–14 The use of EMS transportation is associated with a substantial reduction in ischemic time and treatment delays compared with transportation by personal vehicle. 15 In 1 study, $\approx\!1$ in 300 patients with chest pain transported to the ED by private vehicle had a cardiac arrest en route. 16

2. Two observational studies with a total of 2122 patients with acute myocardial infarction demonstrated higher survival with early administration (median, 1.6 hours from pain onset) of aspirin by health care professionals compared with late administration (median, 3.5 hours from pain onset). 4,7,17 One of the observational studies with 1200 patients demonstrated higher survival at 1 year with early compared with late administration (same medians as reported previously). 4 These same studies found no significant difference in the risk of complications from early as opposed to late aspirin administration.

3. Although harm from aspirin in individuals with nontraumatic chest pain is uncommon, no study has evaluated the risks of aspirin administration in the first aid setting. 8 Therefore, if there are potential contraindications to the use of aspirin by the lay first aid provider, it is reasonable not to encourage aspirin use while awaiting the arrival of EMS.

REFERENCES

1. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, et al. 2021 AHA/ ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice

Guidelines [published corrections appear in Circulation . 2021;144:e455 and Circulation . 2023;148:e281]. Circulation . 2021;144:e368–e454. doi: 10.1161/CIR.0000000000001030 2. Hsia RY, Hale Z, Tabas JA. A national study of the prevalence of lifethreatening diagnoses in patients with chest pain. JAMA Intern Med . 2016;176:1029–1032. doi: 10.1001/jamainternmed.2016.2498 3. Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, et al. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. Circulation . 2006;114:168–182. doi: 10.1161/CIRCULATIONAHA.106.176040 4. Freimark D, Matetzky S, Leor J, Boyko V, Barbash IM, Behar S, Hod H. Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis. Am J Cardiol . 2002;89:381–385. doi: 10.1016/s0002-9149(01)02256-1 5. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS2 (Second International Study of Infarct Survival) Collaborative Group. Lancet . 1988;2:349–360. 6. Tayeb HM, Nelson AJ, Willoughby SR, Worthley MI. Antiplatelet therapy in acute coronary syndromes: current agents and impact on patient outcomes. Patient Relat Outcome Meas . 2011;2:7–19. doi: 10.2147/PROM.S9834 7. Djarv T, Swain JM, Chang WT, Zideman DA, Singletary E. Early or first aid administration versus late or in-hospital administration of aspirin for nontraumatic adult chest pain: a systematic review. Cureus . 2020;12:e6862. doi: 10.7759/cureus.6862 8. Quan D, LoVecchio F, Clark B, Gallagher JV 3rd. Prehospital use of aspirin rarely is associated with adverse events. Prehosp Disaster Med . 2004;19:362–365. doi: 10.1017/s1049023x00001990 9. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, et al; ACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation . 2014;130:e433–e434]. Circulation . 2014;130:e344–e426. doi: 10.1161/CIR.0000000000000134 10. O’Connor RE, Al Ali AS, Brady WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: acute coronary syndromes: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2015;132:S483–S500. doi: 10.1161/CIR.0000000000000263 11. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S2–S27. doi: 10.1161/CIR.0000000000000890 12. Schulte KJ, Mayrovitz HN. Myocardial infarction signs and symptoms: females vs. males. Cureus . 2023;15:e37522. doi: 10.7759/cureus.37522 13. Ornato JP, Hand MM. Warning signs of a heart attack. Circulation . 2014;129:e393–e395. doi: 10.1161/CIRCULATIONAHA.113.006126 14. Canto JG, Fincher C, Kiefe CI, Allison JJ, Li Q, Funkhouser E, Centor RM, Selker HP, Weissman NW. Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol . 2002;90:248–253. doi: 10.1016/s0002-9149(02)02463-3 15. Mathews R, Peterson ED, Li S, Roe MT, Glickman SW, Wiviott SD, Saucedo JF, Antman EM, Jacobs AK, Wang TY. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry–Get With The Guidelines. Circulation . 2011;124:154–163. doi: 10.1161/CIRCULATIONAHA.110.002345 16. Becker L, Larsen MP, Eisenberg MS. Incidence of cardiac arrest during self-transport for chest pain. Ann Emerg Med . 1996;28:612–616. doi: 10.1016/s0196-0644(96)70082-3 17. Barbash I, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, Crystal E, Matetzky S, Boyko V, Mandelzweig L, et al; Israeli Working Group on Intensive Cardiac Care, Israel Heart Society. Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration. Cardiology . 2002;98:141–147. doi: 10.1159/000066324

Anaphylaxis

Background

Anaphylaxis is a life-threatening, systemic allergic reaction that can be triggered by many exposures, including foods, drugs, and insect venom. Signs and symptoms of anaphylaxis include lip and facial swelling, a sensation of the throat closing, difficulty breathing, rash, vomiting or diarrhea, and symptoms of low blood pressure such as changes in level of consciousness, pallor, and dizziness. The mainstay of immediate treatment for anaphylaxis is intramuscular epinephrine, typically administered in the first aid setting with an epinephrine autoinjector. Epinephrine autoinjectors are often prescribed to people with a history of anaphylaxis to self-administer at the first sign of an anaphylactic reaction. First aid providers are sometimes called on to assist people experiencing anaphylaxis as they self-administer this medication. In many cases, this will significantly improve or resolve the person’s symptoms, but sometimes additional epinephrine is required.

ILCOR performed scoping reviews related to anaphylaxis in 2019 and 2022. 1,2 An updated literature search was performed by the writing group in 2023.

|First Aid for Anaphylaxis||| |---|---|---| |COR|LOE|| ||B-NR| 1. If a person experiences anaphylaxis and an epinephrine autoinjector is available, the person should self-administer the autoinjector. | |||| ||C-EO| A first aid provider should assist a person experi- encing anaphylaxis to use their autoinjector if assistance is required. | ||C-EO| 3.1If a person experiences anaphylaxis, the emer- gency response system should be activated. | |2b|B-NR| If a person with anaphylaxis does not respond to the initial dose of epinephrine and arrival of EMS will exceed 5 to 10 minutes, a repeat dose may | |2b|| the initial dose of epinephrine and arrival of EMS will exceed 5 to 10 minutes, a repeat dose may be considered. |

Recommendation-Specific Supportive Text

1. Strong international consensus, based primarily on observational data, endorses early administration of intramuscular epinephrine given in the lateral thigh as the primary treatment of anaphylaxis regardless of the triggering agent. 3–11 2. A person experiencing anaphylaxis may be unable to access or manipulate their autoinjector because of respiratory distress, hypotension, or altered mental status. First aid providers may assist the ill person. Epinephrine is typically injected into the muscle of the lateral thigh. 3–12 3. Approximately 500 to 1000 people die in the United States of anaphylaxis each year. 13 In addition to intramuscular epinephrine, patients with anaphylaxis may require endotracheal intubation, intravenous fluids, vasopressors, and other advanced treatments to survive.

4. It is estimated that between $7\%$ and $18\%$ of people with anaphylaxis require ${>}1$ dose of epinephrine. 14,15 Most patients who required a second dose of epinephrine for anaphylaxis improved after administration. 2 One study found that patients who received a second dose of epinephrine were more likely to be admitted to the hospital than those receiving 1 dose, although this appeared to be due to severity of illness rather than an adverse effect of epinephrine. 16

13. Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med . 2001;161:15–21. doi: 10.1001/archinte.161.1.15 14. Wallace DV. Knowledge gaps in the diagnosis and management of anaphylaxis. Ann Allergy Asthma Immunol . 2023;131:151–169. doi: 10.1016/j.anai.2023.05.010 15. Patel N, Chong KW, Yip AYG, Ierodiakonou D, Bartra J, Boyle RJ, Turner PJ. Use of multiple epinephrine doses in anaphylaxis: a systematic review and meta-analysis. J Allergy Clin Immunol . 2021;148:1307–1315. doi: 10.1016/j.jaci.2021.03.042 16. Campbell RL, Bashore CJ, Lee S, Bellamkonda VR, Li JT, Hagan JB, Lohse CM, Bellolio MF. Predictors of repeat epinephrine administration for emergency department patients with anaphylaxis. J Allergy Clin Immunol Pract . 2015;3:576–584. doi: 10.1016/j.jaip.2015.04.009

REFERENCES

1. Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, et al; Collaborators. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published corrections appear in Circulation . 2024;149:e1128 and Circulation . 2024;149:e1411]. Circulation . 2023;148:e187–e280. doi: 10.1161/CIR.0000000000001179 2. Carlson JN, Cook S, Djarv T, Woodin JA, Singletary E, Zideman DA. Second dose of epinephrine for anaphylaxis in the first aid setting: a scoping review. Cureus . 2020;12:e11401. doi: 10.7759/cureus.11401 3. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al; on behalf of the Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S366–S468. a10.1161/CIR.0000000000000916 4. Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, et al. World Allergy Organization anaphylaxis guidance 2020. World Allergy Organ J . 2020;13:100472. doi: 10.1016/j.waojou.2020.100472 5. de Silva D, Singh C, Muraro A, Worm M, Alviani C, Cardona V, DunnGlvin A, Garvey LH, Riggioni C, Angier E, et al; European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Guidelines Group. Diagnosing, managing and preventing anaphylaxis: systematic review. Allergy . 2021;76:1493–1506. doi: 10.1111/all.14580 6. Dodd A, Hughes A, Sargant N, Whyte AF, Soar J, Turner PJ. Evidence update for the treatment of anaphylaxis. Resuscitation . 2021;163:86–96. doi: 10.1016/j.resuscitation.2021.04.010 7. Gaudio FG, Johnson DE, DiLorenzo K, Anderson A, Musi M, Schimelpfenig T, Leemon D, Blair-Smith C, Lemery J. Wilderness Medical Society clinical practice guidelines on anaphylaxis. Wilderness Environ Med . 2022;33:75– 91. doi: 10.1016/j.wem.2021.11.009 8. McLure M, Eastwood K, Parr M, Bray J. A rapid review of advanced life support guidelines for cardiac arrest associated with anaphylaxis. Resuscitation . 2021;159:137–149. doi: 10.1016/j.resuscitation.2020.10.001 9. Muraro A, Worm M, Alviani C, Cardona V, DunnGalvin A, Garvey LH, Riggioni C, de Silva D, Angier E, Arasi S, et al; European Academy of Allergy and Clinical Immunology, Food Allergy, Anaphylaxis Guidelines Group. EAACI guidelines: anaphylaxis (2021 update). Allergy . 2022;77:357–377. 10. Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, et al; Collaborators Joint Task Force on Practice Parameters Reviewers. Anaphylaxis: a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol . 2020;145:1082–1123. doi: 10.1016/j.jaci.2020.01.017 11. Soar J, Becker LB, Berg KM, Einav S, Ma $\upalpha,$ Olasveengen TM, Paal P, Parr MJA. Cardiopulmonary resuscitation in special circumstances. Lancet . 2021;398:1257–1268. doi: 10.1016/S0140-6736(21)01257-5 12. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol . 2001;108:871– 873. doi: 10.1067/mai.2001.119409

Seizures

Background

Seizures are uncontrolled electrical discharges of the neurons in the brain. Seizures can occur as a result of infections, trauma, poisonings, lack of oxygen, metabolic abnormalities (hypoglycemia), fevers (in children), and underlying neurological conditions such as epilepsy. Febrile seizures occur in $2\%$ to $4\%$ of children, most commonly between 6 months and 2 years of age. Generalized tonic-clonic seizures affect large areas or both sides of the brain and manifest as full-body rhythmic jerking with alterations in consciousness. Focal seizures affect only 1 area of the brain and can present as jerking of only 1 extremity or 1 side of the body, abnormal facial movements, small repetitive movements, or staring spells (focal impaired awareness), with or without changes in consciousness. Some focal seizures will progress to generalized seizures. Urinary incontinence may also occur during a seizure. Seizure duration can be seconds to hours. Most seizures are followed by a postictal period in which the person appears tired and confused for several minutes. Seizures lasting ${>}5$ minutes and multiple seizures occurring one after the other represent a critical medical emergency, status epilepticus. 1

A literature search was performed by the writing group in 2023.

First Aid for Seizures

|COR|LOE|Recommendations| |---|---|---| |||1. First aid providers should activate EMS for| ||| individuals with first-time seizure; seizures last- ing >5 minutes; >1 seizure that occurs without the person returning to baseline mental status in | ||C-LD|| ||C-LD| between; seizures occurring in the water; seizures with traumatic injuries, difficulty breathing, or choking; seizure in an infant |

First Aid for Seizures

|COR|LOE|Recommendations| |---|---|---| ||| 4.For children who have experienced a febrile seizure, administration of antipyretics such as | | 3:NO Benefit |B-R| seizure, administration of antipyretics such as acetaminophen, ibuprofen, or paracetamol is not effective for stopping a seizure or preventing a | | 3:NO Benefit |B-R| effective for stopping a seizure or preventing a subsequent febrile seizure. | |3-Harm|C-EO| 5.The person having the seizure should not be restrained. 6.Nothing should be put in the mouth and no food, liquids, or oral medicines should be given to a person who is experiencing a seizure or who has | |3-Harm|C-EO| liquids, or oral medicines should be given to a person who is experiencing a seizure or who has decreasedresponsiveness after a seizure. |

Recommendation-Specific Supportive Text

1. Seizures are usually self-limited and resolve spontaneously within 1 to 2 minutes. However, seizures lasting ${\tt>}5$ minutes may not stop spontaneously and may need emergency medical intervention such as anticonvulsant medications. 1 For prolonged seizures, respiratory distress, seizures with associated traumatic injuries, seizures occurring in the water, and seizures associated with choking events, EMS should be activated to provide more definitive care 2 (Table7).

2–3. Seizure movements often involve erratic movements of the head, body, and extremities that can result in significant traumatic injury during a fall or from the seizure movements. 2–4 The first aid provider can prevent the person who is experiencing a seizure from unintentional injury. The recovery position is intended to reduce the risk of aspiration if the person vomits during the seizure or the postictal period.

4. Febrile seizures are a common benign condition in childhood, affecting ${\approx}2\%$ to $4\%$ of children. 5 Febrile seizures may be diagnosed by a health care professional after an appropriate evaluation. Two meta-analyses published in 2021 examined the effectiveness of antipyretics at preventing recurrent febrile seizures in children in both the

Table 7. Reasons to Activate the Emergency Response System for Seizures

|First-time seizure| |---| |Seizure in an infant |

same febrile episode and subsequent febrile illnesses. They demonstrated no benefit of seizure prevention to antipyretics in the same illness or a subsequent illness. 6,7 Fever treatment can help children feel better but will not prevent subsequent seizures.

5. Restraining a person experiencing a seizure will not abort the seizure and may lead to injury of the person or the first aid provider. 2–4

6. People experiencing seizures will often clench their jaw, which may lead to traumatic injury within the mouth. Although swallowing the tongue will not occur, people can aspirate blood, saliva, food, or other items during a seizure and the postictal period. Attempting to place something in the mouth risks injury to the person’s teeth or the rescuer’s finger and is generally ineffective. 3,8 Most seizures are followed by a postictal period in which the individual is somnolent, incoherent, and unable to swallow normally and therefore is at risk of aspiration of food, liquids, or medications placed in the mouth. 2,4

REFERENCES

1. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, et al; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care . 2012;17:3–23. doi: 10.1007/s12028-012-9695-z 2. Shafer PO, Gilchrist B, Miller W, Owens S, Ficker D, Haynes-Smith L, Kiriakopoulos E. Improving self-efficacy in seizure first aid: developing a seizure first aid certification program in the United States. Epilepsy Behav . 2022;129:108624. doi: 10.1016/j.yebeh.2022.108624 3. Zarisfi F, Pek JH, Oh JHH, Loke JH, Lim SH. Singapore first aid guidelines 2021. Singapore Med J . 2021;62:427–432. doi: 10.11622/smedj.2021112 4. Rank WP. Seizure first aid for bystanders. Nursing . 2020;50:11–12. doi: 10.1097/01.NURSE.0000697196.36554.fe 5. Berg AT, Shinnar S, Hauser WA, Alemany M, Shapiro ED, Salomon ME, Crain EF. A prospective study of recurrent febrile seizures. N Engl J Med . 1992;327:1122–1127. doi: 10.1056/NEJM199210153271603 6. Offringa M, Newton R, Nevitt SJ, Vraka K. Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev . 2021;6:CD003031. doi: 10.1002/14651858.CD003031.pub4 7. Hashimoto R, Suto M, Tsuji M, Sasaki H, Takehara K, Ishiguro A, Kubota M. Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis. Eur J Pediatr . 2021;180:987–997. doi: 10.1007/s00431-020-03845-8 8. Redant D, Mahomed Z, Beringer C. Foreign body aspiration: a potentially life-threatening complication of seizures. Cureus . 2020;12:e11349. doi: 10.7759/cureus.11349

Hypoglycemia

Background

Blood glucose levels are tightly regulated by several hormones, mainly insulin and glucagon. Normal blood glucose range is 70 to 120 mg/dL (3.9–6.6 mmol/L). Hypoglycemia (blood glucose <70 or ${\tt<}2.8$ mmol/L) can result from starvation, underlying metabolic disorders, deficiencies of hormones, and medications (eg, antidiabetic

medications). Symptoms typically develop when blood glucose falls below 50 to 60 mg/dL (2.8–3.3 mmol/L) and include dizziness, fatigue, feeling shaky or jittery, tachycardia (fast heart rate), confusion, slurred speech, and diaphoresis (sweating). Significant hypoglycemia can lead to a state of unconsciousness and seizures. In the first aid setting, correction of hypoglycemia is performed through the enteral route.

The ILCOR performed a systematic review of glucose administration for hypoglycemia in 2020. 1 An updated literature search was performed by the writing group in 2023.

| First Aid for Hypoglycemia||| |---|---|---| |COR|LOE|Recommendations| ||C-LD| 1. For a person with suspected hypoglycemia who is awake and able to swallow, the first aid provider should encourage the person to swallow oral glucose. | ||C-EO| EEMS should be activated for a person with hypoglycemia who is unable to swallow, has a seizure,or does not improve within 10 minutes of oral glucose administration. | |2a|B-NR| 3.HIf they are available, it is reasonable to use oral glucose tablets in preference to gel or dietary sources of glucose to treat hypoglycemia. | |2a|C-LD| 4. It is reasonable to use simple dietary sugars as an alternative if glucose tablets or gel isnot available to treat hypoglycemia. | |2b|C-LD| 5.FFor children with suspected hypoglycemia who are awake but unwilling or unable to swallow glucose, it may be reasonable to apply a slurry of granulated sugar and water under the tongue. | | 3二 Harm |C-EO| 6.Oral glucose should not be administered to people who are not awake or not able to swallow. |

Recommendation-Specific Supportive Text

1. Administration of ${\geq}20~\mathrm{g}$ oral glucose or the equivalent in glucose-containing foods can rapidly restore blood glucose levels. 2 Oral glucose is available in different forms and can be given through different routes in the first aid setting. Glucose products that are swallowed (eg, tablets or gels) result in higher blood glucose levels than buccally applied glucose (spray or gel). 3 2. Untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death. For people with hypoglycemia who are unable to swallow, intravenous dextrose can be lifesaving. 3-4. Oral glucose tablets demonstrated better resolution of symptoms 15 minutes after treatment compared with dietary sugars such as sucrose, fructose, orange juice, jellybeans, candy tablets, and milk. 4 Although data on this topic are limited, 1 study suggests that glucose tablets are

Table 8. Dietary Sources Containing at Least 15 g Simple Sugars

|1 tablespoon table sugar| |---| |6-8 oz apple or orange juice| |6-8 oz regular (nondiet) soda| |1 tablespoon honey| |1 tablespoon breakfast syrup| |2 strips of fruit leather| |15-25 jellybeans, gummy bears, or hard-shelled candies |

superior to gel in terms of hypoglycemia correction. 5 Dietary sources of simple sugar (Table8) have been shown to be effective in the treatment of hypoglycemia. 6,7 5. In children who are responsive but unwilling to swallow oral glucose, applying a slurry of granulated sugar ( ≈ 1 teaspoon) and water under the tongue resolves hypoglycemia faster than oral granulated sugar. 3,8 6. Attempting to treat severe hypoglycemia with oral glucose in a person who is not fully alert or who is unable to swallow can lead to choking and aspiration.

REFERENCES

1. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 2. Krebs JD, Weatherall M, Corley B, Wiltshire E, McTavish L. Optimizing the management of hypoglycaemia in individuals with type 2 diabetes: a randomized crossover comparison of a weight-based protocol compared with two fixed-dose glucose regimens. Diabetes Obes Metab . 2018;20:1256– 1261. doi: 10.1111/dom.13231 3. De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djarv T. First aid glucose administration routes for symptomatic hypoglycaemia. Cochrane Database Syst Rev . 2019;4:CD013283. doi: 10.1002/14651858.CD013283.pub2 4. Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes: a systematic review and meta-analysis. Emerg Med J . 2017;34:100–106. doi: 10.1136/emermed-2015-205637 5. Slama G, Traynard PY, Desplanque N, Pudar H, Dhunputh I, Letanoux M, Bornet FR, Tchobroutsky G. The search for an optimized treatment of hypoglycemia: carbohydrates in tablets, solutin, or gel for the correction of insulin reactions. Arch Intern Med . 1990;150:589–593. 6. Fumanelli J, Franceschi R, Bonani M, Orrasch M, Cauvin V. Treatment of hypoglycemia during prolonged physical activity in adolescents with type 1 diabetes mellitus. Acta Biomed . 2020;91:e2020103. doi: 10.23750/abm.v91i4.8437 7. Erbas IM, Abaci A, Anik A, Simsek E, Tuhan HU, Kocyigit C, Yildiz M, Dundar BN, Bober E, Catli G. Comparison of the effectiveness of simple carbohydrates on hypoglycemic episodes in children and adolescents with type 1 diabetes mellitus: a randomized study in a diabetes camp. Pediatr Diabetes . 2020;21:1249–1255. doi: 10.1111/pedi.13077 8. Barennes H, Valea I, Nagot N, Van de Perre P, Pussard E. Sublingual sugar administration as an alternative to intravenous dextrose administration to correct hypoglycemia among children in the tropics. Pediatrics . 2005;116:e648–e653. doi: 10.1542/peds.2004-2218

Presyncope

Background

Syncope, a transient loss of consciousness, results from global cerebral hypoperfusion and has an estimated lifetime prevalence of ${\approx}35\%$ . 1,2 Syncope leads to a loss of postural tone that may result in physical injury, which is present in $30\%$ of patients treated in an ED after syncope. 3 Fractures, intracranial hemorrhage, or other organ damage may occur if the individual is upright at the time of the syncopal episode. Syncope causes a considerable medical and socioeconomic burden on the adult population, resulting in $2\%$ to $6\%$ of hospital admissions internationally and accounting for at least $\S2.4$ billion in annual hospital costs in the United States. 3–5

There are many causes of syncope. Vasovagal syncope and orthostatic syncope result in $21.2\%$ and $9.4\%$ of syncopal episodes, respectively. 6 However, syncope

also may have more dangerous causes such as cardiac dysrhythmia. Vasovagal syncope is preceded by prodromal symptoms in about two-thirds of cases. 7 Presyncope is the prodrome of syncope that may last for a few seconds and may include lightheadedness or dizziness, blurry or tunnel vision, nausea, a sensation of warmth, and signs such as diaphoresis and pallor. This prodrome represents a short time in which a first aid intervention may be used to prevent syncope. Physical counterpressure maneuvers (PCMs) are a first aid intervention demonstrated to help prevent syncope. 8,9 PCMs include the contraction of muscles of the body such as those in the legs, arms, abdomen, or neck, causing a rise in blood pressure and alleviating symptoms of near syncope originating from vasovagal or orthostatic causes 8,9 (Table9).

The ILCOR performed a systematic review of first aid interventions for presyncope in 2020, 11 with an evidence update in 2022. 12 An updated literature search was performed by the writing group in 2023.

Table 9. Physical Counterpressure Maneuvers for Presyncope

 PCM indicates physical counterpressure maneuver. Reproduced from Charlton et al. 10 Copyright $\copyright$ 2019, American Heart Association, Inc.

|First Aid for Presyncope|||| |---|---|---|---| |COR|LOE|Recommendations|| ||C-LD| 1. If a person experiences signs or symptoms of presyncope (including pallor, sweating, lightheadedness, visual changes, and weakness) of vasovagal or orthostatic origin, that person || ||C-LD| presyncope (including pallor, sweating, lightheadedness, visual changes, and weakness) of vasovagal or orthostatic origin, that person should maintain or assume a safe position such as assisted sitting or lying down. || |2a|C-LD| 2. Once the person with presyncope is in a safe position, it can be beneficial for that person to use physical PCMs to avoid syncope. || |2b|C-LD| Lower-body PCMs may be preferable to upper-body and abdominal PCMs in first aid for presyncope. || |2b|C-EO| 4.山If no improvement occurs within 1 to 2 minutes, if syncope occurs, or if symptoms worsen or reoccur, the first aid provider should activate || ||C-EO| syncope occurs, or if symptoms worsen or reoccur, the first aid provider should activate emergency services. || | 3:NO Benefit || The use of PCMs is not recommended when symptoms of a heart attack or stroke accompany presyncope. ||

Recommendation-Specific Supportive Text

1. Physical injuries are frequent complications of syncope, occurring in ${\approx}30\%$ of patients admitted to EDs, of whom ${\approx}5\%$ experience severe trauma. 3 Therefore, the initial goal of presyncope treatment should be to assume a safe position to decrease the risk of trauma. 2. A meta-analysis of 11 clinical trials demonstrated an ${\approx}50\%$ reduction in the risk of syncope when PCMs were used compared with no intervention. 9 Although no studies directly assessed the ability of first aid providers to instruct a person with presyncope on PCMs in real time, in several studies, researchers were able to effectively instruct research participants on the use of PCMs before an intervention (eg, tilt table test) or for the treatment of presyncope in the realworld setting. 13–17 3. An observational study enrolling 27 participants with recurrent vasovagal syncope demonstrated better improvements in heart rate and a lower likelihood of syncope with the use of lower-body PCM (squatting with leg crossing) compared with upperbody PCM (handgrip). 8,18 4. In studies involving tilt-table testing, PCMs were able to improve cardiovascular parameters, reduce or eliminate symptoms of presyncope, and prevent syncope within seconds of implementing the PCM. 14,15,19 In a tilt table study of people with vasovagal syncope, continuously applied PCMs were beneficial for at least 2 minutes. 15 5. Dangerous medical conditions such as myocardial infarction or stroke may cause presyncope. Although a systematic review found no reported adverse events or injuries from PCM use, the

study populations included only people with known recurrent orthostatic or vasovagal syncope. 8 PCMs have not been advocated for cardiac causes of syncope and may delay definitive medical care. 20

REFERENCES

1. Walsh K, Hoffmayer K, Hamdan MH. Syncope: diagnosis and management. Curr Probl Cardiol . 2015;40:51–86. doi: 10.1016/j.cpcardiol.2014.11.001 2. Bennett MT, Leader N, Krahn AD. Recurrent syncope: differential diagnosis and management. Heart . 2015;101:1591–1599. doi: 10.1136/heartjnl-2014-306627 3. Bartoletti A, Fabiani P, Bagnoli L, Cappelletti C, Cappellini M, Nappini G, Gianni R, Lavacchi A, Santoro GM. Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage. Eur Heart J . 2008;29:618–624. doi: 10.1093/eurheartj/ehm563 4. Sun BC, Emond JA, Camargo CA Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol . 2005;95:668– 671. doi: 10.1016/j.amjcard.2004.11.013 5. Sun BC. Quality-of-life, health service use, and costs associated with syncope. Prog Cardiovasc Dis . 2013;55:370–375. doi: 10.1016/j.pcad.2012.10.009 6. Kenny RA, Bhangu J, King-Kallimanis BL. Epidemiology of syncope/collapse in younger and older Western patient populations. Prog Cardiovasc Dis . 2013;55:357–363. doi: 10.1016/j.pcad.2012.11.006 7. Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Bloch Thomsen PE, van Dijk JG, Fitzpatrick A, Hohnloser S, Janousek J, et al; Task Force on Syncope, European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope: update 2004. Europace . 2004;6:467– 537. doi: 10.1016/j.eupc.2004.08.008 8. Jensen JL, Ohshimo S, Cassan P, Meyran D, Greene J, Ng KC, Singletary E, Zideman D, First A; Pediatric Task Forces of the International Liaison Committee on Resuscitation. Immediate interventions for presyncope of vasovagal or orthostatic origin: a systematic review. Prehosp Emerg Care . 2020;24:64–76. doi: 10.1080/10903127.2019.1605431 9. Dockx K, Avau B, De Buck E, Vranckx P, Vandekerckhove P. Physical manoeuvers as a preventive intervention to manage vasovagal syncope: a systematic review. PLoS One . 2019;14:e0212012. doi: 10.1371/journal.pone.0212012 10. Charlton NP, Pellegrino JL, Kule A, Slater TM, Epstein JL, Flores GE, Goolsby CA, Orkin AM, Singletary EM, Swain JM. 2019 American Heart Association and American Red Cross focused update for first aid: presyncope: an update to the American Heart Association and American Red Cross Guidelines for First Aid. Circulation . 2019;140:e931–e938. doi: 10.1161/CIR.0000000000000730 11. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 12. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al; Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published correction appears in Circulation . 2024;149:e1218]. Circulation . 2022;146:e483–e557. doi: 10.1161/CIR.0000000000001095 13. Romme JJ, Reitsma JB, Go-Schon IK, Harms MP, Ruiter JH, Luitse JS, Lenders JW, Wieling W, van Dijk N. Prospective evaluation of non-pharmacological treatment in vasovagal syncope. Europace . 2010;12:567– 573. doi: 10.1093/europace/eup414 14. Krediet CT, van Dijk N, Linzer M, van Lieshout JJ, Wieling W. Management of vasovagal syncope: controlling or aborting faints by leg crossing and muscle tensing. Circulation . 2002;106:1684–1689. doi: 10.1161/01.cir.0000030939.12646.8f 15. Brignole M, Croci F, Menozzi C, Solano A, Donateo P, Oddone D, Puggioni E, Lolli G. Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope. J Am Coll Cardiol . 2002;40:2053–2059. doi: 10.1016/s0735-1097(02)02683-9 16. van Dijk N, Quartieri F, Blanc JJ, Garcia-Civera R, Brignole M, Moya A, Wieling W; PC-Trial Investigators. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the Physical Counterpressure Manoeuvres Trial (PC-Trial). J Am Coll Cardiol . 2006;48:1652–1657. doi: 10.1016/j.jacc.2006.06.059 17. Tomaino M, Romeo C, Vitale E, Kus T, Moya A, van Dijk N, Giuli S, D’Ippolito G, Gentili A, Sutton R; International Study on Syncope of Uncertain Etiology 3 (ISSUE-3) Investigators. Physical counter-pressure manoeuvres in preventing syncopal recurrence in patients older than 40 years with recurrent neurally mediated syncope: a controlled study from the Third International Study on Syncope of Uncertain Etiology (ISSUE-3). Europace . 2014;16:1515–1520. doi: 10.1093/europace/euu125 18. Kim KH, Cho JG, Lee KO, Seo TJ, Shon CY, Lim SY, Yun KH, Sohn IS, Hong YJ, Park HW, et al. Usefulness of physical maneuvers for prevention of vasovagal syncope. Circ J . 2005;69:1084–1088. doi: 10.1253/circj.69.1084 19. Krediet CT, Go-Schon IK, van Lieshout JJ, Wieling W. Optimizing squatting as a physical maneuver to prevent vasovagal syncope. Clin Auton Res . 2008;18:179–186. doi: 10.1007/s10286-008-0481-0 20. Williams EL, Khan FM, Claydon VE. Counter pressure maneuvers for syncope prevention: a semi-systematic review and meta-analysis. Front Cardiovasc Med . 2022;9:1016420. doi: 10.3389/fcvm.2022.1016420

ENVIRONMENTAL EMERGENCIES

Bee and Wasp Stings

Background

Stings from bees, wasps, and hornets commonly result in small local reactions consisting of pain, swelling, and itching. Larger local reactions and anaphylaxis may occur. Stinging bees, wasps, and hornets result in ${\approx}60$ deaths per year in the United States. 1 Most deaths are due to anaphylaxis, a severe reaction that may include rapid development of difficulty breathing, tongue or throat swelling, lightheadedness (a possible symptom of low blood pressure), vomiting, and disseminated hives. Death can also occur from massive envenomation, generally from at least 20 stings by large hornets or hundreds of stings from honeybees. 2–4

The honeybee has a barbed stinger that often remains in the skin after the sting and can continue to deliver venom for up to 60 seconds. 5 Other species of bees, wasps, and hornets have smooth stingers and can sting multiple times.

Many people with a history of anaphylaxis have epinephrine autoinjectors, which they are instructed to self-administer at the first sign of anaphylaxis. First aid providers may be called on to assist people experiencing anaphylaxis to self-administer this medication. 3,6,7 Intranasal and sublingual formulations of epinephrine for the treatment of anaphylaxis were not available in the United States or Canada at the time of guideline development.

Treatment for local reactions to bee and wasp stings is intended to reduce local symptoms of pain, swelling, and itching at the site of the sting.

A literature search was performed by the writing group in 2023.

||First Aid for Bee and Wasp Stings|| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1. If a person experiences anaphylaxis due to a bee, wasp, or hornet sting and an epinephrine autoinjector is available, the person should self-administer the autoinjector. | ||C-EO| 2.A A first aid provider should assist a person experiencing anaphylaxis to use the autoinjector if assistance is required. | ||C-EO| ③： If a person experiences anaphylaxis due to a bee, wasp,or hornet sting,the emergency response system should be activated. | ||C-EO| Stings to the eye should be evaluated by a trained medical professional. | |2a|B-NR| Removal of a stinger remaining in the skin as soon as possible by plucking or scraping can be beneficial. | |2a|C-EO| Over-the-counter oral antihistamines can be used to alleviate local itching. | |2a|C-EO| Topical corticosteroids can be used to alleviate local itching. | |2a|C-EO| 8.3. It is reasonable to wash the area of a bee, wasp, or hornet sting with soap and water. | |2b|C-EO| 9 Administration of over-the-counter acetaminophen and nonsteroidal anti-inflammatory agents may be considered to alleviate local pain. | |2b|C-EO| 10. Administration of ice or cold packs may be con- sidered for local pain relief. |

Recommendation-Specific Supportive Text

1–3. Strong international consensus, based primarily on observational data, endorses early administration of epinephrine as the primary treatment of anaphylaxis regardless of the triggering agent. 8–16 Few experimental data were identified pertaining specifically to the treatment of anaphylaxis from bee, wasp, or hornet stings. In 1 observational study detailing 8 cases of anaphylactic reactions to bee stings, 5 of the cases were treated with epinephrine. 7 4. Although rare, stings to the eye itself (as opposed to stings to the eyelid or to the face near the eye) can lead to permanent vision loss and may require immediate medical attention. 17–19 5. In an observational study evaluating honeybee stings in human volunteers, there was no significant difference in the size of wheal when the retained stinger was plucked out compared with scraping for removal. 20 The area of the wheal corresponded directly to the time the bee stinger remained in the skin. In a second observational study conducted in rabbits, the amount of honeybee venom delivered corresponded directly to the amount of time the stinger was embedded in the skin, up to ${\approx}30$ seconds. 5 6–10. Few experimental data were identified to guide treatment of local symptoms from bee, wasp,

or hornet stings. Clinical trials support the use of oral antihistamines and topical corticosteroid for local itching from mosquito bites, 21 but data for bee, wasp, and hornet stings are lacking. Pain can be treated with oral over-the-counter analgesic agents such as acetaminophen and ibuprofen. Pain and swelling can be treated with topical ice or cold packs. 3,6,22–25

REFERENCES

1. QuickStats: number of deaths from hornet, wasp, and bee stings among males and females–National Vital Statistics System, United States, 2011- 2021. MMWR Morb Mortal Wkly Rep . 2023;72:756. 2. Herness J, Snyder MJ, Newman RS. Arthropod bites and stings. Am Fam Physician . 2022;106:137–147. 3. Erickson TB, Cheema N. Arthropod envenomation in North America. Emerg Med Clin North Am . 2017;35:355–375. doi: 10.1016/j.emc.2017.01.001 4. Schmidt JO. Clinical consequences of toxic envenomations by Hymenoptera . Toxicon . 2018;150:96–104. doi: 10.1016/j.toxicon.2018.05.013 5. Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol . 1994;93:831–835. doi: 10.1016/0091-6749(94)90373-5 6. Przybilla B, Rueff F. Insect stings: clinical features and management. Dtsch Arztebl Int . 2012;109:238–248. doi: 10.3238/arztebl.2012.0238 7. Fisher MM, Bowey CJ. Urban envenomation. Med J Aust . 1989;150:695– 698. doi: 10.5694/j.1326-5377.1989.tb136763.x 8. Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, et al. World Allergy Organization anaphylaxis guidance 2020. World Allergy Organ J . 2020;13:100472. doi: 10.1016/j.waojou.2020.100472 9. de Silva D, Singh C, Muraro A, Worm M, Alviani C, Cardona V, DunnGlvin A, Garvey LH, Riggioni C, Angier E, et al; European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Guidelines Group. Diagnosing, managing and preventing anaphylaxis: systematic review. Allergy . 2021;76:1493–1506. doi: 10.1111/all.14580 10. Dodd A, Hughes A, Sargant N, Whyte AF, Soar J, Turner PJ. Evidence update for the treatment of anaphylaxis. Resuscitation . 2021;163:86–96. doi: 10.1016/j.resuscitation.2021.04.010 11. Gaudio FG, Johnson DE, DiLorenzo K, Anderson A, Musi M, Schimelpfenig T, Leemon D, Blair-Smith C, Lemery J. Wilderness Medical Society clinical practice guidelines on anaphylaxis. Wilderness Environ Med . 2022;33:75– 91. doi: 10.1016/j.wem.2021.11.009 12. McLure M, Eastwood K, Parr M, Bray J. A rapid review of advanced life support guidelines for cardiac arrest associated with anaphylaxis. Resuscitation . 2021;159:137–149. doi: 10.1016/j.resuscitation.2020.10.001 13. Muraro A, Worm M, Alviani C, Cardona V, DunnGalvin A, Garvey LH, Riggioni C, de Silva D, Angier E, Arasi S, et al; European Academy of Allergy and Clinical Immunology, Food Allergy, Anaphylaxis Guidelines Group. EAACI guidelines: anaphylaxis (2021 update). Allergy . 2022;77:357–377. 14. Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, et al; on behalf of the Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation . 2020;142(suppl 2):S366–S468. doi: 10.1161/CIR.0000000000000916 15. Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, et al; Collaborators Joint Task Force on Practice Parameters Reviewers. Anaphylaxis: a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol . 2020;145:1082–1123. doi: 10.1016/j.jaci.2020.01.017 16. Soar J, Becker LB, Berg KM, Einav S, Ma Q, Olasveengen TM, Paal P, Parr MJA. Cardiopulmonary resuscitation in special circumstances. Lancet . 2021;398:1257–1268. doi: 10.1016/S0140-6736(21)01257-5 17. Semler-Collery A, Hayek G, Ramadier S, Perone JM. A case of conjunctival bee sting injury with review of the literature on ocular bee stings. Am J Case Rep . 2019;20:1284–1289. doi: 10.12659/AJCR.917592 18. Al Amry M, Al Ghadeer H, Al Gethami AR. Bee sting presumed endophthalmitis: a devastating ocular outcome. Int J Retina Vitreous . 2021;7:52. doi: 10.1186/s40942-021-00320-w 19. Ahmed M, Lee CS, McMillan B, Jain P, Wiley L, Odom JV, Leys M. Predicting visual function after an ocular bee sting. Int Ophthalmol . 2019;39:1621– 1626. doi: 10.1007/s10792-018-0978-z 20. Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet . 1996;348:301–302. doi: 10.1016/s0140-6736(96)01367-0 21. Foex BA, Lee C. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary: oral antihistamines for insect bites. Emerg Med J . 2006;23:721–722. doi: 10.1136/emj.2006.040154 22. Laskowski-Jones L. First aid for bee, wasp, & hornet stings: learn how to protect the victim-and yourself-from the potentially dangerous effects of their venom. Nursing . 2006;36:58–59. doi: 10.1097/00152193-200607000-00048 23. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Rivers LJ, Feldman R, Brown K, Pham NPT, Bronstein AC, DesLauriers C. 2022 Annual report of the National Poison Data System® (NPDS) from America’s Poison Centers®: 40th annual report. Clin Toxicol (Phila) . 2023;61:717–939. doi: 10.1080/15563650.2023.2268981 24. Glaspole I, Douglass J, Czarny D, O’Hehir R. Stinging insect allergies: assessing and managing. Aust Fam Physician . 1401;1997:1395–1399. 25. Almeida RA, Olivo TE, Mendes RP, Barraviera SR, Souza Ldo R, Martins JG, Hashimoto M, Fabris VE, Ferreira Junior RS, Barraviera B. Africanized honeybee stings: how to treat them. Rev Soc Bras Med Trop . 2011;44:755–761.

Tick Bites

Background

There are many tick species in the United States, with activity dependent on the season and geographic location. Some species of tick are carriers of organisms that can cause illness such as Lyme disease or Rocky Mountain Spotted Fever if transmitted to a human host. 1 The Centers for Disease Control and Prevention reports that at least 48000 cases of tick-borne diseases are diagnosed in the United States annually and >100000 people seek treatment in EDs for tick bite exposure. 1

The risk of contracting a tick-borne illness is increased if the tick is attached for ${\tt>}24$ to 48 hours (Figure4.) Early tick removal may prevent disease transmission. 2,3

The Centers for Disease Control and Prevention recommends antibiotic prophylaxis for Lyme disease when a tick bite occurs in a highly endemic region and tick attachment is estimated to have been ${\ge}36$ hours (based

 Figure 4. Risk of Lyme disease transmission based on duration of tick attachment. Reproduced from des Vignes et al 2 with permission of Oxford University Press; permission conveyed through Copyright Clearance Center, Inc.

on the degree of engorgement with blood), if the tick is an Ixodes scapularis tick, if antibiotics can be started within 72 hours, and if there is no contraindication to doxycycline. 4 In areas where Rocky Mountain Spotted Fever is endemic, prophylactic antibiotic administration is not recommended, but doxycycline is recommended at the first sign of fever or rash. 5 Antibiotic prescribing is performed by health care practitioners.

A literature search was performed by the writing group in 2023.

|First Aid for Tick Bites||| |---|---|---| |COR|LOE|Recommendations| ||B-R| 1. Tick bites occurring in regions with high prevalence of Lyme disease should receive prompt consultation with a health care professional within 72 hours after | ||B-R|| ||B-NR| 2. We recommend removal of a tick as soon as possible. | ||C-LD| 3. To remove a tick, we recommend grasping the head of the tick as close to the skin as possible with tweezers ora commercial tick removal device and | ||| tweezers ora commercial tick removal device and pulling upward with steady, even pressure. |

Recommendation-Specific Supportive Text

1. Several clinical trials found that a single dose of prophylactic doxycycline given within 72 hours after an Ixodes scapularis tick bite could prevent Lyme disease. 6–8 Doxycycline prescribing requires treatment by a health care professional. Although the risk is decreased, some people develop Lyme disease despite receiving prophylactic doxycycline, and additional treatment is required.

2. The risk of infection from tick-borne illness increases with the time of tick attachment (Figure4). Although the risk of contracting a tickborne illness appears to be more substantial if the

tick is attached for ${\tt>}24$ to 48 hours, the tick should be removed as soon as possible to minimize the risk of infection 2,9,10 (Figure5).

3. The risk of damaging tick mouthparts appears to be lower when health care professionals remove ticks with tweezers compared with laypeople removing ticks by hand. 12 In tick removal by dermatologists, successful removal was most common when tweezers were used to grasp the tick near the mouthparts compared with lasso and traction devices, card slit devices, and freezing. 13 Other methods of removal, including application of gasoline, nail polish, methylated spirits, petroleum jelly, $70\%$ isopropyl alcohol, or a hot kitchen match, appear to be less effective. 14 Mechanical removal is accepted by most experts. 15–17 Although squeezing the abdomen of the tick on removal has not been definitively linked to transmission of disease, some evidence links squeezing the abdomen of the tick on removal to anaphylaxis resulting from tick bites. 18 As with any injury, hand washing and wound cleansing should follow tick removal. Steps for tick removal are shown in Figure5.

REFERENCES

1. Marx GE, Spillane M, Beck A, Stein Z, Powell AK, Hinckley AF. Emergency department visits for tick bites–United States, January 2017- December 2019. MMWR Morb Mortal Wkly Rep . 2021;70:612–616. doi: 10.15585/mmwr.mm7017a2 2. des Vignes F, Piesman J, Heffernan R, Schulze TL, Stafford KC 3rd, Fish D. Effect of tick removal on transmission of Borrelia burgdorferi and Ehrlichia phagocytophila by Ixodes scapularis nymphs. J Infect Dis . 2001;183:773– 778. doi: 10.1086/318818 3. Pace EJ, O’Reilly M. Tickborne diseases: diagnosis and management. Am Fam Physician . 2020;101:530–540. 4. Eisen L. Tick species infesting humans in the United States. Ticks Tick Borne Dis . 2022;13:102025. doi: 10.1016/j.ttbdis.2022.102025 5. Biggs HM, Behravesh CB, Bradley KK, Dahlgren FS, Drexler NA, Dumler JS, Folk SM, Kato CY, Lash RR, Levin ML, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain Spotted Fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis–United States. MMWR Recomm Rep . 2016;65:1–44. doi: 10.15585/mmwr.rr6502a1 6. Zhou G, Xu X, Zhang Y, Yue P, Luo S, Fan Y, Chen J, Liu M, Dong Y, Li B, et al. Antibiotic prophylaxis for prevention against Lyme disease following tick bite: an updated systematic review and meta-analysis. BMC Infect Dis . 2021;21:1141. doi: 10.1186/s12879-021-06837-7 7. Nadelman RB, Nowakowski J, Fish D, Falco RC, Freeman K, McKenna D, Welch P, Marcus R, Aguero-Rosenfeld ME, Dennis DT, et al; Tick Bite Study Group. Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite. N Engl J Med . 2001;345:79–84. doi: 10.1056/NEJM200107123450201 8. Harms MG, Hofhuis A, Sprong H, Bennema SC, Ferreira JA, Fonville M, Docters van Leeuwen A, Assendelft WJJ, Van Weert H, Van Pelt W, et al. A single dose of doxycycline after an Ixodes ricinus tick bite to prevent Lyme borreliosis: an open-label randomized controlled trial. J Infect . 2021;82:98– 104. doi: 10.1016/j.jinf.2020.06.032 9. Kahl O, Janetzki-Mittmann C, Gray JS, Jonas R, Stein J, de Boer R. Risk of infection with Borrelia burgdorferi sensu lato for a host in relation to the duration of nymphal Ixodes ricinus feeding and the method of tick removal. Zentralbl Bakteriol . 1998;287:41–52. doi: 10.1016/s0934-8840(98)80142-4 10. Eisen L. Pathogen transmission in relation to duration of attachment by Ixodes scapularis ticks. Ticks Tick Borne Dis . 2018;9:535–542. doi: 10.1016/j.ttbdis.2018.01.002 11. Centers for Disease Control and Prevention. What to do after a tick bite. Accessed August 2, 2024. https://www.cdc.gov/ticks/after-a-tick-bite/ 12. Sahin AR, Hakkoymaz H, Tasdogan AM, Kirecci E. Evaluation and comparison of tick detachment techniques and technical mistakes made during tick removal. Ulus Travma Acil Cerrahi Derg . 2020;26:405–410. doi: 10.14744/tjtes.2020.59680 13. Akin Belli A, Dervis E, Kar S, Ergonul O, Gargili A. Revisiting detachment techniques in human-biting ticks. J Am Acad Dermatol . 2016;75:393–397. doi: 10.1016/j.jaad.2016.01.032 14. Huygelen V, Borra V, De Buck E, Vandekerckhove P. Effective methods for tick removal: a systematic review. J Evid Based Med . 2017;10:177–188. doi: 10.1111/jebm.12257 15. Gammons M, Salam G. Tick removal. Am Fam Physician . 2002;66:643–645. 16. Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, et al. Clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis, and treatment of Lyme disease. Arthritis Rheumatol . 2021;73:12–20. doi: 10.1002/art.41562 17. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis . 2006;43:1089–1134. doi: 10.1086/508667 18. Takayama N, Takagaki Y. Tick anaphylaxis triggered by pulling out the tick. Acute Med Surg . 2020;7:e503. doi: 10.1002/ams2.503

 Figure 5. Tick removal. Reproduced from Centers for Disease Control and Prevention. Ticks image gallery. 11

Rash From Poison Ivy, Poison Oak, and Poison Sumac

Background

Contact dermatitis from Toxicodendron species (formerly Rhus ), including poison ivy, poison oak, and poison sumac, is a common problem that affects millions of Americans annually, resulting in millions of visits to health care facilities each year. 1,2 Approximately $50\%$ to $75\%$ of individuals react to urushiol, the allergic compound in Toxicodendron . Skin effects include redness, papules and vesicles, and itching, typically starting within days of exposure and lasting up to 3 weeks. 2 The extent and severity of symptoms are proportional to the area and duration of

urushiol contact with the skin. Therefore, initial treatment is aimed at preventing or removing exposure to urushiol, and later first aid is aimed at management of symptoms. Although most affected individuals do well with homebased care, advanced medical care is sometimes needed for those with severe symptoms. Data on treatment effectiveness are limited, with few clinical trials.

A literature search was performed by the writing group in 2023.

First Aid For Rash From Poison Ivy, Poison Oak, and Poison Sumac

|COR|LOE|Recommendations| |---|---|---| ||B-NR| 1. As soon as exposure to poison ivy, oak, or sumac is recognized, the exposed area should be washedwithsoapandwaterora commercially available decontamination product. | |2b|B-NR| The usefulness of over-the-counter topical steroids to alleviate local symptoms from poison ivy, oak, or sumac is uncertain. | |2b|C-EO| Cool compresses may be considered for relief of local symptoms from exposure to poison ivy, oak, orsumac. | |2b|C-EO| Oatmeal baths may be considered for relief of local symptoms from exposure to poison ivy, oak, or sumac. | |2b|C-EO| The usefulness of over-the-counter antihistamines to alleviate local symptoms from poison ivy, oak, or sumac is uncertain. |

Recommendation-Specific Supportive Text

1. Washing with soap and water can remove up to $100\%$ of poison ivy oils if done immediately after contact. This falls to $50\%$ at 10 minutes, $25\,\%$ at 15 minutes, and $10\%$ at 30 minutes. 3 In 1 study of healthy volunteers who were exposed to crushed poison ivy leaves, washing with a commercial decontamination product, commercial hand cleaner, or dishwashing soap and water produced $55\%$ to $70\%$ reductions in local symptoms compared with control, even when used 2 hours after urushiol application; no significant difference was found among the 3 treatments. 4

2. Topical corticosteroids are often recommended for symptomatic treatment of local symptoms. 5,6 However, those corticosteroids that have been demonstrated to improve local symptoms are not available over the counter. In 1 randomized, blinded trial involving 92 cases of Toxicodendron dermatitis, $0.2\%$ hydrocortisone lotion, $1.0\%$ hydrocortisone ointment, $2.5\%$ hydrocortisone ointment, and $2.5\%$ hydrocortisone cream were not reported to improve symptoms. 7 An expert consensus panel recommended the use of midpotency or high-potency topical corticosteroids for mild and moderate symptoms of Toxicodendron dermatitis, respectively. 5 An observational study enrolling 89 participants

found that the combination of systemic corticosteroids and high-potency topical corticosteroids reduced the duration of itching. 8 In this same study, the use of low-potency corticosteroids was not associated with symptom improvement.

3–4. Although supported by little evidence, cool compresses and oatmeal baths are frequently recommended for symptomatic relief of itching from Toxicodendron exposure. 5,9

5. Although oral antihistamines have been recommended as a treatment for local itching, few data support their use. 2,5,6,8,10 An expert consensus and 2 review articles suggested the use of oral antihistamines for help with sleep at night but questioned their efficacy for itching. 2,5,6 One observational study enrolling 89 participants did not find a statistically significant reduction in symptoms with the use of oral antihistamine. 8

REFERENCES

1. Schappert SM, Burt CW. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 2001- 02. Vital Health Stat 13 . 2006:1–66. 2. Kim Y, Flamm A, ElSohly MA, Kaplan DH, Hage RJ Jr, Hamann CP, Marks JG Jr. Poison ivy, oak, and sumac dermatitis: what is known and what is new? Dermatitis . 2019;30:183–190. doi: 10.1097/DER.0000000000000472 3. Fisher AA. Poison ivy/oak dermatitis, part I: prevention: soap and water, topical barriers, hyposensitization. Cutis . 1996;57:384–386. 4. Stibich AS, Yagan M, Sharma V, Herndon B, Montgomery C. Cost-effective post-exposure prevention of poison ivy dermatitis. Int J Dermatol . 2000;39:515–518. doi: 10.1046/j.1365-4362.2000.00003.x 5. Butt M, Marks JG Jr, Flamm A. Establishing consensus on the treatment of Toxicodendron dermatitis. Dermatitis . 2022;33:220–226. doi: 10.1097/DER.0000000000000894 6. Hunt MJ, Elston DM. Botanical briefs: Toxicodendron dermatitis. Cutis . 2022;110:270–273. doi: 10.12788/cutis.0649 7. Eskind IB, Sigafoos RB, Kelso RW Jr. Treatment of Rhus dermatitis with topical hydrocortisone; a clinical evaluation. AMA Arch Derm Syphilol . 1954;69:410–413. doi: 10.1001/archderm.1954.01540160012002 8. Vaught CK, Mold JW. Poison ivy: how effective are available treatments? J Fam Pract . 2016;65:801–809. 9. Fisher AA. Treatment of Rhus dermatitis with non-prescription products. J Am Med Womens Assoc (1972) . 1972;27:482–485. 10. Slaughter RJ, Beasley MG, Schep LJ. Dermatitis due to Toxicodendron plants: a common occurrence during autumn. N Z Med J . 2017;130:82–83.

Snake Bite

Background

Approximately 8000 to 10000 people are treated for snakebite in the United States each year. 1–3 Two families of venomous snakes ( Crotalinae and Elapidae ) are indigenous to the United States. 4 Most snakebites occur in the warmer months and involve the extremities. 5–7

More than $95\%$ of venomous bites in North America are caused by crotaline snakes ( Crotalinae , also known as pit vipers), specifically rattlesnakes, copperheads, and cottonmouths. 8 Venom from crotaline snakes causes tissue injury and may also cause low blood pressure, bleeding, and muscle fasciculations leading to paralysis. Wounds are generally red, warm, tender, and swollen.

In the United States, bites from coral snakes ( Elapidae ) occur in the Southeast (primarily Florida) and the Southwest (Texas, New Mexico, Arizona). 7 These bites do not cause tissue injury; coral snake venom is primarily neurotoxic and can cause paralysis within minutes to hours.

There is a relative paucity of literature about the most effective first aid treatments for snake envenomation. Application of tourniquets, pressure bandage immobilization, incision, suction, ice application or immersion, and application of electrical current have been advocated, with known risks and unclear benefits. 9–11

These recommendations are specific to snakebites occurring in the United States and Canada and involving indigenous snakes. Snakes in other parts of the world have different venom effects and may require different first aid measures.

A literature search was performed by the writing group in 2023.

|First Aid for Snake Bite in North America||| |---|---|---| |COR|LOE|Recommendations| ||C-EO| 1-EEmergency services should be activated for any person bitten by a venomous or possibly venomous snake. | |2a|C-LD| 2.It is reasonable to rest and immobilize the bitten extremity and minimize exertionbytheperson who was bitten if it does not delay access to emergency medical care. | |2a|C-EO| 3.HIt is reasonable to remove rings and other con- stricting objects from the bitten extremity. | | 3:NO benefit |C-LD| 4.A Application of ice to a snakebite wound is of unproven benefit and may be harmful in some situations. | | 3 Harm |C-LD| 5.TThe use of suction to treat snake bites is potentially harmful. | | 3 Harm |C-LD| The application of electric shock to treat snake bites is potentially harmful. | | 3二 Harm |C-LD| The use of tourniquets to treat snake bites is potentially harmful. | | 3二 Harm |C-LD| 8. The use of pressure immobilization bandaging to treat snake bites is potentially harmful. |

Recommendation-Specific Supportive Text

1. The definitive treatment for snake bite is antivenom, which is not available for use in the first aid setting. It is not practical to treat shock, internal bleeding, or severe neurotoxicity in the first aid setting. A person bitten by a snake that is venomous or might be venomous should seek prompt medical attention. Transport by EMS allows delivery of supportive and stabilizing care before arrival at the hospital.

2. A pit viper bite typically deposits venom intradermally or into the subcutaneous space. In a human experimental study, flow of an intradermally or subcutaneously injected radiotracer increased when the subject walked for $\geq10$ minutes. 12 This could lead to increased systemic absorption of venom. The ideal response in each situation requires

balancing the goals of reducing exertion with avoiding delay to care. 3. Swelling of an envenomated limb may cause rings to constrict and damage the finger. Although never studied, removal of rings and other constricting jewelry is a reasonable first aid action. 4. Ice has not been studied as a first aid treatment for snakebite, 13 and case reports show tissue injury from aggressive cryotherapy. 10 Ice application is not generally recommended for the treatment of snakebite. 4,14,15 5. Suction, with or without incision, is not effective in venom removal 11,16 and may cause tissue injury. 17,18 6. Systematic reviews of human experience and animal experiments suggest that electric shock therapy is ineffective and potentially harmful in snakebite. 15,19,20 7. Tourniquet application was found to be ineffective or to worsen local tissue injury in systematic reviews of human and animal studies. 13,15,19 8. The results of human and animal studies of pressure immobilization bandaging are mixed with regard to both intended effects (delayed onset of systemic toxicity) and to harms (worsening tissue injury). 13,19 Several studies show that medical personnel and lay rescuers had a low rate of appropriate pressure immobilization bandage placement, even under ideal conditions. 21–23 Although a properly placed pressure immobilization bandage may have a role in the management of neurotoxic snakebite, ${\tt>}95\%$ of snake envenomation in North America involves snakes with cytotoxic venom. Given this uncertainty, pressure immobilization bandaging is not currently recommended for use in North America. 24

REFERENCES

1. O’Neil ME, Mack KA, Gilchrist J, Wozniak EJ. Snakebite injuries treated in United States emergency departments, 2001-2004. Wilderness Environ Med . 2007;18:281–287. doi: 10.1580/06-WEME-OR-080R1.1 2. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wilderness Environ Med . 1997;8:8–16. doi: 10.1580/1080-6032(1997)008[0008:drfaai]2.3.co;2 3. Langley RL. Animal-related fatalities in the United States: an update. Wilderness Environ Med . 2005;16:67–74. doi: 10.1580/1080-6032(2005)16[67:afitus]2.0.co;2 4. Seifert SA, Armitage JO, Sanchez EE. Snake envenomation. N Engl J Med . 2022;386:68–78. doi: 10.1056/NEJMra2105228 5. Spano S, Macias F, Snowden B, Vohra R. Snakebite survivors club: retrospective review of rattlesnake bites in central California. Toxicon . 2013;69:38– 41. doi: 10.1016/j.toxicon.2012.11.015 6. Juckett G, Hancox JG. Venomous snakebites in the United States: management review and update. Am Fam Physician . 2002;65:1367–1374. 7. Gold BS, Barish RA, Dart RC. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin North Am . 2004;22:423– 443, ix. doi: 10.1016/j.emc.2004.01.007 8. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med . 2002;347:347–356. doi: 10.1056/NEJMra013477 9. Wang W, Chen QF, Yin RX, Zhu JJ, Li QB, Chang HH, Wu YB, Michelson E. Clinical features and treatment experience: a review of 292 Chinese cobra snakebites. Environ Toxicol Pharmacol . 2014;37:648–655. doi: 10.1016/j.etap.2013.12.018 10. Frank HA. Snakebite or frostbite: what are we doing? An evaluation of cryotherapy for envenomation. Calif Med . 1971;114:25–27. 11. Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite: a study of “mock venom” extraction in a human model. Ann Emerg Med . 2004;43:181– 186. doi: 10.1016/S0196064403008138 12. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and firstaid in simulated peripheral snake or spider envenomation. Med J Aust . 1994;161:695–700. 13. Avau B, Borra V, Vandekerckhove P, De Buck E. The treatment of snake bites in a first aid setting: a systematic review. PLoS Negl Trop Dis . 2016;10:e0005079. doi: 10.1371/journal.pntd.0005079 14. Lavonas EJ, Ruha AM, Banner W, Bebarta V, Bernstein JN, Bush SP, Kerns WP 2nd, Richardson WH, Seifert SA, Tanen DA, et al; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med . 2011;11:2. doi: 10.1186/1471-227X-11-2 15. Kanaan NC, Ray J, Stewart M, Russell KW, Fuller M, Bush SP, Caravati EM, Cardwell MD, Norris RL, Weinstein SA. Wilderness Medical Society practice guidelines for the treatment of pitviper envenomations in the United States and Canada. Wilderness Environ Med . 2015;26:472–487. doi: 10.1016/j.wem.2015.05.007 16. Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model. Wilderness Environ Med . 2000;11:180–188. doi: 10.1580/1080-6032(2000)011[0180:eoanpv]2.3.co;2 17. Holstege CP, Singletary EM. Images in emergency medicine: skin damage following application of suction device for snakebite. Ann Emerg Med . 2006;48:105, 113. doi: 10.1016/j.annemergmed.2005.12.019 18. Bush SP, Hardy DL Sr. Immediate removal of extractor is recommended. Ann Emerg Med . 2001;38:607–608. doi: 10.1067/mem.2001.119280 19. Fry BG. Snakebite: when the human touch becomes a bad touch. Toxins (Basel) . 2018;10:170. doi: 10.3390/toxins10040170 20. Ben Welch E, Gales BJ. Use of stun guns for venomous bites and stings: a review. Wilderness Environ Med . 2001;12:111–117. doi: 10.1580/1080-6032(2001)012[0111:uosgfv]2.0.co;2 21. Simpson ID, Tanwar PD, Andrade C, Kochar DK, Norris RL. The Ebbinghaus retention curve: training does not increase the ability to apply pressure immobilisation in simulated snake bite: implications for snake bite first aid in the developing world. Trans R Soc Trop Med Hyg . 2008;102:451–459. doi: 10.1016/j.trstmh.2008.01.014 22. Norris RL, Ngo J, Nolan K, Hooker G. Physicians and lay people are unable to apply pressure immobilization properly in a simulated snakebite scenario. Wilderness Environ Med . 2005;16:16–21. doi: 10.1580/PR12-04.1 23. Canale E, Isbister GK, Currie BJ. Investigating pressure bandaging for snakebite in a simulated setting: bandage type, training and the effect of transport. Emerg Med Australas . 2009;21:184–190. doi: 10.1111/j.1742-6723.2009.01180.x 24. American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Centres and Clinical Toxicologists, International Society on Toxicology and Asia Pacific Association of Medical Toxicology. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila) . 2011;49:881–882.

Jellyfish Stings

Background

Jellyfish stings are a common summertime occurrence and can cause local pain and discomfort. In North America, most people are treated at the scene of the injury, but some require more advanced medical care. 1 Allergic reactions can occur but are uncommon. Data on treatment recommendations are limited; there is a paucity of clinical trials, and it is not clear that all species of Cnidaria respond to available first aid treatments the same way. Within these limitations, hot water immersion appears to be the most effective for pain relief. Various topical products, including vinegar, baking soda, urea, and meat tenderizer, have

been evaluated but have not consistently demonstrated a reduction in pain, and some increase nematocyst discharge.

A literature search was performed by the writing group in 2023.

|First Aid for Jellyfish Stings||| |---|---|---| |COR|LOE|Recommendations| ||C-EO| 1. A first aid provider should observe a person with a jellyfish sting for systemic reaction and call emergency services for difficulty breathing, signs of shock, or severe pain. | |2a|C-LD| 2.H It is reasonable to remove any remaining tentacles by lifting or pulling while avoiding manual contact. Rinsing the affected area with seawater to remove the tentacle is a reasonable alternative if mechanical removal is not available. | |2a|C-LD| 3. After removal of tentacles, it is reasonable to use nonscalding hot water immersion/irrigation or to apply a heat source to relieve pain. | |2b|C-LD| 4. Topical lidocaine cream or gel may be reasonable for pain control if hot water is not available. |

Recommendation-Specific Supportive Text

1. Most jellyfish stings in North America result only in local symptoms, but severe local symptoms and systemic symptoms from venom can occur. 1 The ideal period of observation is unknown, but most severe reactions occur soon after envenomation. 2. A study of model envenomation evaluated the effect of scraping or pulling Alatina alata (sea wasp) tentacles off simulated tissue compared with rinsing with a number of test solutions. Scraping resulted in more hemolysis than pulling off the tentacle or rinsing with seawater. Rinsing with both seawater and ethanol resulted in increased hemolysis compared with pulling tentacles with tweezers. 2 3. Data from human studies 1–6 generally show benefit from hot water immersion or irrigation compared with alternative treatments such as cold application, papain, vinegar, meat tenderizer, or no treatment. This finding has been confirmed by systematic reviews. 7–9 The most commonly studied water temperature was $40^{\circ}\mathrm{C}$ ${'104^{\circ}\,{\sf F})}$ . 4. Topical application of lidocaine (in either $10\%-$ $15\%$ or $4\%{-}5\%$ formulations) appears to inhibit nematocyst discharge or decrease pain from stings by the tentacles of multiple jellyfish species. 6,10

REFERENCES

1. Thomas CS, Scott SA, Galanis DJ, Goto RS. Box jellyfish ( Carybdea alata ) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: a randomized, placebo-controlled, clinical trial. Hawaii Med J . 2001;60:100–107.

2. Yanagihara AA, Wilcox CL. Cubozoan sting-site seawater rinse, scraping, and ice can increase venom load: upending current first aid recommendations. Toxins (Basel) . 2017;9:105. doi: 10.3390/toxins9030105 3. Yoshimoto CM, Yanagihara AA. Cnidarian (coelenterate) envenomations in Hawai’i improve following heat application. Trans R Soc Trop Med Hyg . 2002;96:300–303. doi: 10.1016/s0035-9203(02)90105-7 4. Nomura JT, Sato RL, Ahern RM, Snow JL, Kuwaye TT, Yamamoto LG. A randomized paired comparison trial of cutaneous treatments for acute jellyfish ( Carybdea alata ) stings. Am J Emerg Med . 2002;20:624–626. doi: 10.1053/ajem.2002.35710 5. Loten C, Stokes B, Worsley D, Seymour JE, Jiang S, Isbister GK. A randomised controlled trial of hot water (45 degrees C) immersion versus ice packs for pain relief in bluebottle stings. Med J Aust . 2006;184:329–333. doi: 10.5694/j.1326-5377.2006.tb00265.x 6. Knudsen KA, Sofia. Hot water immersion treatment for lion’s mane jellyfish stings in Scandinavia. Clin Toxicol (Phila) . 2016;54:512. Abstract. 7. American Red Cross. American Red Cross Scientific Advisory Council scientific review: jellyfish stings. 2016. Accessed January 7, 2023. https:// redcross.org/content/dam/redcross/Health-Safety-Services/scientificadvisory-council/Scientific%20Advisory%20Council%20SCIENTIFIC%20 REVIEW%20-%20Jellyfish%20Stings.pdf 8. Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med . 2012;60:399–414. doi: 10.1016/j.annemergmed.2012.04.010 9. Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J . 2006;23:503–508. doi: 10.1136/emj.2005.028456 10. Birsa LM, Verity PG, Lee RF. Evaluation of the effects of various chemicals on discharge of and pain caused by jellyfish nematocysts. Comp Biochem Physiol C Toxicol Pharmacol . 2010;151:426–430. doi: 10.1016/j.cbpc.2010.01.007

Spider and Scorpion Envenomation

Background

Spider bites and scorpion stings are common occurrences in the United States. 1–5 Although many are benign and cause only self-limited local symptoms, some species of spider such as the black widow and brown recluse and some species of scorpion, for example, the bark scorpion, can cause more severe localized and systemic symptoms. 5,6

Bites from black widow and related spiders (genus Latrodectus ) cause severe crampy pain, muscle rigidity, diaphoresis, and hypertension; although a rash is sometimes observed around the bite site, widow spider bites do not cause local tissue injury. Bites from brown recluse and related spiders (genus Loxosceles ) cause painful ulcerated wounds that progress over days to weeks, sometimes associated with hemolysis and rhabdomyolysis. Bark scorpion ( Centruroides ) stings cause severe localized pain and muscle cramping that may impair breathing in children.

First aid treatment involves localized wound care and over-the-counter analgesics for pain. Data on first aid treatment are limited, with few randomized trials of first aid interventions. Advanced medical care is sometimes needed for the more severe symptoms.

The effects of spider and scorpion envenomation vary widely around the world. These guidelines are relevant to spider bites and scorpion stings occurring in the United States and Canada.

A literature search was performed by the writing group in 2023.

||First Aid forSpider andScorpionEnvenomation|| |---|---|---| |COR|LOE|Recommendations| ||C-EO| 1. Emergency services should be called if a person bitten by a spider or stung by a scorpion develops symptoms throughout the body such as difficulty breathing, muscle rigidity, dizziness, or confusion. | ||C-EO| 2.A A person bitten by a spider or stung by a scorpion should seek medical care if pain extends beyond the site of the bite/sting, becomes severe, and is not controlled by over-the-counter pain medica- tions; if an open wound develops; or if the person experiences symptoms throughout the body. | |2a|C-LD| 3. Over-the-counter acetaminophen and nonsteroi- dal anti-inflammatory agents can be used to allevi- ate local pain from scorpion stings. | |2a|C-LD| 4. If the skin is intact, topical lidocaine can be useful to relieve local pain from scorpion stings. | |2a|C-LD| 5. Ice can be useful for local pain relief from scor- pion stings. |

Recommendation-Specific Supportive Text

1–2. Although many bites and stings of spiders and scorpions result only in local symptoms, severe manifestations can compromise breathing or cause muscle injury and kidney failure. 5,6 These conditions require treatment in a health care setting.

3–5. A randomized trial of 130 adults with scorpion stings occurring in Turkey showed pain improvement with application of topical $5\%$ lidocaine, administration of intravenous acetaminophen, or topical application of ice; the greatest pain reduction was from lidocaine. 7 However, a similar study, also from Turkey, found slightly better pain relief in 106 adult patients who received intravenous acetaminophen or intravenous dexketoprofen (a nonsteroidal anti-inflammatory drug [NSAID]) compared with topical $5\%$ lidocaine or placebo. 8 Although $5\%$ topical lidocaine, oral acetaminophen, and oral NSAIDs are available in the United States without a prescription, intravenous formulations of acetaminophen and NSAIDs are not available in the first aid setting. Overall, these studies provide indirect evidence for the use of acetaminophen, NSAIDs, topical lidocaine, and ice for scorpion stings occurring in the United States. Although ice is commonly recommended, no studies assessing the use of these therapies for spider bites were found.

REFERENCES

1. Monte AA, Bucher-Bartelson B, Heard KJ. A US perspective of symptomatic Latrodectus spp. envenomation and treatment: a National Poison Data System review. Ann Pharmacother . 2011;45:1491–1498. doi: 10.1345/aph.1Q424 2. Kang AM, Brooks DE. Nationwide scorpion exposures reported to US Poison Control Centers from 2005 to 2015. J Med Toxicol . 2017;13:158–165. doi: 10.1007/s13181-016-0594-0 3. Godoy DA, Badenes R, Seifi S, Salehi S, Seifi A. Neurological and systemic manifestations of severe scorpion envenomation. Cureus . 2021;13:e14715. doi: 10.7759/cureus.14715 4. Langley RL. Animal-related fatalities in the United States: an update. Wilderness Environ Med . 2005;16:67–74. doi: 10.1580/1080-6032(2005)16[67:afitus]2.0.co;2 5. Erickson TB, Cheema N. Arthropod envenomation in North America. Emerg Med Clin North Am . 2017;35:355–375. doi: 10.1016/j.emc.2017.01.001 6. Quan D, LoVecchio F, Clark B, Gallagher JV 3rd. Prehospital use of aspirin rarely is associated with adverse events. Prehosp Disaster Med . 2004;19:362–365. doi: 10.1017/s1049023x00001990 7. Aksel G, Guler S, Dogan NO, Corbacioglu SK. A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings. Hum Exp Toxicol . 2015;34:662– 667. doi: 10.1177/0960327114551394 8. Turgut K, Yavuz E, Gulacti U, Aydin I, Sonmez C, Aktas N, Arslan E. Comparison of intravenous paracetamol, dexketoprofen trometamol, or topical lidocaine use for pain relief in scorpion stings: a placebo-controlled, randomized study. Wilderness Environ Med . 2022;33:379–385. doi: 10.1016/j.wem.2022.08.002

Hypothermia

Background

Accidental hypothermia is an environmental emergency that may be encountered in urban, rural, and austere settings. The very young, the very old, and people with impaired temperature perception, regulation, and ability to communicate are at increased risk of hypothermia. In the United States, hypothermia is responsible for $\approx\!1300$ deaths annually. 1 Death rates are highest among men, the elderly, and people who live in rural areas. 2,3

Heat loss occurs through 4 methods: conduction, convection, radiation, and evaporation (Table10). Hypothermia occurs when the core body temperature drops below the normal temperature range near $37^{\circ}\mathrm{C}$ . Individuals may be “cold” or “cold stressed” with temperatures of $35^{\circ}\mathrm{C}$ to $37^{\circ}\mathrm{C}$ . Mild hypothermia begins when the core temperature falls below $35^{\circ}\mathrm{C}$ . Hypothermia progresses through predictable stages in a continuum to death (Table11). First aid providers are unlikely to be able to obtain core body temperatures, so assessment and treatment decisions must be guided by signs and symptoms.

Rewarming may use passive measures (protecting from further heat loss and allowing the body to rewarm itself) or active measures (applying external sources of heat to the body).

These recommendations address mild to severe/ profound hypothermia in children and adults and are not applicable to infants ${<\!60}$ days of age and to cardiac arrest in all age groups.

A literature search was performed by the writing group in 2023.

Table 10. The 4 Mechanisms of Heat Loss

|Mechanism|Definition| |---|---| |Conduction| Heat transferred directly from warmer to cooler objects that are touching eachother | |Convection|Heat transferred to or from gas or liquid that is in motion| |Radiation|Heat released into air from the body| |Evaporation|Heat lost from vaporization of liquid on the skin|

Table 11. Hypothermia Signs, Symptoms, and Potential Rewarming Strategies

|Hypothermia level, °C| Signs and symptoms|Rewarming strategies| |---|---|---| |Cold stress, 35-37||| || Alert Possibly shivering | Remove from cold environment; protect from further heat loss. Passive rewarming is often adequate in healthy people. | |Mild hypothermia, 32-35| Altered level of responsiveness Shivering | Protect from harm such as falls. Passive and active rewarming methods may be used in tandem. Seek additional care. | |||| |Moderate hypothermia, 28-32||Hypothermia with decreased responsiveness, such| || ±Low heart rate Pale, nonblanching exposed skin || ||| Use allavailable passive and active rewarming| ||Associated with frozen tissue/frostbite| methods, handle the patient gently, and activate the| |Severe hypothermia,|||

First Aid for Hypothermia

|COR|LOE|Recommendations| |---|---|---| ||B-R| 1. A person with signs and symptoms of hypother- mia should be protected from further heat loss by moving from the cold environment to a warm one, having saturated clothing removed, being allowed to passively rewarm with blankets, and being actively rewarmed if resources are available. | ||C-LD| ately moved from a cold environment to a warm one, they should be protected from further heat loss by insulation from the ground, covering of head and neck, and shielding from heat loss by wind using a plastic or foil layer in addition to a dry insulating layer. | || C-LD | 3. When using rewarming devices of any kind, the first aid provider should follow the manufacturer's instructions for the device used, place insulation between the heat source and skin, and frequently monitor for burns and pressure injury. | ||C-EO| level of responsiveness such as unresponsive- ness, inability to remain awake, mumbling speech, confusion, or inability to participate in removal of clothing or has pallor, cyanosis, or frozen skin, the emergency response system should be activated while the person is rewarmed by any available method. | || C-EO || ||| 5.FFor patients experiencing cold stress or mild hypothermia who are alert and can safely con- sume oral food or fluids, it is recommended to provide high-calorie foods or drinks. | |2a|C-LD| 6. If a person with hypothermia with a decreased level of responsiveness is wearing damp (not saturated) clothing such as polyester fleece and cannot be immediately moved into a warm environment, active rewarming through the damp clothing is reasonable to initiate with the hypo- thermia wrap technique, using chemical heat blankets, plastic or foil layers, and insulative | | 3:NO Benefit |C-LD|| ||| 7. It is not beneficial to use body-to-body rewarming for active rewarming over other active rewarming techniques such as chemical heat packs or forcedtechniques such as chemical heat packs or forced air systems. |

|First Aid for Hypothermia (Continued)||| |---|---|---| |COR|LOE|Recommendations| | 3:NO Benefit |C-EO|8. It is not effective to treat a person with| | 3:NO Benefit |C-EO| hypothermia by using small glove or boot insert chemical heat packs as the sole or primary means of rewarming. | | 3:NO Benefit |C-EO|| | 3二 Harm | Heat sources, rubbing, and massage should not be applied to the extremities of a person with hypothermia. || | 3二 Harm | 3 Harm | 10. It is potentially harmful to use a warm shower or warm water immersion for rewarming a person | |C-LD| 3 Harm | warm water immersion for rewarming a person with hypothermia with a decreased level of | |C-LD| 3 Harm | with hypothermia with a decreased level of responsiveness (moderate to severe hypother | |C-LD| 3 Harm | mia) because of the risk of core temperature after drop, hypotension, falls, and drowning. | |C-LD| 3 Harm | mia) because of the risk of core temperature after drop, hypotension, falls, and drowning. |

Recommendation-Specific Supportive Text

1. In studies of active torso-warming modalities using a healthy volunteer model of induced severe hypothermia, active rewarming methods were faster than passive spontaneous rewarming methods. In 3 human volunteer studies, core rewarming rates were highest when using forced air or contact heaters with surface insulation, hot water bottles, or heating blankets (rewarming rates, $0.57^{\circ}\mathsf{C}/\mathsf{h}-$ $1.45^{\circ}\mathrm{C}/\mathsf{h})$ ) and body-to-body warming $(0.52^{\circ}\,\mathsf{C}/\mathsf{h})$ compared with passive spontaneous warming under a blanket $(0.1^{\circ}\mathsf{C}/\mathsf{h}{-}0.36^{\circ}\mathsf{C}/\mathsf{h})$ ). 4–6 Subjects in all 3 studies received medication to suppress shivering.

2. In a small, randomized study of volunteers who were dressed in moistened clothing and exposed to a cold and windy environment, use of a vaportight layer and an additional dry insulating layer (the Hibler method) is the most efficient wrapping method to prevent heat loss. 7 Although exposure of the head to cold and wet conditions does not contribute disproportionately to heat loss, head exposure causes a disproportionate increase in

core cooling rate, likely due to redistribution of blood flow to the scalp, neck, and face. 8

3. The risk of burns from active external rewarming was described in a 3-patient case series. The authors, who are subject matter experts, concluded that first aid providers should ensure that manufacturer instructions are followed, insulation (eg, cloth) is placed between the skin and the heat source (unless manufacturer instructions direct otherwise), and regular efforts are made to observe heated skin for signs of impending burn injury (eg, redness). 9 4. Decreased level of responsiveness, mumbling speech, confusion, the inability to participate in removal of wet clothing, pallor, cyanosis, stumbling, and frozen skin are potential signs of life-threatening hypothermia requiring immediate rewarming and advanced care. 10 5. Shivering is a physiological response to cold exposure, capable of increasing heat production significantly, by ${\approx}5$ to 6 times the resting metabolic rate. Although it is an effective method for rewarming, shivering is also highly energy intensive, raising the core temperature of the body but at the cost of substantial calorie expenditure. Providing high-calorie nutrition supports this metabolic demand, aids in maintaining energy reserves, and supports the natural rewarming process of the body. The provided substances should be at a safe temperature to avoid any risk of burning the esophagus. 11 6. In many freezing and windy settings, undressing a hypothermic person may further contribute to their heat loss. In a simulation study evaluating a multilayer wrap such as those used in mountain rescue, a chemical heating blanket inside a foil or plastic vapor barrier wrap was effective at transferring heat across dry and damp (but not saturated) fleece clothing. When evaluated in a simulated scenario involving saturated clothing, the excess moisture rendered the chemical heat packs inert. The researchers conclude that rescuers should cut off saturated clothing in a protected environment before wrapping wet, hypothermic people, but damp clothing need not be removed. 12

7. A simulation study of mildly hypothermic healthy volunteers found that rewarming with an external heat source was more effective than body-to-body heat donation by sharing an insulated bag with an euthermic individual (2.46±1 °C/h compared with 2.55±1.09 °C/h). 13 Another similarly designed simulation study found that core rewarming rates were highest when using an 850-W heater and rigid cover $\langle1.45\ \ {}^{\circ}\mathsf{C}/\mathsf{h}\rangle$ , charcoal heating and 600-W rigid heater $(0.7\ ^{\circ}\mathrm{C}/\mathfrak{h})$ ), or 600-W heater and blanket $(0.57~\mathrm{^\circC/h})$ ) compared with body-to-body warming $(0.52\,^{\circ}\mathrm{C}/\hbar)$ ). 5

8. Chemical heat packs used in studies rewarming hypothermic volunteers are large and are often built into panels in blankets and cover the torso. For example, a recent simulation study used a blanket with 6 heating panels with a combined mass of 397 g. 12 In contrast, small chemical heat packs marketed as glove and boot liners are between 15 and 60 g, and their ability to provide heat is highly variable. 14 The mass and heat generation of glove and boot liners are too low to facilitate the active rewarming of a person with hypothermia.

9. A simulation study describing the role of extremity circulation in relation to core temperature found that heating the extremities and promoting the venous return of cold blood from the extremities may result in cooling of the central circulation. 15 Core temperature drop after external rewarming has been confirmed in small human volunteer studies. 13,16

10. Although people with simple cold stress (cold and shivering with normal mental status) were generally able to safely rewarm in a warm shower or warm water immersion in a singlepatient experimental study of mild hypothermia (core temperature ${\approx}36^{\circ}\mathrm{C})$ , warm bath rewarming was associated with transient core temperature drop, decreases in mean arterial pressure, and increases in heart rate and cardiac output. 16 These effects can lead to decreased perfusion to the vital organs and, in severe cases, cause arrhythmia. In addition, attempting to manage a person with hypothermia who is confused or has a decreased level of alertness in a shower or bathtub is potentially dangerous for the person with hypothermia and the first aid provider.

REFERENCES

1. QuickStats: number of hypothermia-related deaths, by sex–National Vital Statistics System, United States, 1999–2011. MMWR Morb Mortal Wkly Rep . 2013;61:1050. 2. QuickStats: death rates attributed to excessive cold or hypothermia, by urbanization level and sex–National Vital Statistics System, 2018-2020. MMWR Morb Mortal Wkly Rep . 2022;71:282. doi: 10.15585/mmwr.mm7107a6 3. QuickStats: death rates attributed to excessive cold or hypothermia among persons aged ${>}/{=}15$ years, by urbanization level and age group–National Vital Statistics System, 2015-2017. MMWR Morb Mortal Wkly Rep . 2019;68:187. doi: 10.15585/mmwr.mm6807a8 4. Lundgren JP, Henriksson O, Pretorius T, Cahill F, Bristow G, Chochinov A, Pretorius A, Bjornstig U, Giesbrecht GG. Field torso-warming modalities: a comparative study using a human model. Prehosp Emerg Care . 2009;13:371–378. doi: 10.1080/10903120902935348 5. Hultzer MV, Xu X, Marrao C, Bristow G, Chochinov A, Giesbrecht GG. Prehospital torso-warming modalities for severe hypothermia: a comparative study using a human model. CJEM . 2005;7:378–386. 6. Greif R, Rajek A, Laciny S, Bastanmehr H, Sessler DI. Resistive heating is more effective than metallic-foil insulation in an experimental model of accidental hypothermia: a randomized controlled trial. Ann Emerg Med . 2000;35:337–345. doi: 10.1016/s0196-0644(00)70051-5 7. Thomassen O, Faerevik H, Osteras O, Sunde GA, Zakariassen E, Sandsund M, Heltne JK, Brattebo G. Comparison of three different prehospital wrapping methods for preventing hypothermia: a crossover study in humans. Scand J Trauma Resusc Emerg Med . 2011;19:41. doi: 10.1186/1757-7241-19-41 8. Pretorius T, Bristow GK, Steinman AM, Giesbrecht GG. Thermal effects of whole head submersion in cold water on nonshivering humans. J Appl Physiol (1985) . 2006;101:669–675. doi: 10.1152/japplphysiol.01241.2005 9. Giesbrecht GG, Walpoth BH. Risk of burns during active external rewarming for accidental hypothermia. Wilderness Environ Med . 2019;30:431–436. doi: 10.1016/j.wem.2019.06.005 10. Giesbrecht GG. “Cold card” to guide responders in the assessment and care of cold-exposed patients. Wilderness Environ Med . 2018;29:499–503. doi: 10.1016/j.wem.2018.07.001 11. Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, et al. Wilderness Medical Society clinical practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2019 update. Wilderness Environ Med . 2019;30:S47–S69. doi: 10.1016/j.wem.2019.10.002 12. Greene M, Long G, Greene K, Wilkes M. Performance of a chemical heat blanket in dry, damp, and wet conditions inside a mountain rescue hypothermia wrap. Wilderness Environ Med . 2023;34:483–489. doi: 10.1016/j.wem.2023.08.001 13. Giesbrecht GG, Sessler DI, Mekjavic IB, Schroeder M, Bristow GK. Treatment of mild immersion hypothermia by direct body-to-body contact. J Appl Physiol (1985) . 1994;76:2373–2379. doi: 10.1152/jappl.1994.76.6.2373 14. Sands WA, Kimmel WL, Wurtz BR, Stone MH, McNeal JR. Comparison of commercially available disposable chemical hand and foot warmers. Wilderness Environ Med . 2009;20:33–38. doi: 10.1580/08-WEME-OR-243.1 15. Ducharme MB, Tikuisis P. Role of blood as heat source or sink in human limbs during local cooling and heating. J Appl Physiol (1985) . 1994;76:2084–2094. doi: 10.1152/jappl.1994.76.5.2084 16. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitation from mild hypothermia. Resuscitation . 1984;11:21–33. doi: 10.1016/0300-9572(84)90031-5

Frostbite

Background

Frostbite is a condition that results from the freezing of skin and, in severe cases, underlying tissues. The formation of ice crystals within the cells causes cellular and tissue damage. The extremities—fingers, toes, nose, and ears—are particularly susceptible to frostbite. The severity of frostbite varies from mild cases in which only the outer layers of the skin are affected (superficial frostbite) to more severe cases involving deeper tissues. Symptoms include numbness, tingling, pain, and changes in skin color (from pale to hardened and dark). In extreme cases, frostbite can cause tissue necrosis leading to digit or limb loss.

A literature search was performed by the writing group in 2023.

| First Aid for Frostbite||| |---|---|---| |COR|LOE|Recommendations| ||C-LD| 1. The preferred method for warming frostbitten tissue is clean lukewarm water immersion at 37°C to 40°C(99°F-104°F). | ||C-LD| Frostbitten tissue should be rewarmed at the earliest opportunity, as long as there is no risk of refreezing. | ||C-LD| 3.1If clean lukewarm water immersion is not feasible, frostbitten tissue should be allowed to rewarm spontaneously in warm room air or next to the |

|First Aid for Frostbite (Continued)||| |---|---|---| |COR|LOE Recommendations|| ||C-LD| 4. A person with frostbite should seek prompt medical attention. | ||C-EO| 5. Jewelry or other constricting materials should be removed from a frostbitten extremity as soon as possible. | ||C-EO| 6. A person with moderate to severe hypothermia should receive core rewarming before frostbite is treated. | ||C-EO| 7. If posible, a person should protect frostbitten tissue from further injury and avoid walking on frozen feet and toes. | ||C-EO| 8.For frozen and thawed tissue and between the toes and fingers, bulky, clean, dry gauze or sterile cotton dressings should be applied. Circumfer- ential dressings should be wrapped loosely to allow for swelling without placing pressure on the underlying tissue. | |2b|C-EO| 9. It may be reasonable to give ibuprofen to a person with frostbite to prevent further tissue | | 3:NO Benefit |C-EO| 10. It is not recommended for first aid providers to debride blisters associated with frostbite. |

Recommendation-Specific Supportive Text

1. Several animal model studies have demonstrated that water temperature slightly above normal body temperature $(37{-}40^{\circ}\mathrm{C}$ $[99\!-\!104^{\circ}\,{\sf F}])$ is best for rapid rewarming with a warm-water immersion technique. 1,2 In one of these studies, rapid rewarming with warm water $(45^{\circ}\,{\mathsf{C}}\,[1\,1\,3^{\circ}\,{\mathsf{F}}])$ was harmful. 2 More recent human patient case series have demonstrated the safety and efficacy of rewarming frostbitten tissue in the range of $37^{\circ}\mathrm{C}$ to $40^{\circ}\mathrm{C}$ for between 20 and 30 minutes. 3,4 Five recent systematic reviews and clinical practice guidelines also endorse lukewarm water immersion at or near this temperature range. 5–9 If a thermometer is not available, water temperature can be tested against one’s wrist, where it should feel slightly warmer than body temperature.

2. The mechanism of tissue damage in frostbite is the development of ice crystals in cells, which can destroy cell membrane integrity. As a result, it is widely recommended that tissue refreezing be strictly avoided and first aid in-field rewarming be considered only if the risk of refreezing is negligible. 6–8,10

3. Animal studies have demonstrated that use of a warm water immersion technique at a temperature of $37^{\circ}\mathrm{C}$ to $40^{\circ}\mathrm{C}$ $(98.6^{\circ}\,\mathsf{F}{-1}\,04.0^{\circ}\,\mathsf{F})$ is best for rapid rewarming of frozen tissue. Limbs left to thaw spontaneously at $27^{\circ}\mathrm{C}$ to $29^{\circ}\mathrm{C}$ $(8\,1^{\circ}\,{\mathsf{F}}{-}84^{\circ}\,{\mathsf{F}})$ also had good outcomes. Air rewarming can be used as an alternative rewarming method when warm water immersion is not possible. 2

4. Frostbite is a potentially tissue-threatening injury, and estimating the size and severity of frostbitten tissue can be challenging, especially in the first aid setting. Advanced treatment for frostbite such as thrombolytic medication can be administered only in a health care setting and is most effective when given soon after injury. 11,12 Frostbite involving deeper tissue depths may require care at a burn center. 6

5. Tissue of the frozen extremities will swell, so it is recommended to remove constricting items such as jewelry and tight clothing.

6. Frostbite is a common finding in hypothermic individuals. However, rewarming the core of the person with hypothermia is the treatment priority, and rewarming the extremities first can cause the core temperature to decrease. 13,14

7. A characteristic of acute frostbite and frozen tissue is the inability to sense touch, including ongoing mechanical tissue damage. A person with frostbitten fingers and hands or toes and feet may not be aware of ongoing damage caused by movement, especially walking. Experts recommend that frostbitten tissues be protected and that frostbitten hands and feet not be used for climbing or walking whenever it is avoidable. 8

8. Frozen and thawed tissues are extremely vulnerable to further injury and infection. Applying bulky dressings provides a protective layer that insulates the tissue, maintaining an optimal healing environment while shielding the area from external contaminants and physical trauma. After thawing, tissues can become wet, increasing the risk of infection and delayed healing. Clean and dry dressings absorb excess moisture, keeping the area dry and reducing the likelihood of bacterial growth. Edema, or swelling, is a common response in tissues damaged by freezing and thawing attributable to increased fluid accumulation and inflammatory processes. Loose, circumferential wrapping allows expansion as swelling increases, which prevents the constriction of blood flow and further tissue damage. Frozen and thawed tissues are susceptible to pressure sores and necrosis. Bulky dressings distribute pressure more evenly, reducing the risk of localized pressure points that can compromise blood flow and tissue viability. 8

9. NSAIDs decrease the production of prostaglandins and thromboxanes that can cause vasoconstriction, dermal ischemia, and further tissue damage in frostbite. Ibuprofen is recommended by many experts and included in many treatment guidelines, although direct clinical evidence is lacking. 5,8,15

10. Intact skin is an essential barrier for infection. Whenever possible, intact epidermal layers should be left intact.

REFERENCES

1. Martinez Villen G, Garcia Bescos G, Rodriguez Sosa V, Morandeira Garcia JR. Effects of haemodilution and rewarming with regard to digital amputation in frostbite injury: an experimental study in the rabbit. J Hand Surg Br . 2002;27:224–228. doi: 10.1054/jhsb.2001.0743 2. Malhotra MS, Mathew L. Effect of rewarming at various water bath temperatures in experimental frostbite. Aviat Space Environ Med . 1978;49:874–876. 3. Daniel NJ, Storn JM, Elder JH, Chevalier JI, Weinberg NE. Clinical utilization of a sous vide device in the acute rewarming of frostbitten extremities. Am J Emerg Med . 2022;52:200–202. doi: 10.1016/j.ajem.2021.12.026 4. Bilgic S, Ozkan H, Ozenc S, Safaz I, Yildiz C. Treating frostbite. Can Fam Physician . 2008;54:361–363. 5. Zaramo TZ, Green JK, Janis JE. Practical review of the current management of frostbite injuries. Plast Reconstr Surg Glob Open . 2022;10:e4618. doi: 10.1097/GOX.0000000000004618 6. Wibbenmeyer L, Lacey AM, Endorf FW, Logsetty S, Wagner ALL, Gibson ALF, Nygaard RM. American Burn Association clinical practice guidelines on the treatment of severe frostbite. J Burn Care Res . 2023;45:541–556. doi: 10.1093/jbcr/irad022 7. Persitz J, Essa A, Ner EB, Assaraf E, Avisar E. Frostbite of the extremities: recognition, evaluation and treatment. Injury . 2022;53:3088–3093. doi: 10.1016/j.injury.2022.07.040 8. McIntosh SE, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, et al. Wilderness Medical Society clinical practice guidelines for the prevention and treatment of frostbite: 2019 update. Wilderness Environ Med . 2019;30:S19–S32. doi: 10.1016/j.wem.2019.05.002 9. Heil K, Thomas R, Robertson G, Porter A, Milner R, Wood A. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull . 2016;117:79–93. doi: 10.1093/bmb/ldw001 10. Regli IB, Strapazzon G, Falla M, Oberhammer R, Brugger H. Long-term sequelae of frostbite: a scoping review. Int J Environ Res Public Health . 2021;18:9655. doi: 10.3390/ijerph18189655 11. Lorentzen AK, Davis C, Penninga L. Interventions for frostbite injuries. Cochrane Database Syst Rev . 2020;12:CD012980. doi: 10.1002/14651858.CD012980.pub2 12. Hickey S, Whitson A, Jones L, Wibbenmeyer L, Ryan C, Fey R, Litt J, Fabia R, Cancio L, Mohr W, et al. Guidelines for thrombolytic therapy for frostbite. J Burn Care Res . 2020;41:176–183. doi: 10.1093/jbcr/irz148 13. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitation from mild hypothermia. Resuscitation . 1984;11:21–33. 14. Ducharme MB, Tikuisis P. Role of blood as heat source or sink in human limbs during local cooling and heating. J Appl Physiol (1985) . 1994;76:2084–2094. doi: 10.1152/jappl.1994.76.5.2084 15. Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, Cochran A, Imray CH. Frostbite: a practical approach to hospital management. Extrem Physiol Med . 2014;3:7. doi: 10.1186/2046-7648-3-7

Heatstroke and Exertional Hyperthermia

Background

Exertional hyperthermia occurs when a person performs strenuous exercise in a warm environment or is not adequately able to thermoregulate by sweating. Heatstroke is an emergency condition characterized by severe hyperthermia and organ dysfunction, typically with mental status alteration. The growing incidence of heat-reported illness is of increasing concern because of global urbanization and climate change.

The current heat emergency data have several limitations. Most studies were small and involved inducing hyperthermia in asymptomatic, healthy adult volunteers, resulting in indirect evidence for treating adults with heatstroke. Studies involving people with heatstroke are generally observational and use rapidity of temperature reduction as the end point. Few studies are available on

the impact of first aid interventions on crucial clinical outcomes such as mortality, organ damage, and adverse events. No comparative studies of cooling techniques in children were identified.

This topic was the subject of a 2020 ILCOR systematic review, 1 a 2020 AHA/Red Cross focused update, 2 and a 2022 ILCOR evidence update. 3 An updated literature search was performed by the writing group in 2023.

First Aid for Exertional Hyperthermia and Heatstroke

|COR|LOE|Recommendations|| |---|---|---|---| ||C-EO|| 1. For people with exertional hyperthermia or heatstroke,first aid providers should move the individual from the hot environment, remove excess clothing, limit exertion, and provide cool liquids if the person is able to swallow. | ||C-EO|| 2. For people with heatstroke (heat illness with altered mental status),first aid providers should activate emergency services. | |2a|C-LD|| 3. For adults with heatstroke,it is reasonable to initiate immediate active cooling by using whole- body (neck-down) cool- to cold-water immersion for 15 minutes or until neurological symptoms resolve (whichever occurs first). | |2a|C-LD|| 4.For adults with heatstroke, it is reasonable to initiate other forms of active cooling, including commercial ice packs, cold showers, ice sheets and towels, cooling vests and jackets, and evaporative, fanning, or a combination of techniques when water immersion is not available. | |2a|C-EO|| For children with heatstroke, it is reasonable to initi- ate immediate active cooling by using whole-body (neck-down) cool- to cold-water immersion for 15 minutes or until neurological symptoms resolve (whichever occurs first). | ||||| |2a|C-EO|| For children with heatstroke,it is reasonable to initiate other forms of active cooling, including commercial ice packs, cold showers, ice sheets and towels, cooling vests and jackets, and evaporative, fanning, or a combination of techniques when water immersion is not available. | |2b|C-EO|| It may be reasonable for first aid providers, who are trained and willing, to measure core temperature during active cooling for heatstroke. The target core temperature to cool until is 39°C (102.2°F). |

Recommendation-Specific Supportive Text

1. Although not formally studied, these safe, readily available measures are commonly included in standard recommendations of heat exhaustion or heatstroke. 4–6 2. Heatstroke (heat stress accompanied by altered mental status) can lead to muscle injury, coagulopathy, organ failure, cardiovascular collapse, and death. 7,8 Heatstroke is a medical emergency that requires rapid cooling, intravenous fluids, and intensive monitoring and support in a hospital setting. 3. Survival from heatstroke is related to the speed at which temperature reduction is achieved; faster cooling is associated with better survival. 9–11

An ILCOR systematic review of 63 studies of cooling techniques for exertional heat exhaustion and heatstroke found faster cooling rates with water immersion compared with passive cooling. 1 There was no significant difference in the rate of body temperature reduction across water temperatures of 2 to $26^{\circ}\mathrm{C}$ $(36^{\circ}\,{\mathsf{F}}{-}79^{\circ}\,{\mathsf{F}})$ , indicating that the act of immersion, rather than water temperature, is most important. 4. The listed cooling methods reduce temperature more slowly than immersion methods but more quickly than passive body cooling or application of ice packs to the axilla and groin. 12–14 5–6. Although much of the hyperthermia literature includes adolescent athletes and military recruits in the studied population, studies enrolling younger children have not been completed. 15 In the absence of pediatric-specific studies, pediatric recommendations mirror recommendations for adolescents and adults. 15–18 7. The primary outcome of active cooling for heatstroke is core temperature reduction. Although core temperature measurement is typically outside the scope of lay first aid providers, it may be appropriate in some settings and circumstances. 4,15,18

REFERENCES

1. Douma MJ, Aves T, Allan KS, Bendall JC, Berry DC, Chang WT, Epstein J, Hood N, Singletary EM, Zideman D, et al; First Aid Task Force of the International Liaison Committee on Resuscitation. First aid cooling techniques for heat stroke and exertional hyperthermia: a systematic review and meta-analysis. Resuscitation . 2020;148:173–190. doi: 10.1016/j.resuscitation.2020.01.007 2. Pellegrino JL, Charlton NP, Carlson JN, Flores GE, Goolsby CA, Hoover AV, Kule A, Magid DJ, Orkin AM, Singletary EM, et al. 2020 American Heart Association and American Red Cross focused update for first aid. Circulation . 2020;142:e287–e303. doi: 10.1161/CIR.0000000000000900 3. Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, et al; Collaborators. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published correction appears in Circulation. 2024;149:e1218]. Circulation . 2022;146:e483–e557. doi: 10.1161/CIR.0000000000001095 4. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med . 2014;25:S55–S65. doi: 10.1016/j.wem.2014.07.017 5. Casa DJ, DeMartini JK, Bergeron MF, Csillan D, Eichner ER, Lopez RM, Ferrara MS, Miller KC, O’Connor F, Sawka MN, et al. National Athletic Trainers’ Association position statement: exertional heat illnesses. J Athl Train . 2015;50:986–1000. doi: 10.4085/1062-6050-50.9.07 6. Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO; American College of Sports Medicine. American College of Sports Medicine position stand: exertional heat illness during training and competition. Med Sci Sports Exerc . 2007;39:556–572. 7. Yezli S, Yassin Y, Ghallab S, Abdullah M, Abuyassin B, Vishwakarma R, Bouchama A. Classic heat stroke in a desert climate: a systematic review of 2632 cases. J Intern Med . 2023;294:7–20. doi: 10.1111/joim.13633 8. Garcia CK, Renteria LI, Leite-Santos G, Leon LR, Laitano O. Exertional heat stroke: pathophysiology and risk factors. BMJ Med . 2022;1:e000239. doi: 10.1136/bmjmed-2022-000239 9. Vicario SJ, Okabajue R, Haltom T. Rapid cooling in classic heatstroke: effect on mortality rates. Am J Emerg Med . 1986;4:394–398. doi: 10.1016/0735-6757(86)90185-3 10. Kanda J, Nakahara S, Nakamura S, Miyake Y, Shimizu K, Yokobori S, Yaguchi A, Sakamoto T. Association between active cooling and lower mortality among patients with heat stroke and heat exhaustion. PLoS One . 2021;16:e0259441. doi: 10.1371/journal.pone.0259441 11. Filep EM, Murata Y, Endres BD, Kim G, Stearns RL, Casa DJ. Exertional heat stroke, modality cooling rate, and survival outcomes: a systematic review. Medicina (Kaunas) . 2020;56:589. doi: 10.3390/medicina56110589 12. Sinclair WH, Rudzki SJ, Leicht AS, Fogarty AL, Winter SK, Patterson MJ. Efficacy of field treatments to reduce body core temperature in hyperthermic subjects. Med Sci Sports Exerc . 2009;41:1984–1990. doi: 10.1249/MSS.0b013e3181a7ae82 13. Nye EA, Eberman LE, Games KE, Carriker C. Comparison of whole-body cooling techniques for athletes and military personnel. Int J Exerc Sci . 2017;10:294–300. 14. Kielblock AJ, Van Rensburg JP, Franz RM. Body cooling as a method for reducing hyperthermia: an evaluation of techniques. S Afr Med J . 1986;69:378–380. 15. Mangus CW, Canares TL. Heat-related illness in children in an era of extreme temperatures. Pediatr Rev . 2019;40:97–107. doi: 10.1542/pir.2017-0322 16. Davies D. Extreme heat: tips to keep kids safe when temperatures soar. Healthy Children.org. 2023. Accessed December 30, 2023. https:// healthychildren.org/English/safety-prevention/at-home/Pages/Protecting-Children-from-Extreme-Heat-Information-for-Parents.aspx 17. Hicks A, Komar L. Too hot! Preventing, recognizing and managing heat injury in children. Paediatr Child Health . 2023;28:72–74. doi: 10.1093/pch/pxac092 18. Bergeron MF, Devore C, Rice SG; Council on Sports Medicine and Fitness and Council on School Health. Policy statement: climatic heat stress and exercising children and adolescents. Pediatrics . 2011;128:e741–e747. doi: 10.1542/peds.2011-1664

Oral Rehydration for Exertional Dehydration

Background

Dehydration associated with exertion is a health concern frequently encountered in the first aid setting, particularly in sporting events. The condition continues to pose significant risks to athletes and participants involved in physically demanding activities. It is characterized by reduced total body water content, often exacerbated by increased perspiration, respiratory water loss, high ambient temperatures, and inadequate fluid intake. This imbalance in fluid homeostasis can lead to diminished physical performance, cognitive impairments, and in severe cases, life-threatening complications such as heatstroke or acute kidney injury. Although various hydration strategies have been used to prevent or mitigate these outcomes, there has been a lack of consistency in past treatment recommendations.

This topic was the subject of a 2-part ILCOR systematic review in 2023. 1,2

Oral Rehydration for Exertional Dehydration

|COR|LOE|Recommendations| |---|---|---| ||C-LD|1. In the absence of shock, confusion, or inability to| ||C-LD|swallow, first aid providers should assist or| ||C-LD|encourage individuals with exertional dehydration to| ||C-LD|orally rehydrate with any available rehydration drink| ||B-R|or potable water.| |2a|B-R| 2. It is reasonable to choose 4% to 9% carbohydrate- electrolyte drink over potable water, 0% to 3.9% | |2a|B-R| electrolyte drink over potable water, 0% to 3.9% carbohydrate-electrolyte drinks, coconut water, or | |2a|B-R|low-fat cow's milk, if each is readily available.|

Recommendation-Specific Supportive Text

1–2. A pair of 2023 ILCOR systematic reviews 1,2 identified 22 studies comparing carbohydrateelectrolyte drinks and other beverages with water for effective oral rehydration. These studies used surrogate markers of rehydration, typically urine output. The authors of these studies considered low urine output to represent retention of the administered fluids, an indirect measure of rehydration effectiveness. Although there was variability between studies, the review authors concluded that carbohydrateelectrolyte drinks $(4\%{-}9\%$ glucose concentration) were overall associated with the highest net fluid balance. No beverage was superior for all end points studied, and all beverages except beer were equal or superior to potable water for some end points in some studies.

REFERENCES

1. Borra V, De Brier N, Berry DC, Zideman D, Singletary E, De Buck E; International Liaison Committee on Resuscitation First Aid Task Force. Oral rehydration beverages for treating exercise-associated dehydration: a systematic review, part I: carbohydrate-electrolyte solutions [published online December 20, 2023]. J Athl Train . doi: 10.4085/1062-6050-0682.22 2. De Brier N, Borra V, Berry DC, Zideman D, Singletary E, De Buck E; International Liaison Committee on Resuscitation First Aid Task Force. A systematic review on oral rehydration beverages for treating exercise-associated dehydration, part II: the effectiveness of alternatives to carbohydrate-electrolyte drinks [published online December 20, 2023]. J Athl Train . 2023. doi: 10.4085/1062-6050-0686.22

TOXICOLOGY EMERGENCIES

Opioid Overdose

Background

Opioid overdose is a leading cause of death in the United States and worldwide. More than 80000 people in the United States died of opioid overdose in 2021, with a $14\%$ increase in the age-adjusted death rate from opioid overdose in a single year. 1 In the same year, 1.06 million people were treated in US EDs for nonfatal opioid overdose. 2 Most overdoses are unintentional.

Opioid overdose causes central nervous system depression (sleepiness, unresponsiveness) and respiratory depression (slowed and stopped breathing), which, if untreated, progresses to cardiac arrest.

Naloxone is an antidote that reverses the effect of opioid overdose, restoring consciousness and breathing. Naloxone can be administered by multiple routes, and naloxone nasal spray is available in the United States without a prescription.

Because it can be difficult to reliably ascertain the presence or absence of a pulse in the first aid setting, these guidelines follow the Opioid-Associated Emergency for Lay Responders Algorithm (Figure6). This

 Figure 6. Opioid-Associated Emergency for Lay Responders Algorithm.

AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services. \*For adult and adolescent victims, responders should perform compressions and rescue breaths for opioid-associated emergencies if they are trained and perform hands-only CPR if not trained to perform rescue breaths. For infants and children, CPR should include compressions with rescue breaths.

does not preclude people with appropriate training from using the Opioid-Associated Emergency for Health Care Providers Algorithm.

Nothing in these guidelines is intended to preclude the use of other opioid antagonists (eg, nalmefene), which are available by prescription only in the United States at the time of this writing.

These recommendations adapt those found in the 2020 AHA adult basic and advanced life support and pediatric basic and advanced life support guidelines and the “2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning” for the first aid setting. 3–5 An updated literature search was performed by the writing group in 2023.

||First Aid for Opioid Overdose|| |---|---|---| |COR|LOE|Recommendations| ||B-R|1. It is beneficial for first aid providers to receive| ||B-R|training in responding to opioid overdose, including| ||B-NR| 2. A first aid provider who encounters a person with suspected opioid overdose who is unresponsive and not breathing or not breathing normally should | ||B-NR| suspected opioid overdose who is unresponsive and not breathing or not breathing normally shouldand not breathing or not breathing normally should activate the emergency response system, provideactivate the emergency response system, provide high-quality CPR (compressions plus ventilation), | ||B-NR| high-quality CPR (compressions plus ventilation), and administernaloxone. |

Recommendation-Specific Supportive Text

1. Ten controlled studies assessed the impact of opioid overdose training on the ability of individuals with opioid use disorder to recognize opioid-associated resuscitation emergencies or their willingness to administer naloxone. 6–15 One study 13

found that the rate of naloxone administration was higher in those who had received opioid training compared with those who had not $\langle32\%$ versus $0\%$ ), although another study found no difference in the provision of aid between trained and untrained responders. 14 Interventions that included skills practice (ie, naloxone administration) were more likely to lead to improved clinical performance compared with interventions without skills practice, 7,16–21 and an RCT showed that people who use opioids and their significant others were more likely to administer naloxone if they received hands-on training compared with watching a video. 10 Opioid education and naloxone distribution programs are widely accepted by first aid providers in various settings. 22–33

2. More than 20 studies 34–62 demonstrate that naloxone is a safe and effective treatment for central nervous system and respiratory depression due to opioid overdose when given in various settings. Major complications are rare and dose related. No studies compared naloxone administration with standard resuscitation or ventilatory support alone. In addition to circumstantial evidence of opioid exposure, miosis is strongly correlated with response to naloxone administration, 63,64 although many factors affect pupil size, 65 and it is not established whether first aid providers can reliably identify miosis. Naloxone has an excellent safety profile and is unlikely to be harmful if given to a person with respiratory depression who does not have an opioid overdose. 66,67 A person who is breathing normally does not require naloxone.

Early activation of the emergency response system is critical for people with suspected opioid overdose. Rescuers cannot be certain that the person’s clinical condition is due to opioid-induced respiratory depression alone. This is particularly true in first aid settings, where determination of the presence of a pulse is unreliable, 68,69 but even trained first responders have difficulty rapidly determining pulselessness. 70 Intranasal naloxone takes several minutes to restore adequate respirations, 39,55,56,58–60,62 and ventilatory support is crucial during this time. Naloxone is not effective in other medical conditions, including overdose involving nonopioids and cardiac arrest resulting from any cause. People who respond to naloxone administration are at risk of recurrent central nervous system or respiratory depression and require a period of observation before safe discharge from a health care setting. 71–74 The risk of providing CPR to a person who is not in cardiac arrest is low. 75 Therefore, the safest course for a first aid provider is to immediately activate the emergency response system, delivering high-quality CPR that includes both compressions and ventilation, and administer naloxone. A health care professional who is able to reliably assess for the presence of a pulse can use the appropriate health care professional algorithm.

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Real-world study of multiple naloxone administration for opioid overdose reversal among bystanders. Harm Reduct J . 2022;19:49. doi: 10.1186/s12954-022-00627-3 53. Weisshaar S, Brandt L, Litschauer B, Sheik-Rezaei S, Moser L, Nirnberger G, Kuhberger E, Bauer U, Firbas C, Gouya G, et al. Dose-dependent naloxone-induced morphine withdrawal symptoms in opioid-dependent males: a double-blinded, randomized study. Br J Clin Pharmacol . 2020;86:1610–1619. doi: 10.1111/bcp.14271 54. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med . 1998;5:293–299. doi: 10.1111/j.1553-2712.1998.tb02707.x 55. Skulberg AK, Tylleskar I, Valberg M, Braarud AC, Dale J, Heyerdahl F, Skalhegg T, Barstein J, Mellesmo S, Dale O. Comparison of intranasal and intramuscular naloxone in opioid overdoses managed by ambulance staff: a double-dummy, randomised, controlled trial. Addiction . 2022;117:1658– 1667. doi: 10.1111/add.15806 56. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care . 2009;13:512–515. doi: 10.1080/10903120903144866 57. Osterwalder JJ. Naloxone: for intoxications with intravenous heroin and heroin mixtures: harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol . 1996;34:409–416. doi: 10.3109/15563659609013811 58. Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction . 2009;104:2067–2074. doi: 10.1111/j.1360-0443.2009.02724.x 59. Kelly AM, Kerr D, Dietze P, Patrick I, Walker T, Koutsogiannis Z. Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose. Med J Aust . 2005;182:24–27. doi: 10.5694/j.1326-5377.2005.tb06550.x 60. Dietze P, Jauncey M, Salmon A, Mohebbi M, Latimer J, van Beek I, McGrath C, Kerr D. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Netw Open . 2019;2:e1914977. doi: 10.1001/jamanetworkopen.2019.14977 61. Cetrullo C, Di Nino GF, Melloni C, Pieri C, Zanoni A. Naloxone antagonism toward opiate analgesic drugs: clinical experimental study [in Italian]. Minerva Anestesiol . 1983;49:199–204. 62. Barton ED, Colwell CB, Wolfe T, Fosnocht D, Gravitz C, Bryan T, Dunn W, Benson J, Bailey J. Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med . 2005;29:265–271. doi: 10.1016/j.jemermed.2005.03.007 63. Friedman MS, Manini AF. Validation of criteria to guide prehospital naloxone administration for drug-related altered mental status. J Med Toxicol . 2016;12:270–275. doi: 10.1007/s13181-016-0549-5 64. Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med . 1991;20:246– 252. doi: 10.1016/s0196-0644(05)80933-3 65. Boyer EW. Management of opioid analgesic overdose. N Engl J Med . 2012;367:146–155. doi: 10.1056/NEJMra1202561 66. Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opin Drug Saf . 2015;14:1137– 1146. doi: 10.1517/14740338.2015.1037274 67. Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, et al; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Council on Clinical Cardiology. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation . 2021;143:e836–e870. doi: 10.1161/CIR.0000000000000958 68. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation . 1996;33:107–116. doi: 10.1016/s0300-9572(96)01016-7 69. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation . 1997;35:23–26. doi: 10.1016/s0300-9572(96)01092-1 70. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: what if there is no pulse? Crit Care Med . 2000;28:N183–N185. doi: 10.1097/00003246-200011001-00002 71. Zuckerman M, Weisberg SN, Boyer EW. Pitfalls of intranasal naloxone. Prehosp Emerg Care . 2014;18:550–554. doi: 10.3109/10903127.2014.896961 72. Heaton JD, Bhandari B, Faryar KA, Huecker MR. Retrospective review of need for delayed naloxone or oxygen in emergency department patients receiving naloxone for heroin reversal. J Emerg Med . 2019;56:642–651. doi: 10.1016/j.jemermed.2019.02.015 73. Etherington J, Christenson J, Innes G, Grafstein E, Pennington S, Spinelli JJ, Gao M, Lahiffe B, Wanger K, Fernandes C. Is early discharge safe after naloxone reversal of presumed opioid overdose? CJEM . 2000;2:156–162. doi: 10.1017/s1481803500004863 74. Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J . 2005;22:612–616. doi: 10.1136/emj.2003.009613 75. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castren M, Chung SP, Considine J, Couper K, Escalante R, et al; Adult Basic Life Support Collaborators. Adult basic life support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation . 2020;156:A35–A79. doi: 10.1016/j.resuscitation.2020.09.010

Chemical Exposure to the Skin

Background

Exposure to caustic chemicals is a danger both at home and in the workplace. Although caustic injuries make up only ${\approx}3\%$ of burns, they can lead to significant morbidity and mortality. 1 There are many different types of caustic products, but they fall primarily in the categories of acids and alkalis. The extent of the injury from caustic materials is related to the mechanism and concentration of the chemical, its depth of penetration, the volume of chemical that the victim is exposed to, the body site involved, and how long the exposure lasts. 2,3

Rapid removal of the caustic agent is the key to first aid. When first aid is provided for caustic injury, it is important not to contaminate other individuals or areas with the substance. Personal protective equipment should

be worn when exposure to the caustic agent is possible. Although some caustic liquids may be more easily removed or treated with specialized agents, running water is a readily available resource that can be used as a decontamination agent. 4 Poison centers can provide further information on additional treatment recommendations, including duration of irrigation or other decontamination strategies.

A literature search was performed by the writing group in 2023.

|First Aid for Chemical Exposure to the Skin||| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1.Immediate skin decontamination is recommended after a chemical exposure. | ||B-NR| Unless otherwise recommended by local guide lines or chemical-specific information, skin exposed to caustic chemical should be irigated with running water for at least 15 minutes. | ||C-LD| 3. It can be beneficial to follow local guidelines, fol- low chemical-specific procedures, or consult a regional poison center when assisting a person with chemical exposures. | ||C-EO| Contaminated clothing, jewelry, and other surrounding material should be removed from the area of a chemical exposure. | ||C-EO| EMS should be called when a person with chemi- cal exposure has respiratory symptoms, systemic symptoms, or large chemical exposures. | |2a|C-LD| 6.1It is reasonable to brush off any dry chemical be- fore irrigation with water. |

Recommendation-Specific Supportive Text

1–2, 4. An observational study reported outcomes for 35 patients with caustic dermal injury from various agents. 5 Patients who received immediate irrigation within 10 minutes and with a “large volume” of water for at least 15 minutes had decreased degree of full-thickness burns, number of full-thickness burns, and mean length of hospital stay compared with those who did not receive immediate irrigation. A second observational study evaluated the effect of immediate first aid, defined as copious water irrigation within 3 minutes of the exposure, compared with delayed irrigation in 83 patients. 6 The number of full-thickness burns, mean hospital days, and delayed complications were all lower in patients with immediate irrigation compared with those with delayed irrigation. Removal of contaminated clothing and jewelry avoids trapping chemicals against the skin during decontamination. 7

3. Exposures to some chemicals such as those in the home may result from low concentrations and amounts of the chemical that, if appropriately irrigated, may not result in burns to the skin and do not need more advanced medical care. However, in the industrial setting or with more

concentrated or potent chemicals, significant injury may occur and, even with immediate irrigation, needs advanced medical care. Sources of chemical-specific treatment recommendations include Safety Data Sheets and poison centers.

5. Some chemicals such as hydrofluoric acid 8 and phenol 9 are best decontaminated with substances other than water and may require treatment other than simple decontamination. Washing with a commercial decontamination solution if available may be more effective than water for some exposures. 10–12 Some poisons can be absorbed through the skin or mucus membranes, leading to systemic toxicity. Recommendations for decontamination in specific circumstances can be obtained from local protocols, hazardous materials references, and regional poison centers.

6. Some dry chemicals such as sodium hydroxide, elemental sodium, or elemental potassium may react with water to cause caustic or thermal injury. Dry decontamination (brushing off as much chemical powder as possible while avoiding spreading the contaminant to other areas) before irrigation of the area with water may reduce this effect. 1,13

REFERENCES

1. Palao R, Monge I, Ruiz M, Barret JP. Chemical burns: pathophysiology and treatment. Burns . 2010;36:295–304. doi: 10.1016/j.burns.2009.07.009 2. Olaitan PB, Jiburum BC. Chemical injuries from assaults: an increasing trend in a developing country. Indian J Plast Surg . 2008;41:20–23. doi: 10.4103/0970-0358.41106 3. Fitzpatrick KT, Moylan JA. Emergency care of chemical burns. Postgrad Med . 1985;78:189–194. doi: 10.1080/00325481.1985.11699164 4. Brent J. Water-based solutions are the best decontaminating fluids for dermal corrosive exposures: a mini review. Clin Toxicol (Phila) . 2013;51:731– 736. doi: 10.3109/15563650.2013.838628 5. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of prompt first aid. J Trauma . 1982;22:420–423. doi: 10.1097/00005373-198205000-00013 6. Moran KD, O’Reilly T, Munster AM. Chemical burns: a ten-year experience. Am Surg . 1987;53:652–653. 7. Cibulsky SM, Kirk MA, Ignacio JS, Leary AD, Schwartz MD. Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities . US Department of Homeland Security and US Department of Health and Human Services; 2014. 8. Burgher F, Mathieu L, Lati E, Gasser P, Peno-Mazzarino L, Blomet J, Hall AH, Maibach HI. Part 2: comparison of emergency washing solutions in $70\%$ hydrofluoric acid-burned human skin in an established ex vivo explants model. Cutan Ocul Toxicol . 2011;30:108–115. doi: 10.3109/15569527.2010.534748 9. Hunter DM, Timerding BL, Leonard RB, McCalmont TH, Schwartz E. Effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns. Ann Emerg Med . 1992;21:1303–1307. doi: 10.1016/s0196-0644(05)81891-8 10. Zack-Williams SD, Ahmad Z, Moiemen NS. The clinical efficacy of Diphoterine® in the management of cutaneous chemical burns: a 2-year evaluation study. Ann Burns Fire Disasters . 2015;28:9–12. 11. Hall AH, Blomet J, Mathieu L. Diphoterine for emergent eye/skin chemical splash decontamination: a review. Vet Hum Toxicol . 2002;44:228– 231. 12. Donoghue AM. Diphoterine for alkali chemical splashes to the skin at alumina refineries. Int J Dermatol . 2010;49:894–900. doi: 10.1111/j.1365-4632.2009.04397.x 13. Robinett DA, Shelton B, Dyer KS. Special considerations in hazardous materials burns. J Emerg Med . 2010;39:544–553. doi: 10.1016/j.jemermed.2007.10.045

Chemical Exposure to the Eye

Background

Caustic chemical exposure to the eyes is a danger both at home and in the workplace. 1 Chemical injury to the eye represents between $10\%$ to $22\%$ of all eye injuries. 2,3 The extent of the eye injury from caustic materials is related to the chemical involved and how long the exposure lasts. 3 Therefore, rapid removal of the caustic agent is the key to first aid. Although some chemicals may have specific decontamination techniques, running water is a readily available resource that has been demonstrated to be an effective decontamination agent. 4 Regional poison centers or local protocols can provide further information on additional treatment recommendations, including duration of irrigation or other decontamination strategies.

A literature search was performed by the writing group in 2023.

|First Aid for Chemical Exposure to the Eye||| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1. Decontamination by irrigation should be performed immediately after chemical exposure to the eyes. | ||C-LD| 2.Unless otherwise recommended by local guide lines, irrigation with a copious amount of tap water for 15 minutes should be performed. | ||C-EO| 3.√ When providing first aid for chemical eye injury, first aid providers should avoid contaminating other individuals, areas, or the other eye with the caustic substance. | |2a|B-NR| Eye irrigation with normal saline, Ringer's lactate solution, or a commercial eye wash solution if immediately available is reasonable. | |2a|C-LD| 5. It is reasonable for individuals with ocular exposure to industrial chemicals to adhere to local guidelines or recommendations from a poison center. |

Recommendation-Specific Supportive Text

1–3. Early eye irrigation is associated with reduced eye damage in human observational and animal experimental studies. 5–9 Cross-contamination of the contralateral eye, the injured person’s skin, or other people’s skin risks additional injury. Although studies comparing different durations of eye irrigation are not available, 15 minutes of continuous irrigation appeared to be effective in an observational study and an animal experiment. 4,5 Some people may need assistance maintaining open eyelids during irrigation. Although many reviews recommend irrigation until the eye pH is normal, pH test paper is not routinely available in the first aid setting.

4. A prospective observational study enrolling 1495 patients with 2194 corrosive eye injuries

demonstrated that patients irrigated with a commercial eye irrigation solution had significantly less severe-grade eye injury compared with those treated with isotonic phosphate buffer, Ringer’s lactate, or $0.9\%$ saline solution. 4 Irrigation with a balanced salt solution may be more comfortable than irrigation with other irrigation fluids. 8

5. Approximately $8\%$ of chemical eye injuries in working-aged people occur in the occupational setting. These settings may use chemicals that require specific decontamination techniques for ideal treatment. US poison centers assist in management of >80000 ocular chemical exposures per year. 10

REFERENCES

1. Haring RS, Sheffield ID, Channa R, Canner JK, Schneider EB. Epidemiologic trends of chemical ocular burns in the United States. JAMA Ophthalmol . 2016;134:1119–1124. doi: 10.1001/jamaophthalmol.2016.2645 2. Quesada JM, Lloves JM, Delgado DV. Ocular chemical burns in the workplace: epidemiological characteristics. Burns . 2020;46:1212–1218. doi: 10.1016/j.burns.2019.11.007 3. Dua HS, Ting DSJ, Al Saadi A, Said DG. Chemical eye injury: pathophysiology, assessment and management. Eye (Lond) . 2020;34:2001–2019. doi: 10.1038/s41433-020-1026-6 4. Wiesner N, Dutescu RM, Uthoff D, Kottek A, Reim M, Schrage N. First aid therapy for corrosive chemical eye burns: results of a 30-year longitudinal study with two different decontamination concepts. Graefes Arch Clin Exp Ophthalmol . 2019;257:1795–1803. doi: 10.1007/s00417-019-04350-x 5. Rihawi S, Frentz M, Becker J, Reim M, Schrage NF. The consequences of delayed intervention when treating chemical eye burns. Graefes Arch Clin Exp Ophthalmol . 2007;245:1507–1513. doi: 10.1007/s00417-007-0597-2 6. Kuckelkorn R, Kottek A, Schrage N, Reim M. Poor prognosis of severe chemical and thermal eye burns: the need for adequate emergency care and primary prevention. Int Arch Occup Environ Health . 1995;67:281–284. doi: 10.1007/BF00409410 7. Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica . 2006;220:225–228. doi: 10.1159/000093075 8. Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs . 2012;9:129–138. doi: 10.1111/j.1741-6787.2011.00220.x 9. Chau JP, Lee DT, Lo SH. Eye irrigation for patients with ocular chemical burns: a systematic review. JBI Libr Syst Rev . 2010;8:470–519. doi: 10.11124/01938924-201008120-00001 10. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Rivers LJ, Feldman R, Brown K, Pham NPT, Bronstein AC, DesLauriers C. 2022 Annual report of the National Poison Data System® (NPDS) from America’s Poison Centers®: 40th annual report. Clin Toxicol (Phila) . 2023;61:717–939. doi: 10.1080/15563650.2023.2268981

TRAUMA

External Bleeding Control

Background

Trauma is a leading cause of morbidity and mortality throughout the world, resulting in millions of deaths and hospitalizations each year. Uncontrolled bleeding is the most important preventable cause of death in $35\%$ of trauma patients and can occur before the arrival of emergency services. 1–3 Life-threatening bleeding can be recognized by pooling of blood on the ground, blood that is

rapidly flowing or spurting from the wound, bleeding that continues despite direct manual pressure, or bleeding that results in systemic symptoms such as drowsiness, dizziness, chest pain, or loss of consciousness. Because death can occur within minutes, first aid providers are essential in providing immediate care. Control of bleeding is a foundational first aid skill, and applying direct pressure is the mainstay of treatment. For extremity bleeding that is not effectively controlled with direct pressure, tourniquet application can be an appropriate intervention.

Direct manual pressure is the hallmark of hemorrhage control. If available, hemostatic dressings (which contain materials that help promote blood clotting), pressure dressings, mechanical pressure devices, and tourniquets may augment the effectiveness of direct manual pressure or avoid the need for ongoing direct manual pressure. These devices may also be useful in a mass casualty event, when there are not adequate resources to provide direct pressure to all victims. Tourniquets are beneficial for extremity hemorrhage only when they can be applied proximal to the wound. Both commercial and improvised tourniquets can be used. No human studies have assessed the effectiveness of manual pressure points in individuals with life-threatening bleeding.

These guidelines are intended for use in the civilian first aid setting. The management of life-threatening bleeding in tactical rescue situations, mass casualty events, and military conflict is outside the scope of these guidelines.

This topic was the subject of several 2020 ILCOR systematic reviews. 4 An updated literature search was performed by the writing group in 2023.

|First Aid for Severe External Bleeding||| |---|---|---| |COR|LOE|Recommendations| ||C-LD| 1. Direct manual pressure should be applied to achieve initial control of external bleeding. | |2a|C-LD| 2.AA hemostatic dressing can be useful as adjunctive therapy to improve the effectiveness of direct manual pressure. | |2b|C-LD| Once bleeding has been controlled, it may be reasonable to apply a pressure dressing to maintain bleeding cessation. | |2b|C-LD| 4.1The utility of indirect manual pressure (ie, pres- sure points) for bleeding control is uncertain. | |2b|C-EO| Mechanical pressure such as pressure bandages or devices might be considered in some situa- tions when direct manual pressure is not feasible. |

Recommendation-Specific Supportive Text

1, 5. In 3 different RCTs conducted in hospitalized participants undergoing endovascular procedures, there was a shorter time to bleeding cessation for bleeding arterial wounds with the use of direct manual pressure than with the use of at least some mechanical compression devices. 5–7 No studies on mechanical pressure

for traumatic injuries or in the first aid setting were identified.

2. In an RCT of 160 patients in the ED with stab wounds to the limbs, the proportion with cessation of bleeding in ${<}5$ minutes was higher for participants who received a hemostatic dressing plus direct pressure $(5\,1.2\%)$ compared with participants who received direct pressure alone $(32.5\%)$ ). 8 There are currently no data addressing which type of dressing may be more effective in the first aid setting, but 3 inhospital RCTs suggest no difference between dressing types in time to cessation of bleeding or complications. 9–11 3. Commercial pressure dressings and elastic adhesive dressings may be effective in maintaining hemorrhage control or even as the primary means of hemorrhage control when applied by people who have received bleeding control training, including by non–health care personnel. 12–14 4. No studies were identified evaluating the effectiveness of manual compression of the femoral or brachial artery (also known as pressure points) to control distal hemorrhage. Data on the use of pressure points for life-threatening bleeding come from manikin studies and studies using healthy human volunteers, with no human studies evaluating pressure points in individuals with life-threatening external bleeding. 4,15 In a volunteer study, manual digital occlusion of the brachial or femoral artery eliminated distal blood flow in most subjects, but the effect was not sustained; distal pulses returned in a median of 40 seconds after brachial artery occlusion and 20 seconds of femoral artery occlusion. 16

| First Aid for Life-Threatening Extremity Bleeding That Is Not Controlled by Direct Pressure ||| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1. For life-threatening extremity bleeding, a tourniquet should be applied and tightened until the bleeding stops. | |2a|C-LD| 2.A A commercial tourniquet is probably superior to an improvised tourniquet. | |2a|C-EO| 3.HIf an improvised tourniquet is used, it is reason- ableforthetourniquettobeatleast2inwidth. |

Recommendation-Specific Supportive Text

1. Observational studies of patients with life-threatening extremity bleeding report lower mortality when a tourniquet is placed in the prehospital setting as opposed to only after hospital arrival. 4,16–18 Tourniquet application by health care professionals and laypeople appears to be safe: In 2 observational studies including 255 people with prehospital

tourniquet application by police, EMS personnel, and laypeople, no person had decreased limb function attributed to tourniquet use. 19,20 A recent systematic review found no sign that tourniquet use was associated with increased amputation rates, and nerve palsy rates were low. 4 Commercial windlass tourniquets appear to be appropriate for use in children as young as 2 years of age 4,21 and to successfully occlude distal extremity pulses in schoolaged child volunteers (6–16 years of age). 22

2. Simulation studies with healthy adult volunteers 23–25 and manikins 26 reported a higher rate of distal pulse ablation or simulated arterial compression with commercial tourniquets compared with improvised tourniquets. No pediatric studies comparing commercial with improvised tourniquets in children were identified. Some training may be required for successful application of commercial tourniquets by laypeople. 27–29

3. Narrow tourniquets cause more pain and tissue damage and are less effective than wider tourniquets. 16,30,31 Wider cuff tourniquets require less pressure to occlude arterial blood flow than narrow tourniquets. 30,32 High tourniquet pressure is associated with an increased risk of nerve compression injury. 33

REFERENCES

1. Scerbo MH, Holcomb JB, Taub E, Gates K, Love JD, Wade CE, Cotton BA. The trauma center is too late: major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. J Trauma Acute Care Surg . 2017;83:1165–1172. doi: 10.1097/TA.0000000000001666 2. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma . 2006;60:S3–11. doi: 10.1097/01.ta.0000199961.02677.19 3. Jacobs L, Burns KJ. The Hartford Consensus to improve survivability in mass casualty events: process to policy. Am J Disaster Med . 2014;9:67–71. doi: 10.5055/ajdm.2014.0143 4. Charlton NP, Swain JM, Brozek JL, Ludwikowska M, Singletary E, Zideman D, Epstein J, Darzi A, Bak A, Karam S, et al. Control of severe, life-threatening external bleeding in the out-of-hospital setting: a systematic review. Prehosp Emerg Care . 2021;25:235–267. doi: 10.1080/10903127.2020.1743801 5. Walker SB, Cleary S, Higgins M. Comparison of the FemoStop device and manual pressure in reducing groin puncture site complications following coronary angioplasty and coronary stent placement. Int J Nurs Pract . 2001;7:366–375. doi: 10.1046/j.1440-172x.2001.00291.x 6. Lehmann KG, Heath-Lange SJ, Ferris ST. Randomized comparison of hemostasis techniques after invasive cardiovascular procedures. Am Heart J . 1999;138:1118–1125. doi: 10.1016/s0002-8703(99)70078-5 7. Chlan LL, Sabo J, Savik K. Effects of three groin compression methods on patient discomfort, distress, and vascular complications following a percutaneous coronary intervention procedure. Nurs Res . 2005;54:391–398. doi: 10.1097/00006199-200511000-00005 8. Hatamabadi HR, Asayesh Zarchi F, Kariman H, Arhami Dolatabadi A, Tabatabaey A, Amini A. Celox-coated gauze for the treatment of civilian penetrating trauma: a randomized clinical trial. Trauma Mon . 2015;20:e23862. doi: 10.5812/traumamon.23862 9. Schwarz T, Rastan A, Pochert V, Sixt S, Schwarzwalder U, Burgelin KH, Buttner HJ, Muller C, Neumann FJ, Zeller T. Mechanical compression versus haemostatic wound dressing after femoral artery sheath removal: a prospective, randomized study. Vasa . 2009;38:53–59. doi: 10.1024/0301-1526.38.1.53 10. Nguyen N, Hasan S, Caufield L, Ling FS, Narins CR. Randomized controlled trial of topical hemostasis pad use for achieving vascular hemostasis following percutaneous coronary intervention. Catheter Cardiovasc Interv . 2007;69:801–807. doi: 10.1002/ccd.21024 11. McConnell MK, McDilda K, Bridges R, Marsh N, Jenkins $\mathsf{G},$ , Dowdy J, Prasnikar M. Comparison of different methods for achieving hemostasis after arterial sheath removal. J Cardiovasc Nurs . 2012;27:E1–E5. doi: 10.1097/JCN.0b013e318223881b 12. Naimer SA, Tanami M, Malichi A, Moryosef D. Control of traumatic wound bleeding by compression with a compact elastic adhesive dressing. Mil Med . 2006;171:644–647. doi: 10.7205/milmed.171.7.644 13. Naimer SA, Chemla F. Elastic adhesive dressing treatment of bleeding wounds in trauma victims. Am J Emerg Med . 2000;18:816–819. doi: 10.1053/ajem.2000.18126 14. Boulanger H, Ahriz-Saksi S, Flamant M, Vigeral P. Evaluation of post-puncture bleeding time of arteriovenous fistulas with IRIS® bandage. J Vasc Access . 2014;15:102–107. doi: 10.5301/jva.5000176 15. Pikman Gavriely R, Lior Y, Gelikas S, Levy S, Ahimor A, Glassberg E, Shapira S, Benov A, Avital G. Manual pressure points technique for massive hemorrhage control: a prospective human volunteer study. Prehosp Emerg Care . 2023;27:586–591. doi: 10.1080/10903127.2022.2122644 16. Swan KG Jr, Wright DS, Barbagiovanni SS, Swan BC, Swan KG. Tourniquets revisited. J Trauma . 2009;66:672–675. doi: 10.1097/TA.0b013e3181986959 17. Teixeira PGR, Brown CVR, Emigh B, Long M, Foreman M, Eastridge B, Gale S, Truitt MS, Dissanaike S, Duane T, et al; Texas Tourniquet Study Group. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury. J Am Coll Surg . 2018;226:769–776. e1. doi: 10.1016/j.jamcollsurg.2018.01.047 18. Hashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. Characteristics and outcomes of prehospital tourniquet use for trauma in the United States. Prehosp Emerg Care . 2023;27:31–37. doi: 10.1080/10903127.2021.2025283 19. Inaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T, Benjamin E, Demetriades D. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg . 2015;79:232–7;quiz 332. doi: 10.1097/TA.0000000000000747 20. Barnard LM, Guan S, Zarmer L, Mills B, Blackwood J, Bulger E, Yang BY, Johnston P, Vavilala MS, Sayre MR, et al. Prehospital tourniquet use: an evaluation of community application and outcome. J Trauma Acute Care Surg . 2021;90:1040–1047. doi: 10.1097/TA.0000000000003145 21. Kelly JR, Levy MJ, Reyes J, Anders J. Effectiveness of the combat application tourniquet for arterial occlusion in young children. J Trauma Acute Care Surg . 2020;88:644–647. doi: 10.1097/TA.0000000000002594 22. Harcke HT, Lawrence LL, Gripp EW, Kecskemethy HH, Kruse RW, Murphy SG. Adult tourniquet for use in school-age emergencies. Pediatrics . 2019;143:e20183447. doi: 10.1542/peds.2018-3447 23. King RB, Filips D, Blitz S, Logsetty S. Evaluation of possible tourniquet systems for use in the Canadian forces. J Trauma . 2006;60:1061–1071. doi: 10.1097/01.ta.0000215429.94483.a7 24. Heldenberg E, Aharony S, Wolf T, Vishne T. Evaluating new types of tourniquets by the Israeli naval special warfare unit. Disaster Mil Med . 2015;1:1. doi: 10.1186/2054-314X-1-1 25. Guo JY, Liu Y, Ma YL, Pi HY, Wang JR. Evaluation of emergency tourniquets for prehospital use in China. Chin J Traumatol . 2011;14:151–155. 26. Lyles WE 3rd, Kragh JF Jr, Aden JK 3rd, Dubick MA. Testing tourniquet use in a manikin model: two improvised techniques. J Spec Oper Med . 2015;15:21–26. doi: 10.55460/EJ4J-SS7L 27. Ross EM, Mapp JG, Redman TT, Brown DJ, Kharod CU, Wampler DA. The tourniquet gap: a pilot study of the intuitive placement of three tourniquet types by laypersons. J Emerg Med . 2018;54:307–314. doi: 10.1016/j.jemermed.2017.09.011 28. Portela RC, Taylor SE, Sherrill CS, Dowlen WS, March J, Kitch B, Brewer K. Application of different commercial tourniquets by laypersons: would publicaccess tourniquets work without training? Acad Emerg Med . 2020;27:276– 282. doi: 10.1111/acem.13857 29. Dennis A, Bajani F, Schlanser V, Tatebe LC, Impens A, Ivkovic K, Li A, Pickett T, Butler C, Kaminsky M, et al. Missing expectations: windlass tourniquet use without formal training yields poor results. J Trauma Acute Care Surg . 2019;87:1096–1103. doi: 10.1097/TA.0000000000002431 30. Wall PL, Duevel DC, Hassan MB, Welander JD, Sahr SM, Buising CM. Tourniquets and occlusion: the pressure of design. Mil Med . 2013;178:578–587. doi: 10.7205/MILMED-D-12-00490 31. Montgomery HR, Hammesfahr R, Fisher AD, Cain JS, Greydanus DJ, Butler FK Jr, Goolsby C, Eastman AL. 2019 Recommended limb tourniquets in tactical combat casualty care. J Spec Oper Med . 2019;19:27–50. doi: 10.55460/HQDV-7SXN 32. Graham B, Breault MJ, McEwen JA, McGraw RW. Occlusion of arterial flow in the extremities at subsystolic pressures through the use of wide tourniquet cuffs. Clin Orthop Relat Res . 1993;286:257–261. doi: 10.1097/00003086-199301000-00038 33. Masri BA, Eisen A, Duncan CP, McEwen JA. Tourniquet-induced nerve compression injuries are caused by high pressure levels and gradients: a review of the evidence to guide safe surgical, pre-hospital and blood flow restriction usage. BMC Biomed Eng . 2020;2:7. doi: 10.1186/s42490-020-00041-5

Open Chest Wounds

Background

An open chest wound (a wound through the chest wall into the lung cavity) is immediately life-threatening. Management of an open chest wound in an out-of-hospital setting while awaiting the arrival of EMS is a challenging scenario for a first aid provider. In patients with chest trauma who are breathing spontaneously, air can enter the pleural space through the chest wall defect or through a lung wound during the inspiratory (negative intrathoracic pressure) phase of the respiratory cycle (a “sucking chest wound”). The goal of a chest seal is to prevent air entry through the wound. Air can exit through the chest wall defect when intrathoracic pressure exceeds ambient pressure such as during the expiratory phase of spontaneous respirations, during positive-pressure ventilation (eg, rescue breathing, bag-mask ventilation), or if a tension pneumothorax is developing. The goal of a chest seal is to prevent air entry into the pleural space. The greatest concern is the improper use of an occlusive dressing or device that could lead to fatal tension pneumothorax by preventing air from exiting through the chest wound. It may be difficult for first aid providers to monitor for signs of tension pneumothorax such as decreased air movement on the affected side and low blood pressure.

A literature search was performed by the writing group in 2023.

Recommendation for the Care of Open Chest Wounds

|COR|LOE|Recommendations| |---|---|---| ||C-EO| 1. An open chest wound is a medical emergency requiring immediate activation of the emergency response system. | ||C-EO| 2.1 If a dressing is placed, the first aid provider should monitor the person for worsening of breathing/symptoms and loosen or remove the | ||| breathing/symptoms and loosen or remove the dressing if breathing worsens. | |2a|C-LD| 3. In the first aid situation, it is reasonable to leave an open chest wound exposed to ambient air; an open chest wound exposed to ambient air; place a clean, nonocclusive, dry dressing (eg,place a clean, nonocclusive, dry dressing (eg, gauze dressing, part of a tee shirt); or place a | |||specialized dressing such as a vented chest seal.|

Recommendation-Specific Supportive Text

1. Open chest wounds, whether from penetrating trauma or massive blunt trauma, are a medical emergency.

2. One possible cause of worsening breathing is the creation of a tension pneumothorax because air is no longer able to leave the pleural cavity after placement of a dressing. Loosening or removing the dressing may relieve tension pneumothorax.

3. The goal of sealing an open chest wound is to increase the airflow resistance through the chest wall defect so that it is greater than resistance through the trachea, allowing proper lung ventilation. This is balanced against the risk of causing tension pneumothorax.

For stab wounds, most handgun wounds, and many rifle wounds, a small wound does not lead to enough air leak to impair respirations. For larger chest wall defects such as those caused by high-velocity rifle wounds, shotgun wounds, and blast injuries, first aid interventions designed to reduce air entry through the wound are theoretically beneficial. Placement of a nonocclusive specialized dressing such as a vented chest seal may achieve this goal.

There are no human studies of chest seals to inform our treatment recommendations. The skill required to apply these devices correctly is unknown. The effect of these devices on patient-important outcomes (morbidity and mortality) is unknown. The available evidence comes from porcine models and studies on healthy human volunteers. Reported outcomes across the available evidence are disparate, including device adhesion on soiled porcine chest walls, 1 adhesion of new design for a vented chest seal on healthy volunteers and vent function, 2 and valve malfunction and labored breathing in a porcine model of tension pneumothorax and hemothorax. 3 One porcine study demonstrated that both vented and unvented chest seals provided improvements in breathing and blood oxygenation; however, in the presence of ongoing intrapleural air accumulation, the unvented chest seal eventually led to tension pneumothorax and hypoxemia. 4

The risk of occlusive dressing use in penetrating chest trauma has been detailed in the published literature since the 1950s. 5 Chest seal evaluations in animal models of hemopneumothoraxes have demonstrated how these devices can fail. 3 Any dressing or device placed over an opening in the chest wall has the potential to cause a tension pneumothorax, particularly if the device does not allow egress of air. A first aid provider who places a dressing or device should be aware of the potential complications and monitor for its occurrence.

REFERENCES

1. Arnaud F, Maudlin-Jeronimo E, Higgins A, Kheirabadi B, McCarron R, Kennedy D, Housler G. Adherence evaluation of vented chest seals in a swine skin model. Injury . 2016;47:2097–2104. doi: 10.1016/j.injury.2016.05.041

2. Hoggarth A, Grist M, Board B, Murch T. Development of a new vented chest seal dressing for treatment of open pneumothorax. J Spec Oper Med . 2020;20:159–165. doi: 10.55460/28BO-67AK 3. Kheirabadi BS, Terrazas IB, Miranda N, Voelker AN, Arnaud F, Klemcke HG, Butler FK, Dubick MA. Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model. J Trauma Acute Care Surg . 2017;83:182–189. doi: 10.1097/TA.0000000000001501 4. Kheirabadi BS, Terrazas IB, Koller A, Allen PB, Klemcke HG, Convertino VA, Dubick MA, Gerhardt RT, Blackbourne LH. Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model. J Trauma Acute Care Surg . 2013;75:150–156. doi: 10.1097/ta.0b013e3182988afe 5. Haynes BW Jr. Dangers of emergency occlusive dressing in sucking wounds of the chest. J Am Med Assoc . 1952;150:1404. doi: 10.1001/jama.1952.63680140002011a

Superficial Wounds

Background

Superficial wounds and abrasions occur when the topmost layer of skin, the epidermis, is damaged. Often resulting from friction against a rough surface, they are frequently seen in outdoor activities, sports, work, and everyday accidents. Proper first aid care can prevent infection, accelerate healing, and reduce scarring.

A literature search was performed by the writing group in 2023.

| First Aid for Superficial Wounds||| |---|---|---| |COR|LOE|Recommendations| ||C-EO| 1. Superficial wounds and abrasions should be thoroughly irrigated until there is no obvious debris or foreign matter in the wound. | ||C-EO| 2.AA superficial wound caused by an animal or human bite or with contamination with human or animal saliva should be evaluated in a medical facility as soon as possible. | |2a|B-R| 3. It is reasonable to use running tap water or sterile saline solutions for wound iigation instead of antiseptic agents such as povidone-iodine. | |2a|B-R| 4. It is reasonable to cover clean superficial wounds and abrasions with an occlusive dressing to promote wound healing. | |2a|C-EO| 5.HIf a person with superficial wound or abrasion develops redness, swelling, foul-smelling wound drainage, increased pain, or fever, it is reasonable to remove the dressing, inspect the wound, and obtain medical care. |

Recommendation-Specific Supportive Text

1. Although a 2022 Cochrane systematic review found no trials reporting wound infection that compared cleansing with tap water with no cleansing, 1 cleansing a wound to prevent infection makes empirical sense. Infection rates of wounds irrigated with tap water are similar to infection rates of wounds irrigated with sterile saline solution. 2,3 Although there is a paucity of evidence to show that any irrigation reduces infection rates in minor traumatic wounds 4 and simple rinsing may not provide the irrigation pressure needed to remove most bacterial contamination, 5,6 cleansing

of traumatic wounds is generally accepted and recommended. 7–9 2. Human and animal bite wounds or wounds contaminated with human or animal saliva are at increased risk for infection. 10 Early administration of antibiotics appears to prevent infection from high-risk human and other mammalian bites to the hand and may be useful for other bites. 10–12 3. Several studies have not demonstrated a benefit of wound cleansing with povidone-iodine in addition to irrigation. 1,13 Similar infection rates appear to occur when wounds are irrigated with tap water, boiled water, distilled water, or sterile saline. 1,14,15 4. Occlusive dressings such as film, petrolatum, hydrogel, and cellulose/collagen dressings result in better wound healing than dry dressings. 16,17 There is no indication that antibiotic or antibacterial dressings improve wound healing or decrease infection rates in clean wounds. 18–20 5. Wound infection often requires treatment with antibiotics, which must be prescribed by a health care professional.

REFERENCES

1. Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane Database Syst Rev . 2022;9:CD003861. doi: 10.1002/14651858.CD003861.pub4 2. Holman M. Using tap water compared with normal saline for cleansing wounds in adults: a literature review of the evidence. J Wound Care . 2023;32:507–512. doi: 10.12968/jowc.2023.32.8.507 3. Huang CY, Choong MY. Comparison of wounds’ infection rate between tap water and normal saline cleansing: a meta-analysis of randomised control trials. Int Wound J . 2019;16:300–301. doi: 10.1111/iwj.12980 4. Hollander JE, Richman PB, Werblud M, Miller T, Huggler J, Singer AJ. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med . 1998;31:73–77. doi: 10.1016/s0196-0644(98)70284-7 5. Stevenson TR, Thacker JG, Rodeheaver GT, Bacchetta C, Edgerton MT, Edlich RF. Cleansing the traumatic wound by high pressure syringe irrigation. JACEP . 1976;5:17–21. doi: 10.1016/s0361-1124(76)80160-8 6. Rodeheaver GT, Pettry D, Thacker JG, Edgerton MT, Edlich RF. Wound cleansing by high pressure irrigation. Surg Gynecol Obstet . 1975;141:357– 362. 7. Lewis K, Pay JL. Wound irrigation. StatPearls . StatPearls Publishing; 2023. 8. Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am . 2003;21:205–231. doi: 10.1016/s0733-8627(02)00087-1 9. Barnes S, D’Amore K, Propersi M, Reyes M. Acute traumatic wounds: evaluation, cleansing, and repair in the ED. Emerg Med Pract . 2021;23(suppl 12):1–43. 10. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev . 2001:CD001738. doi: 10.1002/14651858.CD001738 11. Looke D, Dendle C. Bites (mammalian). BMJ Clin Evid . 2010;2010:0914. 12. Cicuttin E, Sartelli M, Scozzafava E, Tartaglia D, Cremonini C, Brevi B, Ramacciotti N, Musetti S, Strambi S, Podda M, et al. Antibiotic prophylaxis in torso, maxillofacial, and skin traumatic lesions: a systematic review of recent evidence. Antibiotics (Basel) . 2022;11:139. doi: 10.3390/antibiotics11020139 13. Ghafouri HB, Zare M, Bazrafshan A, Abazarian N, Ramim T. Randomized, controlled trial of povidone-iodine to reduce simple traumatic wound infections in the emergency department. Injury . 2016;47:1913–1918. doi: 10.1016/j.injury.2016.05.031 14. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF. Wound irrigation in children: saline solution or tap water? Ann Emerg Med . 2003;41:609– 616. doi: 10.1067/mem.2003.137 15. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med . 2007;14:404–409. doi: 10.1197/j.aem.2007.01.007 16. Zhang L, Wang S, Tan M, Zhou H, Tang Y, Zou Y. Efficacy of oxidized regenerated cellulose/collagen dressing for management of skin wounds: a systematic review and meta-analysis. Evid Based Complement Alternat Med . 2021;2021:1058671. doi: 10.1155/2021/1058671 17. Beam JW. Occlusive dressings and the healing of standardized abrasions. J Athl Train . 2008;43:600–607. doi: 10.4085/1062-6050-43.6.600 18. Saco M, Howe N, Nathoo R, Cherpelis B. Topical antibiotic prophylaxis for prevention of surgical wound infections from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat . 2015;26:151– 158. doi: 10.3109/09546634.2014.906547 19. Norman G, Dumville JC, Mohapatra DP, Owens GL, Crosbie EJ. Antibiotics and antiseptics for surgical wounds healing by secondary intention. Cochrane Database Syst Rev . 2016;3:CD011712. doi: 10.1002/14651858.CD011712.pub2 20. Chen PJ, Hua YM, Toh HS, Lee MC. Topical antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: a systematic review and meta-analysis. BJS Open . 2021;5:zrab125. doi: 10.1093/bjsopen/zrab125

Spinal Motion Restriction

Background

Strategies for spinal immobilization in patients with actual or potential spinal injuries have been used for decades because of concerns that movements associated with extrication and transportation could lead to worsening of original injury or additional new injury. However, these practices (rigid cervical collar and long spine board application) have been driven more by legal considerations and unproven theories than by concrete scientific or clinical evidence. Growing data suggest that they might even be detrimental, leading to their widespread deadoption.

These recommendations are intended for the members of the general public providing first aid. Appropriate exceptions may be made for first aid providers with additional training and special duties working in specific circumstances (eg, lifeguards treating a person with a diving injury).

This topic was the subject of a 2015 ILCOR systematic review 1 and a 2019 ILCOR scoping review. 2

|First Aid for Suspected Spinal Injury||| |---|---|---| |COR|LOE|Recommendations| ||| 1. For a person with a suspected spinal injury. the first aid provider should have the person | ||C-EO|remain as still as possible (unless safety| ||C-EO|considerationswarrant movement) and activate the| |||| | 3 Harm |C-LD| We recommend against routine spinal immobilization for patients with penetrating trauma (eg, gunshot or knife wounds). | |||| | 3 Harm |C-LD| 3.We recommend against the routine use of rigid cervical collars and long spine boards for spinalcervical collars and long spine boards for spinal immobilization by first aid providers. |

Recommendation-Specific Supportive Text

1. Spinal cord injuries in adults and children are often associated with significant and frequently

life-threatening injuries to the head and brain, chest, and abdomen. 3,4 Having the injured person remain still may reduce the risk of worsening spinal cord or other injury while awaiting the arrival of EMS personnel.

2. A systematic review and meta-analysis found that routine spinal immobilization for penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurological deficits. 5,6

3. The gradual de-emphasis and deadoption of the use of spinal immobilization by professional EMS have not been associated with an increase in disabling spinal cord injuries. 7 Systematic reviews have found that immobilization devices, including rigid cervical collars and spine boards, are associated with patient discomfort and pressure ulcer development. 8–10 Prior treatment guidelines from the AHA, the Red Cross, and ILCOR and a 2019 systematic review provided a weak recommendation against the routine use of cervical collars for stable patients in the first aid setting. 1,11,12

REFERENCES

1. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation . 2015;132(suppl 2):S574– S589. doi: 10.1161/CIR.0000000000000269 2. Woodin JA, Orkin AM, Djarv T, Singletary EM, Zideman DA; International Liaison Committee on Resuscitation First Aid Task Force. Cervical spinal motion restriction scoping review and task force insights. 2021. Accessed December 1, 2021. https://costr.ilcor.org/document/cervical-spinal-motion-restriction-scoping-review 3. Haske D, Lefering R, Stock JP, Kreinest M; TraumaRegister DGU. Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures. Eur J Trauma Emerg Surg . 2022;48:1975–1983. doi: 10.1007/s00068-020-01515-w 4. Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Prehospital factors associated with cervical spine injury in pediatric blunt trauma patients. Acad Emerg Med . 2021;28:553–561. doi: 10.1111/acem.14176 5. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg . 2018;84:736–744. doi: 10.1097/TA.0000000000001764 6. Fischer PE, Perina DG, Delbridge TR, Fallat ME, Salomone JP, Dodd J, Bulger EM, Gestring ML. Spinal motion restriction in the trauma patient: a joint position statement. Prehosp Emerg Care . 2018;22:659–661. doi: 10.1080/10903127.2018.1481476 7. Clemency BM, Natalzia P, Innes J, Guarino S, Welch JV, Haghdel A, Noyes E, Jordan J, Lindstrom HA, Lerner EB. A change from a spinal immobilization to a spinal motion restriction protocol was not associated with an increase in disabling spinal cord injuries. Prehosp Disaster Med . 2021;36:708–712. doi: 10.1017/S1049023X21001187 8. Sardo PMG, Teixeira JPF, Machado A, Oliveira BF, Alves IM. A systematic review of prevalence and incidence of pressure ulcers/injuries in hospital emergency services. J Tissue Viability . 2023;32:179–187. doi: 10.1016/j.jtv.2023.02.001 9. Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg . 2014;76:1131–1141. doi: 10.1097/TA.0000000000000153 10. Geldenhuys MJ, Downing C. Evidence-based nursing care for spinal nursing immobilization: a systematic review. J Emerg Nurs . 2020;46:318–337. doi: 10.1016/j.jen.2020.02.007 11. Zideman DA, De Buck ED, Singletary EM, Cassan P, Chalkias AF, Evans TR, Hafner CM, Handley AJ, Meyran D, Schunder-Tatzber S, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 9: first aid. Resuscitation . 2015;95:278–287. doi: 10.1016/j.resuscitation.2015.07.031 12. Maschmann C, Jeppesen E, Rubin MA, Barfod C. New clinical guidelines on the spinal stabilisation of adult trauma patients: consensus and evidence based. Scand J Trauma Resusc Emerg Med . 2019;27:77. doi: 10.1186/s13049-019-0655-x

Concussion

Background

Concussion is a type of mild traumatic brain injury that is caused by an action or injury that rapidly moves the head and brain back and forth. According to the National Center for Health Statistics, in 2022, 2.3 million children and adolescents had ever received a diagnosis of concussion or brain injury. 1 Signs and symptoms of concussions include headache, nausea, impaired balance, difficulties concentrating, confusion, emotional lability, and fatigue. 2,3 Repeated concussions may lead to long-term difficulties with memory, concentrating, fatigue, headache, and other neurological sequelae. 2,4–6

Symptom-based tools have been developed to assess the presence and severity of a concussion during sports; however, they require specific training. 2,5,7–12 To date, there is no validated scoring system for concussion identification in the first aid setting.

ILCOR performed a scoping review on concussion assessment in 2020. 13 An updated literature search was performed by the writing group in 2023.

|First Aid for Concussion||| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1. A person with signs and symptoms of a concus- sionshould beimmediatelyremoved from activitysionshould beimmediatelyremoved from activity (play/sports) and not allowed to return to activity(play/sports) and not allowed to return to activity until evaluated by a health care professional. | ||B-NR|| ||C-EO| For a person with signs or symptoms of severe head injury (such as loss of consciousness, | ||C-EO| head injury (such as loss of consciousness, worsening headache, vomiting,altered mental | ||C-EO||

Recommendation-Specific Supportive Text

1. A broad consensus of health care organizations recommends removing the person with a concussion from sports and other activities posing a risk of reinjury until the injured person has fully recovered. 2,14–17 Specific requirements and timing of return to contact vary and should be determined in consultation with a health care professional.

2. Loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizure, neurological signs and symptoms, and skull fracture are all associated with an increased risk of life-threatening brain injury such as epidural hematoma, subdural hematoma, open skull fracture, or brain edema, which may require hospital treatment.

REFERENCES

1. QuickStats: percentage of children and adolescents aged ≤ 17 years who had ever received a diagnosis of concussion or brain injury, by sex and age group–National Health Interview Survey, United States, 2022. MMWR Morb Mortal Wkly Rep . 2023;72:899. doi: 10.15585/mmwr.mm7233a5 2. Halstead ME, Walter KD, Moffatt K; Council on Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics . 2018;142:e20183074. doi: 10.1542/peds.2018-3074 3. Carney N, Ghajar J, Jagoda A, Bedrick S, Davis-O’Reilly C, du Coudray H, Hack D, Helfand N, Huddleston A, Nettleton T, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery . 2014;75:S3–S15. doi: 10.1227/neu.0000000000000433 4. Rivara FP, Tennyson R, Mills B, Browd SR, Emery CA, Gioia G, Giza CC, Herring S, Janz KF, LaBella C, et al; Four Corners Youth Consortium. Consensus statement on sports-related concussions in youth sports using a modified Delphi approach. JAMA Pediatr . 2020;174:79–85. doi: 10.1001/jamapediatrics.2019.4006 5. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med . 2023;57:695–711. doi: 10.1136/bjsports-2023-106898 6. May T, Foris LA, Donnally IC. Second impact syndrome. StatPearls . StatPearls Publishing; 2023. 7. Zuckerbraun NS, Atabaki S, Collins MW, Thomas D, Gioia GA. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics . 2014;133:635–642. doi: 10.1542/peds.2013-2600 8. Schneider KJ, Patricios JS, Meeuwisse W, Schneider GM, Hayden KA, Premji Z, Ahmed OH, Blauwet C, Broglio S, Cantu RC, et al. Amsterdam 2022 process: a summary of the methodology for the Amsterdam International Consensus on Concussion in Sport. Br J Sports Med . 2023;57:712– 721. doi: 10.1136/bjsports-2022-106663 9. Echemendia RJ, Burma JS, Bruce JM, Davis GA, Giza CC, Guskiewicz KM, Naidu D, Black AM, Broglio S, Kemp S, et al. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med . 2023;57:722–735. doi: 10.1136/bjsports-2022-106661 10. Echemendia RJ, Ahmed OH, Bailey CM, Bruce JM, Burma JS, Davis GA, Gioia G, Howell D, Fuller GW, Master CL, et al. Introducing the Concussion Recognition Tool 6 (CRT6). Br J Sports Med . 2023;57:689–691. doi: 10.1136/bjsports-2023-106851 11. Caccese JB, Garcia GP, Kontos AP, Port N, Valerio K, Broglio SP, McCrea M, McAllister TW, Pasquina PF, Buckley TA; CARE Consortium Investigators. Test-retest reliability and efficacy of individual symptoms in concussion management. Clin J Sport Med . 2023;33:52–60. doi: 10.1097/JSM.0000000000001084 12. Alsalaheen B, Stockdale K, Pechumer D, Broglio SP. Validity of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT). Sports Med . 2016;46:1487–1501. doi: 10.1007/s40279-016-0532-y 13. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 14. Herring S, Kibler WB, Putukian M, Solomon GS, Boyajian-O’Neill L, Dec KL, Franks RR, Indelicato PA, LaBella CR, Leddy JJ, et al. Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement. Br J Sports Med . 2021;55:1251–1261. doi: 10.1136/bjsports-2021-104235 15. Centers for Disease Control and Prevention. Managing return to activities: information for health care professionals. 2023. Accessed October 2, 2023. https://www.cdc.gov/heads-up/hcp/clinical-guidance/index.html 16. Agarwal NT, Thakkar R, Than, K. Concussion. American Association of Neurological Surgeons. 2023. Accessed October 2, 2023. https:// aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Concussion 17. Karlson K. Concussion in sports. American College of Sports Medicine. 2011. Accessed October 2, 2023. https://acsm.org/docs/default-source/ files-for-resource-library/concussion-in-sports.pdf

Sprains and Strains

Background

Strains and sprains are common soft tissue injuries that occur after movements or falls that stress joints or muscles. These lead to overstretching or tearing of ligaments, tendons, and muscles. Acute symptoms after the injury include pain, swelling, and limited mobility to the affected extremity or joint. Studies of therapy during the subacute and healing phases of sprain and strain injuries provide indirect evidence for the first aid setting.

The ILCOR performed a systematic review of compression wraps in 2020. 1 An updated literature search was performed by the writing group in 2023.

||First Aid for Sprains and Strains|| |---|---|---| |COR|LOE|Recommendations| || 1. A person with a painful extremity injury that limits use should avoid activities that cause pain and seek medical attention. || |||| |C-LD| 2. It can be useful for first aid providers to apply cold (such as with ice and water surrounded by a damp cloth) to an acute sprain or strain for pain and swelling. Cold application should be limited to 20 to 30 minutes per application without direct || |C-LD||| ||| contact on the skin to avoid cold injury.| |20|C-LD| 3. First aid providers may consider applying a com- pression wrap after an acute ankle sprain or strain to promote comfort after an injury. Application of the compression wrap should be performed with- | |20|C-LD|| |20|||

Recommendation-Specific Supportive Text

1. The mainstay of treatment for strains and sprains is rest and limiting the use of the injured extremity. Often in the first aid setting, there is uncertainty about whether an injury is a sprain, strain, or a fracture; limiting use of the injured extremity avoids worsening the injury.

2. Cold application can acutely decrease pain and swelling in joint sprains and muscle strains. In an RCT of 74 patients with sports-related soft tissue injury, cold therapy to soft tissue injuries improved pain scores at weeks 1, 2, and 4 after injury. 2 Cold therapy improved edema compared with heat therapy in the acute time period. 3 However, cold application has not been demonstrated to improve function or time to recovery. 4 The greatest tissue cooling is achieved by using a bag filled with ice and water surrounded by a damp cloth. 5,6 Other modalities such as refreezable gel packs or ice alone can also be used but do not cool the area as effectively as an ice and water mixture. 6,7 Experts recommend limiting the duration of cold application to 20 to 30 minutes for 3 to 4 times daily. 8 To prevent cold injury, ice should not be placed directly on the skin.

3. Applying a compression wrap to an acute ankle sprain may provide comfort and relieve pain in the acute time frame. 9,10 Caution should be taken when applying compression to not compromise circulation from overtightening the compression wrap. A systematic review of 6 RCTs and 2 nonrandomized trials concluded that compression wraps did not reduce swelling or pain in ankle sprains or strains during the recovery time frame. 11 In addition, compression wraps did not improve ankle joint function, range of motion, or time to recovery. 12 A systematic review of 8 RCTs did not find a significant difference between rigid, semirigid, and flexible compression wraps when analyzing postinjury symptoms and ankle stability. 12,13 No studies were identified that address the utility of compression wraps for other joint injuries.

Fractures

Background

Extremity fractures are painful injuries that can become life or limb threatening when involving long bones, major blood vessels, or extensive soft tissue damage. Fractures of a long bone such as the femur can cause severe external or internal bleeding, and open fractures (if the fractured bone disrupts the skin) are at high risk for infection. Signs of an extremity fracture may include obvious deformity, swelling, or bruising of a limb; severe pain with movement or inability to move an extremity; or visible, protruding bone.

After an extensive literature review performed by the writing group in 2023, these recommendations were based on consensus from expert opinion because the search identified no published studies on caring for fractures in the first aid setting.

REFERENCES

1. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S2–S27. doi: 10.1161/CIR.0000000000000890 2. Airaksinen OV, Kyrklund N, Latvala K, Kouri JP, Gronblad M, Kolari P. Efficacy of cold gel for soft tissue injuries: a prospective randomized double-blinded trial. Am J Sports Med . 2003;31:680–684. doi: 10.1177/03635465030310050801 3. Cote DJ, Prentice WE Jr, Hooker DN, Shields EW. Comparison of three treatment procedures for minimizing ankle sprain swelling. Phys Ther . 1988;68:1072–1076. doi: 10.1093/ptj/68.7.1072 4. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. Br J Sports Med . 2006;40:700–705. doi: 10.1136/bjsm.2006.025932 5. Merrick MA, Jutte LS, Smith ME. Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. J Athl Train . 2003;38:28–33. 6. Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael TJ, Baker RJ. Comparisons of cubed ice, crushed ice, and wetted ice on intramuscular and surface temperature changes. J Athl Train . 2009;44:136–141. doi: 10.4085/1062-6050-44.2.136 7. Kanlayanaphotporn R, Janwantanakul P. Comparison of skin surface temperature during the application of various cryotherapy modalities. Arch Phys Med Rehabil . 2005;86:1411–1415. doi: 10.1016/j.apmr.2004.11.034 8. Kruckeberg BM, Beahrs T, Haddad SL. Sprained ankle. Rosemont, IL: American Academy of Orthopaedic Surgeons. 2022. Accessed December 10, 2023. https://orthoinfo.aaos.org/en/diseases--conditions/sprained-ankle/ 9. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med . 2005;39:91– 96. doi: 10.1136/bjsm.2003.009233 10. Bendahou M, Khiami F, Saidi K, Blanchard C, Scepi M, Riou B, Besch S, Hausfater P. Compression stockings in ankle sprain: a multicenter randomized study. Am J Emerg Med . 2014;32:1005–1010. doi: 10.1016/j.ajem.2014.05.054 11. Borra V, Berry DC, Zideman D, Singletary E, De Buck E. Compression wrapping for acute closed extremity joint injuries: a systematic review. J Athl Train . 2020;55:789–800. doi: 10.4085/1062-6050-0093.20 12. Altomare D, Fusco G, Bertolino E, Ranieri R, Sconza C, Lipina M, Kon E, Marcacci M, Bianchini L, Di Matteo B. Evidence-based treatment choices for acute lateral ankle sprain: a comprehensive systematic review. Eur Rev Med Pharmacol Sci . 2022;26:1876–1884. doi: 10.26355/eurrev_202203_28333 13. Zhao Dubuc Y, Mazzone B, Yoder AJ, Esposito ER, Kang TH, Loh KJ, Farrokhi S. Ankle sprain bracing solutions and future design consideration for civilian and military use. Expert Rev Med Devices . 2022;19:113–122. doi: 10.1080/17434440.2022.2039622

First Aid for Fractures

|COR|LOE|Recommendations| |---|---|---| ||C-EO| 1. If a fracture is associated with an open wound and severe bleeding,theFirst Aid for Severe External Bleeding and First Aid for Life- Threatening Extremity Bleeding That Is Not Controlled by Direct Pressurerecommendations should be followed. | ||C-EO| 2.1If a fractured extremity is blue, purple, or pale, the emergency response system should be activated immediately. | |2a|C-EO| Splinting of a fractured extremity can be useful to reduce pain,reduce risk for further injury, and facilitate transport to a medical facility. | |2b|C-EO| 4-It maybereasonabletotreatadeformedfrac- tured extremity in the position found unless straightening the fracture is necessary to facilitate safe and prompt transport to a medical facility. | |2b|C-EO| Covering open wounds associated with a suspected fracture with a clean dressing may be useful to lower theriskforfurther contamination and infection. |

Recommendation-Specific Supportive Text

1. Long-bone fractures and open fractures can cause substantial and possibly life-threatening blood loss. 2. Blue, purple, or pale extremities may indicate poor perfusion to the extremity, a limb-threatening injury for which professional medical care should be sought immediately. 3. There is a lack of evidence demonstrating clear benefits from fracture splinting in the prehospital first aid setting. However, fracture immobilization is an essential part of definitive fracture treatment. Splinting as a first aid measure may be helpful to reduce pain, prevent further injury, and facilitate transport. 1,2 4. Splinting an injured extremity in the position found is accepted first aid practice. 3,4 Although reducing angulated fractures may reduce pain and improve

blood flow, there are risks, including injury to nerves, blood vessels, and other soft tissue, as well as risk of converting a closed fracture to an open fracture. No study evaluating whether first aid providers are able to perform fracture reduction safely could be found. 4

5. As with any open wound, covering an open fracture protects against additional contamination. 3

REFERENCES

1. Perkins TJ. Fracture management: effective prehospital splinting techniques. Emerg Med Serv . 2007;36:35–37, 39. 2. Cuske J. The lost art of splinting: how to properly immobilize extremities & manage pain. JEMS . 2008;33:50–64; quiz 66. doi: 10.1016/S0197-2510(08)70253-5 3. Lee C, Porter KM. Prehospital management of lower limb fractures. Emerg Med J . 2005;22:660–663. doi: 10.1136/emj.2005.024489 4. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WW, Swain JM, Lojero-Wheatley LF, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation . 2015;132(suppl 2):S574– S589. doi: 10.1161/CIR.0000000000000269

Burns: Cooling Thermal Burns

Background

Thermal burns are caused by contact with flames, hot liquids, hot surfaces, and hot gases. Burns can lead to damaging physical, functional, cosmetic, and psychosocial consequences. 1 Immediate first aid care can reduce these consequences, and understanding the indications for ED referral can be lifesaving. 2

Superficial (first-degree) burns are characterized by skin redness and pain without blistering or other loosening or destruction of the skin surface (Figure7). The intact skin maintains its barrier function. First-degree

burns generally heal without scarring, and the risk of infection is low. Partial-thickness (second-degree) and full-thickness (third-degree) burns involve destruction of the epidermis and injury to deeper layers and often require treatment beyond what can be provided in the first aid setting to speed healing, prevent infection, and reduce scarring. 2,4 Large partial-thickness burns (partialthickness burns that involve the face, hands, feet, or genitalia), all full-thickness burns, and concern for inhalation injury (soot around the nose or mouth, difficulty breathing) require hospital treatment.

Active cooling to “stop the burn” has long been advocated as essential immediate first aid for thermal burns. Although burn-cooling sprays have also been studied, the majority of studies involve immediate application of cool running water. There is a lack of international consensus about the optimal duration of cooling of thermal burns.

This topic was last reviewed by ILCOR in $2022^{5}$ and was included in a 2022 update. 6 An updated literature search was performed by the writing group in 2023.

| First Aid Cooling of Thermal Burns||| |---|---|---| |COR|LOE|Recommendations| ||B-NR| 1. Thermal burns should be cooled immediately, preferably with clean running water. | ||C-LD| 2.F Preadolescent children with thermal burns being actively cooled with running water should be monitored for signs or symptoms of hypothermia. | |2b|B-NR| 3.It may be reasonable to cool thermal burns for 5 to 20 minutes. | |2b|C-LD| 4.HIf clean running water is not available, it may be reasonable to cool superficial burns (with the skin intact) with ice wrapped in cloth. |

 Figure 7. Depth of burns. Reproduced from Jeschke et al. 3 Copyright $\copyright$ 2020, Springer Nature Limited.

Recommendation-Specific Supportive Text

1. Cooling of burns with running water is an established and beneficial intervention with little risk of harm. 5,6 A meta-analysis of observational data (7 studies, 11383 adults and children) suggests a decrease in the need for subsequent care in patients with thermal burns who receive immediate active cooling with clean running water. 7 2. Because of their larger surface area–to–volume ratio, preadolescent children are more likely to develop hypothermia than adolescents and adults. A study of 117 children with thermal burns who received whole-body cooling in the shower reported that 5 children $(4\%)$ developed hypothermia or were visibly cold with shivering. 8 By observing for signs and symptoms of hypothermia and, when possible, monitoring temperature, first aid providers can avoid accidentally causing a child with burn injury to become hypothermic. 3. An ILCOR meta-analysis of 4 studies involving 5978 adults and children did not demonstrate a clear duration of cooling that was most effective and concluded that the ideal cooling duration is unknown. 5 Leading international organizations recommend active cooling durations of 5 to 20 minutes. 9–12 4. Porcine model thermal burn studies have demonstrated that ice reduces tissue temperatures after thermal burn, but the application of ice has not resulted in faster wound re-epithelializing, or healing with less scarring, compared with no treatment. Of note, there is risk of additional tissue damage when ice is used with compression. 13 If cool or cold clean running water is unavailable and ice is used, the ice should be placed in a cloth or towel before being applied to the burn area and limited to 10 minutes of application time to prevent frostbite injury.

Thermal Burn Care After Cooling

| First Aid for Thermal Burns After Cooling||| |---|---|---| |COR|LOE|Recommendations| |||1. A person with a full-thickness burn or with a partial-| ||B-NR|thickness burn that is larger than the person's| ||B-NR|palm or involves the person's face, hands, feet, or| ||B-NR|genitals should promptly seek evaluation by a health| ||C-EO|care professional.| ||C-EO| For a person with evidence of smoke inhalation injury such as facial burns, difficulty breathing. singed nasal hairs, or soot around the nose or | ||C-EO| singed nasal hairs, or soot around the nose or mouth, EMS should be activated. | || 3. A person with thermal burns should promptly remove all jewelry,belts, and other tight items from burned areas. ||

||First Aid for Thermal Burns After Cooling (Continued)||| |---|---|---|---| |COR|LOE||| |2a|B-NR| 4. It is reasonable to give over-the-counter pain medications for pain from thermal burns. || |2b|B-R||| |2b|B-R| After cooling, for small partial-thickness burns being managed at home, it may be reasonable to apply petrolatum,petrolatum-based antibioticointment, || |2b|B-R|honey, or aloe vera and a clean nonadherent|| ||||| |2b|C-EO|After cooling, while awaiting evaluation by a health|| |2b|C-EO| care professional, it may be reasonable to loosely cover a burn that has intact skin or an intact blistercover a burn that has intact skin or an intact blister with a clean cloth or nonadherent dry dressing. || |2b|C-EO|||

Recommendation-Specific Supportive Text

1. Burns involving the face, hands, feet, and genitals may require surgical intervention to prevent permanent disability. Burns with a large surface area can lead to significant fluid loss and multisystem organ failure. The American Burn Association recommends that patients with second- or third-degree burns involving the face, hands, feet, and genitals and those involving ${>}10\%$ body surface area $(5\%$ in children) be treated in a specialized burn center because of the likely need for intravenous fluid resuscitation, surgery, and other specialized treatments. 14,15

2. Inhalation injury from hot smoke can lead rapidly to loss of the airway due to airway swelling. Evidence of inhalation injury can also be indicative of carbon monoxide poisoning. A person with signs of inhalation injury such as facial burns, difficulty breathing, singed nasal hairs, or soot around the nose or mouth should have EMS activated immediately. 15a 3. Because burned tissue swells, expert consensus advocates that jewelry be removed before the onset of swelling to prevent constriction and vascular ischemia. 9

4. Over-the-counter analgesics such as acetaminophen or NSAIDs are well tolerated and generally recommended for burn pain. 16,17 A prospective study enrolling 61 patients with second- or third-degree burns randomly assigned to either receive 800 mg IV ibuprofen or placebo every 6 hours found no significant incidence in serious adverse events. 18

5. Petrolatum (with or without topical antibiotics such as polymyxin), honey, and aloe have been shown to improve healing time in patients with partial-thickness, “open” burns, including unroofed blisters, compared with no dressing or various controls. 3,19–31 Most studies assessed the use of various burn treatments daily or continuously until complete healing; short-term use in the first aid setting has not been well studied. Specialized burn dressings are assumed not to be available in the first aid setting.

6. Covering a partial- or full-thickness burn with a nonadherent bandage or clean cloth protects the wound and reduces pain while avoiding heat entrapment until the burn can be assessed by a health care professional. 14

REFERENCES

1. Kattan AE, AlShomer F, Alhujayri AK, Addar A, Aljerian A. Current knowledge of burn injury first aid practices and applied traditional remedies: a nationwide survey. Burns Trauma . 2016;4:37. doi: 10.1186/s41038-016-0063-7 2. Lloyd EC, Rodgers BC, Michener M, Williams MS. Outpatient burns: prevention and care. Am Fam Physician . 2012;85:25–32. 3. Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers . 2020;6:11. doi: 10.1038/s41572-020-0145-5 4. Yasti AC, Senel E, Saydam M, Ozok G, Coruh A, Yorganci K. Guideline and treatment algorithm for burn injuries. Ulus Travma Acil Cerrahi Derg . 2015;21:79–89. doi: 10.5505/tjtes.2015.88261 5. Djarv T, Douma M, Palmieri T, Meyran D, Berry D, Kloeck D, Bendall J, Morrison LJ, Singletary EM, Zideman D; et al. Duration of cooling with water for thermal burns as a first aid intervention: a systematic review. Burns . 2022;48:251–262. doi: 10.1016/j.burns.2021.10.007 6. Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, et al; Collaborators. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: summary from the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group [published correction appears in Circulation. 2022;145:e760]. Circulation . 2022;145:e645–e721. doi: 10.1161/CIR.0000000000001017 7. Griffin B, Cabilan CJ, Ayoub B, Xu HG, Palmieri T, Kimble R, Singer Y. The effect of 20 minutes of cool running water first aid within three hours of thermal burn injury on patient outcomes: a systematic review and meta-analysis. Australas Emerg Care . 2022;25:367–376. doi: 10.1016/j.auec.2022.05.004 8. Fein M, Quinn J, Watt K, Nichols T, Kimble R, Cuttle L. Prehospital paediatric burn care: new priorities in paramedic reporting. Emerg Med Australas . 2014;26:609–615. doi: 10.1111/1742-6723.12313 9. American Burn Association. Initial first aid treatment for minor burns. 2019. Accessed January 7, 2024. https://ameriburn.org/wp-content/uploads/2017/05/burnfirstaid.pdf 10. American Red Cross. ARC SAC advisory: burn cooling. 2019. Accessed January 7, 2024. https://redcross.org/content/dam/redcross/docs/ Burn%20Cooling%E2%80%94ADVISORY.pdf 11. American Academy of Dermatology. How to treat a first-degree, minor burn. 2023. Accessed January 7, 2024. https://aad.org/public/everyday-care/ injured-skin/burns/treat-minor-burns 12. British Red Cross. Learn first aid for someone who has a burn. 2023. Accessed January 7, 2024. https://redcross.org.uk/first-aid/learn-first-aid/ burns 13. Cuttle L, Kempf M, Liu PY, Kravchuk O, Kimble RM. The optimal duration and delay of first aid treatment for deep partial thickness burn injuries. Burns . 2010;36:673–679. doi: 10.1016/j.burns.2009.08.002 14. Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, et al. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med . 2020;39:253–267. doi: 10.1016/j.accpm.2020.03.006 15. Bettencourt AP, Romanowski KS, Joe V, Jeng J, Carter JE, Cartotto R, Craig CK, Fabia R, Vercruysse GA, Hickerson WL, et al. Updating the burn center referral criteria: results from the 2018 eDelphi Consensus Study. J Burn Care Res . 2020;41:1052–1062. doi: 10.1093/jbcr/iraa038 15a. Mlcak RP, Bulger EM, Jeschke MG. Inhalation injury from heat, smoke, or chemical irritants. UpToDate. Alphen aan den Rijn, Netherlands: Wolters Kluwer, 2023. Accessed April 7, 2024. https://www.uptodate.com/contents/inhalation-injury-from-heat-smoke-or-chemical-irritants 16. Faucher L, Furukawa K. Practice guidelines for the management of pain. J Burn Care Res . 2006;27:659–668. doi: 10.1097/01.BCR.0000238117.41490.00 17. Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, Carter D, Liu YM, Nitzschke S, Bhalla P, et al. American Burn Association guidelines on the management of acute pain in the adult burn patient: a review of the literature, a compilation of expert opinion and next steps. J Burn Care Res . 2020;41:1152–1164. doi: 10.1093/jbcr/iraa120 18. Promes JT, Safcsak K, Pavliv L, Voss B, Rock A. A prospective, multicenter, randomized, double-blind trial of IV ibuprofen for treatment of fever and pain in burn patients. J Burn Care Res . 2011;32:79–90. doi: 10.1097/BCR.0b013e3182037300 19. Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev . 2013;2013:CD002106. doi: 10.1002/14651858.CD002106.pub4 20. Sharma S, Alfonso AR, Gordon AJ, Kwong J, Lin LJ, Chiu ES. Second-degree burns and aloe vera: a meta-analysis and systematic review. Adv Skin Wound Care . 2022;35:1–9. doi: 10.1097/01.ASW.0000875056.29059.78 21. Norman G, Christie J, Liu Z, Westby MJ, Jefferies JM, Hudson T, Edwards J, Mohapatra DP, Hassan IA, Dumville JC. Antiseptics for burns. Cochrane Database Syst Rev . 2017;7:CD011821. doi: 10.1002/14651858.CD011821.pub2 22. Aziz Z, Abdul Rasool Hassan B. The effects of honey compared to silver sulfadiazine for the treatment of burns: a systematic review of randomized controlled trials. Burns . 2017;43:50–57. doi: 10.1016/j.burns.2016.07.004 23. Zago LR, Prado K, Benedito VL, Pereira MM. The use of babosa (aloe vera) in treating burns: a literature review. Braz J Biol . 2021;83:e249209. doi: 10.1590/1519-6984.249209 24. Yilmaz AC, Aygin D. Honey dressing in wound treatment: a systematic review. Complement Ther Med . 2020;51:102388. doi: 10.1016/j.ctim.2020.102388 25. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: a prospective randomized study. Burns . 1996;22:491–493. doi: 10.1016/0305-4179(96)00007-1 26. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg . 1991;78:497–498. doi: 10.1002/bjs.1800780435 27. Maenthaisong R, Chaiyakunapruk N, Niruntraporn S, Kongkaew C. The efficacy of aloe vera used for burn wound healing: a systematic review. Burns . 2007;33:713–718. doi: 10.1016/j.burns.2006.10.384 28. Lu LC, Chang FY, Lv GZ, Lan SH. Effectiveness and safety of compound polymyxin B ointment in treatment of burn wounds: a meta-analysis. J Burn Care Res . 2022;43:453–461. doi: 10.1093/jbcr/irab099 29. Heinrich JJ, Brand DA, Cuono CB. The role of topical treatment as a determinant of infection in outpatient burns. J Burn Care Rehabil . 1988;9:253– 257. doi: 10.1097/00004630-198805000-00003 30. Genuino GA, Baluyut-Angeles KV, Espiritu AP, Lapitan MC, Buckley BS. Topical petrolatum gel alone versus topical silver sulfadiazine with standard gauze dressings for the treatment of superficial partial thickness burns in adults: a randomized controlled trial. Burns . 2014;40:1267–1273. doi: 10.1016/j.burns.2014.07.024 31. Febriyenti F, Lucida H, Almahdy A, Alfikriyah I, Hanif M. Wound-healing effect of honey gel and film. J Pharm Bioallied Sci . 2019;11:176–180. doi: 10.4103/jpbs.JPBS_184_18

Dental Avulsion

Background

After traumatic avulsion of a permanent tooth, the chance of survival of the tooth is greatest if it can be replanted immediately after the time of injury. The injured person may be able to replant the tooth themselves with follow-up care delivered by a dentist; in many cases, however, the individual is unable to replant the tooth themselves, and a dentist or physician is needed for further care.

If immediate intervention cannot occur, minimizing extra-alveolar dry time by transporting the avulsed tooth in a medium that can preserve the viability of the periodontal ligament cells improves the chances of successful reimplantation. The efficacy of various storage materials and methods available to the first aid provider has been evaluated in the literature compared with cow’s milk or the patient’s saliva. In addition to the methods evaluated later, storage in aloe vera gel and coconut water has been proposed; these techniques were not

supported by enough consistent evidence to inform a recommendation. 1–3

These recommendations pertain only to the avulsion of permanent teeth; primary teeth (also known as deciduous teeth or baby teeth) are not typically replanted.

The ILCOR performed a systematic review on this topic in 2020. 4 An updated literature search was performed by the writing group in 2023.

|First Aid for Dental Avulsion||| |---|---|---| |COR|LOE|Recommendations| ||| 1. When a permanent tooth becomes avulsed (knocked out), initial actions include removing visible debris from the tooth by brief rinsing ( |

Recommendation-Specific Supportive Text

1. The likelihood of successful reimplantation decreases rapidly as long as the tooth remains out of the socket, particularly if the periosteal ligament dies or is injured. 5–7 2. Many people need assistance reimplanting a tooth, particularly if the injured person is a child. Stabilization of the reimplanted tooth by a dentist is often necessary. 6 3. Storage of an avulsed permanent tooth in Hanks Balanced Salt Solution, oral rehydration salt solutions, propolis, rice water, and cling wrap has demonstrated improved periodontal ligament cell viability compared with storage in cow’s milk. 1,8–11 Oral rehydration salt solution is the nonproprietary name for the balanced mixture of glucose and electrolytes (sodium, chloride, potassium, and citrate) that has been used to treat and prevent clinical dehydration due to diarrheal diseases. 12 Oral rehydration salt solutions can be purchased commercially or made from materials commonly found in the home. Table12 provides a ranking of solutions based on the likelihood of successful reimplantation after avulsed tooth storage.

Table 12. Storage Media Options for an Avulsed Tooth

|First choice (highest rate of reimplantation success)| |---| |Hanks Balanced Salt Solution| |Oral rehydration salt solutions| |Propolis solution (10%, 50%, or 100%)| |Rice water (preprepared)| |Wrapping in cling film| |Second-line options| |Cow's milk (any fat content)| |The person's saliva| | Third-line options| |Another person's saliva| |Probiotic media (eg, probiotic yogurt, Lactobacillus reuteri solution)| |Egg white| |Almond milk|

4–5. Observational studies comparing cow’s milk and the injured person’s own saliva as storage media found no difference in the rates of successful replantation. 10,11 Depending on the injured person’s age and mental status, temporary storage of the avulsed tooth in the injured person’s mouth may pose a choking hazard. Storing the tooth in the mouth of another person involves infection risk, although in some cases (eg, a parent), the people involved may consider this risk to be acceptable. 1,5,7–9,11,13

6. Two studies found harm to periodontal ligament cell viability when a tooth is stored in tap water. 14,15

REFERENCES

1. Souza BDM, Garcia LFR, Bortoluzzi EA, Felippe WT, Felippe MCS. Effects of several storage media on viability and proliferation capacity of periodontal ligament cells. Eur Arch Paediatr Dent . 2020;21:53–59. doi: 10.1007/s40368-019-00450-8 2. Sharma M. In vitro periodontal ligament cell viability in different storage media. Braz Dent J . 2016;27:408–411. doi: 10.1590/0103-6440201602294 3. Abraham B, Kumaran P, Varma BR, Mamachan Xavier A, Kumar SJ. Comparative evaluation of the efficacy of aloe vera gel with milk and Hank’s Balanced Salt Solution in maintaining the viability of PDL cells in avulsed teeth. J Clin Diagn Res . 2019;13:ZC11–ZC15. doi: 10.7860/JCDR/2019/37876.12700 4. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S2–S27. doi: 10.1161/CIR.0000000000000890 5. Wang G, Wang C, Qin M. A retrospective study of survival of 196 replanted permanent teeth in children. Dent Traumatol . 2019;35:251–258. doi: 10.1111/edt.12475 6. Coste SC, Silva EFE, Santos LCM, Barbato Ferreira DA, Cortes MIS, Colosimo EA, Bastos JV. Survival of replanted permanent teeth after traumatic avulsion. J Endod . 2020;46:370–375. doi: 10.1016/j.joen.2019.11.013 7. Chappuis V, von Arx T. Replantation of 45 avulsed permanent teeth: a 1-year follow-up study. Dent Traumatol . 2005;21:289–296. doi: 10.1111/j.1600-9657.2005.00330.x 8. Zhang N, Cheng Y, Li F, Kang Q. Network meta-analysis of 10 storage mediums for preserving avulsed teeth. Front Med (Lausanne) . 2021;8:749278. doi: 10.3389/fmed.2021.749278 9. Sinpreechanon P, Boonzong U, Sricholpech M. Comparative evaluation of periodontal ligament fibroblasts stored in different types of milk: effects on viability and biosynthesis of collagen. Eur J Oral Sci . 2019;127:323–332. doi: 10.1111/eos.12621 10. De Brier N, O D, Borra V, Singletary EM, Zideman DA, De Buck E; International Liaison Committee on Resuscitation First Aid Task Force. Storage of an avulsed tooth prior to replantation: a systematic review and metaanalysis. Dent Traumatol . 2020;36:453–476. doi: 10.1111/edt.12564 11. Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djarv T, et al; First Aid Science Collaborators. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation . 2020;142(suppl 1):S284–S334. doi: 10.1161/CIR.0000000000000897 12. World Health Organization. Oral rehydration salts: production of the new ORS. 2006. Accessed September 29, 2023. https://iris.who.int/bitstream/ handle/10665/69227/WHO_FCH_CAH_06.1.pdf 13. Karayilmaz H, Kirzioglu Z, Erken Gungor O. Aetiology, treatment patterns and long-term outcomes of tooth avulsion in children and adolescents. Pak J Med Sci . 2013;29:464–468. doi: 10.12669/pjms.292.3283 14. Talebi M, Parisay I, Afshari JT, Shajiei A, Ghadim MS. Viability and reproducibility of periodontal ligament cells on avulsed teeth stored in Ham’s F-10 solution. J Clin Pediatr Dent . 2018;42:203–207. doi: 10.17796/1053-4628-42.3.6 15. Pileggi R, Dumsha TC, Nor JE. Assessment of post-traumatic PDL cells viability by a novel collagenase assay. Dent Traumatol . 2002;18:186–189. doi: 10.1034/j.1600-9657.2002.00092.x

Suspected Foreign Body in the Eye

Background

Eye injuries are a common presentation to EDs; about half of those presentations are due to ocular foreign bodies. 1 Foreign-body sensation can be caused by a loose foreign body (eg, an eyelash or piece of dust or sand), a foreign body embedded on the surface of the cornea, superficial corneal abrasion, a penetrating eye injury, or other causes such as chemical injury, ultraviolet radiation exposure, eye inflammation, or infection. 2 Ocular foreign bodies are a common workplace injury. 3

High-speed injuries such as from grinding or injuries from sharp objects can cause significant injury to the globe ranging from simple corneal abrasion to penetration injury to the anterior or posterior chamber of the eye. Foreign bodies embedded on the cornea often need to be removed by a health care professional.

Although it is common for health care professionals to prescribe antibiotics to prevent infection from corneal abrasions or foreign body, the utility of this practice is unclear. 4,5

Overall, limited data are available on the treatment of a suspected foreign body in the eye by a first aid provider.

A literature search was performed by the writing group in 2023.

||First Aid for Suspected Foreign Body in the Eye||| |---|---|---|---| |COR|LOE|Recommendations|| ||| 1-A A person who sustains a high-velocity eye injury (such as injuries from grinding, nailing, or machinery), penetrating eye injury from a || ||C-LD| machinery), penetrating eye injury from a sharp or metal object, irregular pupil after || ||C-LD| after trauma should seek immediate medical attention. || ||C-LD| A person who has persistent foreign-body sensation in the eye should seek immediate medical attention. ||

|||First Aid for Suspected Foreign Body in the Eye (Continued)|| |---|---|---|---| |COR|LOE||| ||C-LD| A person who develops a foreign-body sensa- tion in the eye associated with contact lens use should remove the contact lens, discontinue con- || ||C-LD| tion in the eye associated with contact lens use should remove the contact lens, discontinue con- tact lens use, and seek medical attention. || ||C-EO| 4. A person with a foreign-body sensation in the eye should not rub their eye. || ||C-EO| 5.T Taping a hard plastic eye shield, paper cup, or plastic cup over the eye can help prevent unintentional touching of the eye. || |2a|| 6. It is reasonable for a person with a foreign body in the eye from a low-energy mechanism (eg, dust, dirt, other object blown into the eye by wind; || |2a|C-EO| dirt, other object blown into the eye by wind; eyelash in the eye) to attempt to remove the for- || |2a|C-EO| eyelash in the eye) to attempt to remove the for- eign body by allowing natural tears to wash out the object or by irrigating theeye with tap water || |2a|| the object or by irrigating theeye with tap water or a commercial eye wash solution. || ||C-EO| It is reasonable to take over-the-counter oral acetaminophen or NSAIDs to treat residualacetaminophen or NSAIDs to treat residual discomfort after ocularforeign-bodyremoval. ||

Recommendation-Specific Supportive Text

1. Loss of visual acuity, bleeding from the eye, and alteration of the normal structural appearance of the eye such as irregular pupil shape may represent serious pathology such as a penetrating globe injury, corneal ulceration, infection, or corneal abrasion and are likely to require treatment by a health care professional. 3,6 2. In an observational study of 79 participants with a foreign-body sensation, those with no foreign body present after irrigation had a greater improvement in pain score than those in whom a foreign body remained present after irrigation and those who did not receive eye irrigation. 7 If there is no improvement in pain after simple irrigation, there may be a retained foreign body or abrasion, and the person should be evaluated by a health care professional. 3. Contact lenses can be a cause of a corneal abrasion or ulcer, both of which cause foreignbody sensation. A corneal ulcer can cause penetrating eye injury and permanent eye scarring. 8,9 Evaluation by a health care professional can differentiate these conditions and enable appropriate treatment. 4–5. Rubbing the eye may worsen corneal abrasion from an ocular foreign body or worsen a penetrating eye injury. 3 Taping an eye shield or a paper or plastic drinking cup over the injured eye may prevent the person from rubbing their eye. 10–12 6. In a quasi-randomized study, 79 adults with a foreign-body sensation and no signs of openglobe injury received low-pressure eye irrigation with 500 mL normal saline with the head in the dependent position compared with no irrigation. Those with irrigation had significantly lower foreign-body retention and better improvement

in pain than those without irrigation. 7 Tap water irrigation is well tolerated in studies of patients with chemical exposure to the eye 13 and is readily available in most settings. Some people may need assistance maintaining open eyelids during irrigation.

7. Few experimental data were identified to guide the first aid treatment of local symptoms from a suspected foreign body. Expert opinion recommends the use of over-the-counter oral analgesic agents such as acetaminophen and ibuprofen. 3,6

REFERENCES

1. McGwin G Jr, Owsley C. Incidence of emergency department-treated eye injury in the United States. Arch Ophthalmol . 2005;123:662–666. doi: 10.1001/archopht.123.5.662 2. Jayamanne DG. Do patients presenting to accident and emergency departments with the sensation of a foreign body in the eye (gritty eye) have significant ocular disease? J Accid Emerg Med . 1995;12:286–287. doi: 10.1136/emj.12.4.286 3. Ahmed F, House RJ, Feldman BH. Corneal abrasions and corneal foreign bodies. Prim Care . 2015;42:363–375. doi: 10.1016/j.pop.2015.05.004 4. Kruger RA, Higgins J, Rashford S, Fitzgerald B, Land R. Emergency eye injuries. Aust Fam Physician . 1990;19:934–938. 5. Algarni AM, Guyatt GH, Turner A, Alamri S. Antibiotic prophylaxis for corneal abrasion. Cochrane Database Syst Rev . 2022;5:CD014617. doi: 10.1002/14651858.CD014617.pub2 6. Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician . 2013;87:114–120. 7. Chou HD, Chen KJ, Kang EY, Lin JY, Yeh PH, Chen YT, Cheng CT, Lai CC, Wu WC, Hwang YS, et al. Eye irrigation as a first-line treatment and diagnostic method for emergency department patients who complain of ocular foreign bodies. Sci Rep . 2021;11:23386. doi: 10.1038/s41598-021-02989-3 8. Szczotka-Flynn LB, Pearlman E, Ghannoum M. Microbial contamination of contact lenses, lens care solutions, and their accessories: a literature review. Eye Contact Lens . 2010;36:116–129. doi: 10.1097/ICL.0b013e3181d20cae 9. Lee SY, Kim YH, Johnson D, Mondino BJ, Weissman BA. Contact lens complications in an urgent-care population: the University of California, Los Angeles, contact lens study. Eye Contact Lens . 2012;38:49–52. doi: 10.1097/ICL.0b013e31823ff20e 10. Stevens S. How to apply an eye pad, shield, and bandage. Community Eye Health . 2010;23:56. 11. US Department of Health and Human Services. Preventing and responding to eye injuries. 2024. Accessed April 9, 2024. https://eclkc.ohs.acf.hhs. gov/practicas-de-seguridad/articulo/preventing-responding-eye-injuries 12. Gudgel DT. Recognizing and treating eye injuries. 2023. American Academy of Ophthalmology. Accessed April 9, 2024. https://aao.org/eye-health/ tips-prevention/injuries# 13. Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica . 2006;220:225–228. doi: 10.1159/000093075

Epistaxis

Background

Nose bleeds (epistaxis) are acute bleeding from the nares or nasal cavity that may occur spontaneously or as a result of trauma. Epistaxis is usually self-limited and resolves spontaneously. Epistaxis is most common in people ${<}10$ years and ${\ge}60$ years of age. 1 Epistaxis is the primary reason for 1 in every 313 ED visits in the United States. 2 The risk of epistaxis is likely increased in people taking oral anticoagulant medications. 3–5

ILCOR performed a systematic review of cryotherapy for epistaxis in 2021. 6 An updated literature search was performed by the writing group in 2023.

||First Aid for Epistaxis|| |---|---|---| |COR|LOE|Recommendations| ||C-LD| 1-A A person experiencing epistaxis should sit with their head slightly forward with their nostrils pinched for 10 to 15 minutes. | ||C-EO| 2， A person experiencing epistaxis that does not stop after 15 minutes of continuous manual pressure or who becomes lightheaded from epistaxis should seek medical attention. | ||C-EO| 3.AA person with epistaxis due to trauma should seek medical attention if they experience signs of brain in- jury, obvious nasal deformity, or signs of facial fracture. | |2a|C-LD| 4. It is reasonable for a person experiencing epistaxis who is taking anticoagulant or antiplatelet medication, or who has a blood-clotting disorder, to seek care from a health care professional, unless bleeding has stopped. | |2b|C-LD| The usefulness of cryotherapy (ice) for managing epistaxis in the first aid setting is unknown. |

Recommendation-Specific Supportive Text

1–2. The treatment of nose bleeds (epistaxis) involves having the person sit down and continuously hold the lower third or soft portion of the nose pinched closed to help the blood clot. 5 Leaning forward stops blood from entering the airway (which can cause trouble breathing) or the stomach (which can cause vomiting). The bleeding person should be instructed to breathe through their mouth and spit out any blood. Nasal pressure alone is the only intervention required in the vast majority of cases, including $20\%$ of cases managed in EDs. 7 Ongoing epistaxis can lead to anemia and shock due to blood loss. 3. Traumatic epistaxis is a form of craniofacial trauma and may be associated with traumatic brain injury and facial bone fractures. Signs of traumatic brain injury, including loss of consciousness, altered mental status, repeated vomiting, change in vision, difficulty moving or walking, or severe headache, indicate the potential for a medical emergency requiring activation of the emergency response system. Epistaxis is associated with nasal bone fracture, which is associated with fractures of other facial bones. 8 4. Patients taking either anticoagulant or antiplatelet therapy, including aspirin, are at increased risk of severe epistaxis and hospital admission compared with patients not on these medications, 9 and often have multiple comorbidities. Nosebleed in these patients is more likely to require intervention from a health care professional than nosebleed in people not taking anticoagulant medication. 3–5,10,11

5. A 2020 ILCOR scoping review of the management of epistaxis in the first aid setting found only expert opinion and indirect evidence for the use of cryotherapy (ice) for epistaxis. Some experts believe that cryotherapy can vasoconstrict the blood vessels of the nasal mucosa and reduce the flowing blood and blood volume when applied to the nose. Studies of cryotherapy application methods were found to be inconsistent and never applied directly to the nose but instead to the forehead, in the mouth, around the neck, or in a combination. The scoping review found that the literature lacks the evidence to support recommendations for using cryotherapy as an intervention for epistaxis in the first aid setting. 6

first aid settings. The vast majority of research returned through our searches was indirect to first aid, extrapolated from in-hospital settings involving health care professionals. Research evaluating care by first aid providers in the first aid setting is urgently needed.

Similarly, first aid research would benefit from patient-and public-involved research methods. First aid research (and guideline development) should include the active involvement of individuals who provide first aid (laypeople and trained responders) and who are in groups targeted by first aid guidelines (early childhood educators, workplace safety personnel, athletic trainers). Furthermore, effective first aid may result in the ill or injured person appropriately not seeking additional care; thus, the avoided health care interaction is never recorded and cannot be reported in research. Therefore, novel

REFERENCES

1. Pallin DJ, Chng Y-M, McKay MP, Emond JA, Pelletier AJ, Camargo CA. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med . 2005;46:77–81. doi: 10.1016/j.annemergmed.2004.12.014 2. Sethi RKV, Kozin ED, Abt NB, Bergmark R, Gray ST. Treatment disparities in the management of epistaxis in United States emergency departments. Laryngoscope . 2018;128:356–362. doi: 10.1002/lary.26683 3. Ross A, Engebretsen S, Mahoney R, Bathula S. Risk factors and management for epistaxis in a hospitalized adult sample. Spartan Med Res J . 2022;7:37760. doi: 10.51894/001c.37760 4. Buchberger AMS, Baumann A, Johnson F, Peters N, Piontek G, Storck K, Pickhard A. The role of oral anticoagulants in epistaxis. Eur Arch Otorhinolaryngol . 2018;275:2035–2043. doi: 10.1007/s00405-018-5043-z 5. Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg . 2020;162:S1–S38. doi: 10.1177/0194599819890327 6. Berry D, Carlson JN, Singletary E, Zideman DA, Ring J. Use of cryotherapy for managing epistaxis in the first aid setting: a scoping review. Cureus . 2021;13:e14832. doi: 10.7759/cureus.14832 7. Newton E, Lasso A, Petrcich W, Kilty SJ. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol Head Neck Surg . 2016;45:24. doi: 10.1186/s40463-016-0138-2 8. Pham TT, Lester E, Grigorian A, Roditi RE, Nahmias JT. National analysis of risk factors for nasal fractures and associated injuries in trauma. Craniomaxillofac Trauma Reconstr . 2019;12:221–227. doi: 10.1055/s-0039-1677724 9. Yaniv D, Zavdy O, Sapir E, Levi L, Soudry E. The impact of traditional anticoagulants, novel anticoagulants, and antiplatelets on epistaxis. Laryngoscope . 2021;131:1946–1951. doi: 10.1002/lary.29417 10. National ENT Trainee Research Network. The British Rhinological Society multidisciplinary consensus recommendations on the hospital management of epistaxis. J Laryngol Otol . 2017;131:1142–1156. 11. Hadar A, Shaul C, Ghantous J, Tarnovsky Y, Cohen A, Zini A, Peleg U. Risk factors for severe clinical course in epistaxis patients [published online July 26, 2023]. Ear Nose Throat J . doi: 10.1177/01455613231189056. https://journals.sagepub.com/doi/full/10.1177/014556132311 89056?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_ id=ori%3Arid%3Acrossref.org

KNOWLEDGE GAPS AND PRIORITIES OF RESEARCH

Throughout the evidence search, synthesis, and guideline writing process, our group identified several knowledge gaps and research priorities. Overall, there is a lack of first aid research, meaning research evaluating care provided by nonprofessional responders in prehospital

Table 13. First Aid: Key Knowledge Gaps

| Which “red flag" signs and symptoms are most important for first aid providers to learn to identify? | |---| | What is the role of positioning in individuals with a decreased level of alertness (ie, supine vs recovery) on the incidence and detection of cardiac arrest? | | What is the effect of passive leg raise on individuals experiencing syncope and shock in the first aid setting? | | What is the effectiveness of oxygen administered in the first aid setting for adults or children exhibiting signs or symptoms of shortness of breath, dif- ficulty breathing, or hypoxia? Are there important safety concerns in the first aid setting? | | How accurate and trustworthy are pulse oximeters used by first aid provid- ers, and what is the role of the pulse oximeter as a component of a first aid assessment? | | What barriers exist for first aid providers assisting individuals to take their own medication during acute exacerbations of asthma, anaphylaxis, diabetes? | | What are the most effective, safe, and practical rewarming methods for hypothermic people in the first aid setting? | | What are the most effective and practical rewarming methods for individuals with frostbite? | | What is the best way for first aid providers to assess the severity of hypothermia? Are first aid providers willing and able to accurately measure core temperature? | | Are untrained rescuers and first aid providers able to effectively apply tourniquets to control life-threatening bleeding? Does this vary between various manufactured and improvised devices? | | Is indirect manual pressure, including use of compression of pressure points or the use of mechanical pressure devices, effective for bleeding control in the first aid setting? | | Are open chest wounds best managed with occlusive dressings or with nonocclusive dressings or left open in the first aid setting? | | Willthe deadoption of spine immobilization practices cause benefit or harm for injured individuals? | |Does splinting of long-bone fractures reduce pain or improve outcome?| | Is straightening of an angulated fracture by first aid providers associated with less pain, bleeding, or nerve or muscle injury compared with immobilization in the position found? | | What are the ideal cooling method and duration for thermal burns treated in the first aid setting? |

research methods are required to describe the effectiveness of first aid care from the perspective of health care system avoidance.

Some conditions and therapies have a particular paucity of evidence to guide treatments, despite being foundational content for first aid courses, such as the immobilization of long-bone fractures, rewarming of frostbite, or cooling of thermal burns. RCTs of different immobilization strategies and cooling/warming methods are needed. The role of technology such as mobile phones and wearables is also an important area for future research, including fall detection, measurement and monitoring of vital signs, and just-in-time training, instructions, and decision support tools.

The majority of first aid providers and recipients in the research used to develop these guidelines are male and White and reside in North America and Western Europe. The unique needs and perspectives of people not fitting this narrow description are required. Researchers should record and report the sex and ethnicity of their participants and strive for great diversity in recruitment when feasible. Low-resource settings and low- and middle-income countries may experience the greatest impact from robust first aid training, and work is urgently required to understand the unique first aid needs in these communities and settings. In addition, more work needs to be done studying different approaches to first aid in infants, toddlers, and children.

Some critical knowledge gaps identified by the writing group are summarized in Table13.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This guideline was approved by the American Heart Association Science Advisory and Coordinating Committee on June 19, 2024, the American Red Cross on June 15, 2024, and the American Heart Association Executive Committee on August 5, 2024. A copy of the document is available at https://professional. heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskluwer.com

The American Heart Association requests that this document be cited as follows: Hewett Brumberg EK, Douma MJ, Alibertis K; Charlton NP, Goldman MP, Harper-Kirksey K, Hawkins SC, Hoover A, Leichtle S, Kule A, McClure SF, Wang GS, Whelchel M, White L, Lavonas EJ; on behalf of the American Heart Association and American Red Cross. 2024 American Heart Association and American Red Cross guidelines for first aid. Circulation. 2024;150:e•••–e•••. doi: 10.1161/CIR.0000000000001281

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (https://www.heart.org/en/about-us/ statements-and-policies/copyright-request-form).

Acknowledgments

The writing group acknowledges the early contributions from Shama Patel, MD, and Fred A. Severyn, MD, as well as Chalan King of the American Heart Association and Ronnie Terrell of the American Red Cross for their administrative support.

Disclosures

Writing Group Disclosures

| Writing Group Member |Employment| Research Grant | other Research Support | Speakers' Bureau/ Honoraria | Expert Witness | Ownership Interest | Consultant/ Advisory Board |Other| |---|---|---|---|---|---|---|---|---| |Matthew J. Douma| University of Alberta (Canada) |None|None|None|None|None|None|None| | Elizabeth K. Hewett Brumberg | UPMC Children's Hospital of Pittsburgh |None|None|None|None|None| American Red Cross* |None| | Kostas Alibertis| University of Virginia Health System |None|None|None|None|None|None|None| |Nathan P. Charlton|University of Virginia|None|None|None|None|None|None|None| |Michael P. Goldman|Yale School of Medicine|None|None|None|None|None|None|None| | Katrina Harper-Kirksey|Cedars-Sinai|None|None|None|None|None|None|None| | Seth C. Hawkins| Wake Forest School of Medicine |None|None|None|None|None|None| Wilderness Medical Society*; Cambridge University Press* | |Amber Hoover| American Heart Association |None|None|None|None|None|None|None| |Amy Kule| Loyola University Medical Center |None|None|None|None|None|None|None| | Eric J. Lavonas|Denver Health|None|None|None|None|None| American Heart Associationt |None|

Writing Group Disclosures Continued

| Writing Group Member |Employment| Research Grant | Other Research Support | Speakers' Bureau/ Honoraria | Expert Witness | Ownership Interest | Consultant/ Advisory Board |Other| |---|---|---|---|---|---|---|---|---| |Stefan Leichtle| Virginia Commonwealth University Medical Center |None|None|None|None|None|None|None| | Sarah Frances McClure | Cody Regional Health System |None|None|None|None|None|None|None| |George Sam Wang|University of Colorado|None|None|None|None|None|None|None| |MarkWhelchel|American Red Cross|None|None|None|None|None|None|None| |Lynn White|Global Medical Response|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. \*Modest.

†Significant.

Reviewer Disclosures

|Reviewer|Employment (Where?)| Research Grant | Other Research Support | Speakers' Bureau/ Honoraria | Expert Witness | Ownership Interest | Consultant/Advisory Board |Other| |---|---|---|---|---|---|---|---|---| | Bruce J. Barnhart|University of Arizona|None|None|Zoll Medicalt|None|None|None|None| | Sarita Chung|Harvard University|None|None|None|None|None| American Red Cross Scientific Advisory Board* |None| |Andre Pennardt| Federal Emergency Management Agency |None|None|None|None|None| Committee for Tactical Emergency Casualty Caret |None| |Tia T. Raymond| Medical City Children's Hospital |None|None|None|None|None|None|None| |WillSmith| Wilderness and Emergency Medicine Consulting (WEMC), LLC |None|None|None|None|None|None|None| | Paria M Wilson| Cincinnati Children's Hospital Medical Center |None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $\S5000$ or more during any 12-month period, or $5\%$ or more of the person’s gross income; or (b) the person owns $5\%$ or more of the voting stock or share of the entity, or owns $\S5000$ or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

\*Modest.

†Significant.

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