Editor’s Note: This is part four of a four-part series.
The International Liaison Committee on Resuscitation (ILCOR) appointed a task force in 2013 to prepare recommendations regarding first-aid care by trained or untrained rescuers. The recommendations were released with the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The goal was to provide an evidence base for the initial care provided by laypersons, EMS, and physicians outside of the office or hospital setting.
ACEP Now has partnered with three emergency medicine residency training programs (Wake Forest School of Medicine, Winston-Salem, North Carolina; Mayo School of Graduate Medical Education/Mayo Clinic, Rochester, Minnesota; and Warren Alpert Medical School of Brown University, Providence, Rhode Island) to review 15 of these recommendations following the PICO (Population, Intervention, Comparator, and Outcomes) analytic format utilized by the recommendation authors.
- Howard Mell, MD, MPH, CPE, FACEP, emergency physician and member of ACEP Now’s editorial advisory board
- Jessica L. Smith, MD, FACEP, associate professor (clinical), Warren Alpert Medical School of Brown University, and program director, Emergency Medicine Residency
- Jason Stopyra, MD, FACEP, assistant professor, Wake Forest Baptist Medical Center, Department of Emergency Medicine
- Matthew Sztajnkrycer, MD, PHD, FACEP, associate professor, Mayo Clinic, Department of Emergency Medicine
Reference: Singletary EM, Charlton NP, Epstein JL, 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.
First-Aid Education (FA 773)
Recommendation Author: Jennifer Beatty, MD
Dr. Beatty is a member of the residency training class of 2018 at the Wake Forest University School of Medicine.
Question: Among patients receiving first aid (P), does care from trained first-aid providers (I) compared with care from untrained persons (C) change survival rates, recognition of acute injury/illness, prevention of further illness/injury, time to resolution of injury, likelihood of harm, or time to symptom resolution (O)?
Results: Results: Low- or very-low-quality observational studies were identified to address some PICO outcomes.
Outcomes: One low-quality observational study showed reduced mortality among 1,341 patients initially managed by first-aid providers (9.8 percent versus 15.6 percent). One very-low-quality observational study of 125 subjects with burns showed 88.5 percent of patients treated by first-aid providers required hospitalization fewer than 10 days versus only 67.2 percent of subjects without intervention. One low-quality observational study of 244 burn patients showed benefit from care after a burn treatment campaign, with reduction in requiring inpatient wound care/surgery (35.6 percent versus 64.2 percent). Additionally, a review was found that showed training of laypersons with a stroke assessment system led to improved recognition of stroke after training (94.4 percent versus 76.4 percent).
Discussion: Compared to untrained persons, there is evidence that trained first-aid providers are associated with increased survival from trauma, shorter length of hospitalization after burns, prevention of further burn injuries, and stroke recognition.
Recommendation: Education and training in first aid should be undertaken to improve outcomes after injury and illness. This is a weak recommendation based on low-quality evidence.
Note from Dr. Stopyra: This recommendation suggests that ancillary ED personnel (greeters, security officers, registration personnel) should be trained in first aid. It also tells us that we should take the lead when we encounter the ill or injured outside of the hospital.
Exertional Dehydration (FA 584)
Recommendation Author: Jessica A. Stanich, MD
Dr. Stanich is a member of the emergency medicine residency training class of 2017 at the Mayo School of Graduate Medical Education/Mayo Clinic.
Question: Among adults and children with exertion-related dehydration (P), does drinking oral carbohydrate-electrolyte liquids (I) compared with drinking water (C) change volume/hydration status, vital signs, development of hyperthermia, development of hyponatremia, need for advanced medical care, blood glucose, or patient satisfaction (O)?
Results: Of 1,751 citations initially identified, 12 studies comparing carbohydrate-electrolyte (CE) liquids with water were included in the final analysis. Studies were rated very low quality to moderate quality and downgraded based upon risk of bias and imprecision.
Outcomes: For the critical outcome of volume/hydration status, results suggested that 3% to 8% CE solutions were superior to water for the rehydration of individuals with simple exercise-induced dehydration, although results were mixed. No difference in core temperature was noted after hydration with 5% to 8% CE solutions versus water. No difference in patient satisfaction, based upon nausea or stomach upset scores, was noted between 3% to 8% CE solutions and water. Additionally, 5% to 8% CE solutions were associated with increased serum sodium two to four hours after hydration. No studies evaluated the important outcomes of blood glucose and need for advanced medical care.
Discussion: First-aid providers must recognize signs and symptoms of dehydration and initiate fluid resuscitation when appropriate. The presence or absence of thirst is a poor surrogate for need for rehydration. Available studies demonstrated conflicting results for the primary outcome of rehydration and limited to no information on critical secondary outcomes.
Recommendations: For simple exertion-related dehydration, 3% to 8% CE therapy is the preferred treatment. Acceptable alternatives include water, 12% CE solution, coconut water, 2% milk, tea, tea-CE, or caffeinated tea beverages (weak recommendation, very-low-quality evidence).
Note from Dr. Mell: While the evidence is weak, it seems that oral CE liquids are superior to water alone for the rehydration of individuals with simple exercise-induced dehydration. Sports drinks may have value.
Spinal Motion Restriction (FA 772)
Recommendation Author: Jonathan Thorndike, MD
Dr. Thorndike is a member of the emergency medicine residency training class of 2019 at the Warren Alpert Medical School of Brown University.
Question: Among adults and children with suspected cervical trauma (P), does spinal motion restriction (I) compared to no spinal restriction (C) improve outcomes or reduce complications (O)?
Results: A total of 25 nonrandomized studies that addressed the PICO question were included in the analysis. All studies were observational and deemed to be low- to very-low-quality evidence. Methodology ranged from convenience samples of healthy volunteers to large retrospective reviews.
Outcomes: One observational study showed no difference in neurological injury between patients treated with cervical collars and those without, but analysis was incomplete due to nonpublished intervention and control group means and standard deviations. One small study showed no difference in patient comfort between the two groups. Regarding complications, studies suggest that c-collars cause increased intracranial pressure but no decrease in tidal volume. One pediatric study showed no limitation of spine movement by c-collars, although 13 nonpediatric studies demonstrated movement limitation. There was no evidence to address the outcomes of overall mortality, pain, or hospital length of stay for soft, semi-rigid collars or sandbags.
Discussion: C-collars are effective at reducing spine motion, but for first-aid providers, the risks of complications such as unnecessary neck motion or increased intracranial pressure outweigh the benefit of attempting placement. It may be difficult for first-aid providers to determine which patients are at high risk for spinal injury and thus who could benefit the most from immobilization.
Recommendation: The task force recommends against the routine application of cervical collars by first-aid providers.
Note from Dr. Smith: First responders should focus on reducing cervical spinal movement in trauma rather than applying devices to restrict spine movement. Although not part of the review, there is also potential value in manual cervical stabilization in certain circumstances.