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Part 13: First Aid: 2010 American Heart Association and American Red Cross
International Consensus on First Aid Science With Treatment Recommendations
David Markenson, Jeffrey D. Ferguson, Leon Chameides, Pascal Cassan, Kin-Lai Chung, Jonathan L. Epstein, Louis Gonzales, Mary Fran Hazinski, Rita Ann Herrington, Jeffrey L. Pellegrino, Norda Ratcliff and Adam J. Singer on behalf of the First Aid Chapter Collaborators Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright 2010 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: An erratum has been published regarding this article. Please see the attached page for: Data Supplement (unedited) at: Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions:
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2010 American Heart Association and American Red Cross International
Consensus on First Aid Science With Treatment Recommendations
David Markenson, Co-Chair*; Jeffrey D. Ferguson, Co-Chair*; Leon Chameides; Pascal Cassan; Kin-Lai Chung; Jonathan L. Epstein; Louis Gonzales; Mary Fran Hazinski; Rita Ann Herrington; Jeffrey L. Pellegrino; Norda Ratcliff; Adam J. Singer; on behalf of the First Aid Chapter Collaborators Note From the Writing Group: Throughout this article, the
and Treatment Recommendation was reached by the Board. This reader will notice combinations of superscripted letters and document is a report of the group's consensus.
numbers (eg, "Dilution with Milk or ). These As in 2005, the worksheets revealed the continuing paucity callouts are hyperlinked to evidence-based worksheets, which of scientific evidence to support specific first aid interven- were used in the development of this article. An appendix of tions. Very little research is being conducted in first aid, and worksheets, applicable to this article, is located at the end of most of the recommendations are extrapolations from re- the text. The worksheets, co-copyrighted by the American search and experience in other medical venues, animal Heart Association and American Red Cross, are available in studies, and case series. It is hoped that this document will be PDF format and are open access. a stimulus to future research in first aid.
The American Heart Association (AHA) and the American First Aid for Medical Emergencies
Red Cross cofounded the National First Aid Science Advi- sory Board in order to review and evaluate the scientific literature on first aid in preparation for the 2005 Consensus on The medical questions addressed include poisoning, anaphy- Science and Treatment Recommendation document.1 In prepa- laxis, oxygen administration, and aspirin administration for a ration for the 2010 process, the National First Aid Science suspected coronary event.
Advisory Board was broadened into an International First Aid No changes were recommended for first aid management Science Advisory Board with inclusion of representatives from of acute poisoning.
a number of international first aid organizations (Table).
In reviewing epinephrine administration for anaphy- laxis, evidence was found that laypeople and some medicaland prehospital professionals are unable to recognize the The Process
signs and symptoms of anaphylaxis and therefore cannot, The International First Aid Science Advisory Board identified without training, make an independent decision to admin- 38 questions in first aid practice that had not been subjected to an ister epinephrine with an auto-injector or to administer a evidence review process or that needed to be updated since the second dose if the first is not effective. This issue takes on 2005 process. Two or more members of the International First added importance in view of legislation in some jurisdic- Aid Science Advisory Board volunteered to independently tions that permits these actions.
review the scientific literature and complete an evidence-based No evidence was found, except in decompression inju- review worksheet summarizing the literature (see Part 2 of this ries, to support the routine administration of oxygen by supplement for additional information). After the evidence was first aid providers.
presented to the full board, a draft consensus summary of the The administration of aspirin to a victim experiencing chest scientific evidence and a draft consensus treatment recommen- discomfort is problematic. The literature is clear on the benefit of dation were developed and represented at a subsequent meeting.
early administration of aspirin in an acute coronary event, except Thus, each question, evidence-based review, draft summary of when there is a clear contraindication, such as aspirin allergy or science, and draft treatment recommendation was presented and a bleeding disorder. Less clear, however, is whether first aid discussed on 2 separate occasions, and a Consensus on Science providers can recognize the signs and symptoms of an acute The American Heart Association and the American Red Cross request that this document be cited as follows: Markenson D, Ferguson JD, Chameides L, Cassan P, Chung K-L, Epstein JL, Gonzales L, Hazinski MF, Herrington RA, Pellegrino JL, Ratcliff N, Singer AJ; on behalf of the First Aid ChapterCollaborators. Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science. Circulation.
2010;122(suppl 2):S582–S605.
*Co-chairs and equal first co-authors.
(Circulation. 2010;122[suppl ]:S582–S605.)
2010 American Heart Association, Inc., and American Red Cross.
Circulation is available at
Markenson et al
Part 13: First Aid
International First Aid Science Advisory Board
Syrup of
Consensus on Science American Academy of Pediatrics Two LOE 2 studies8,9 and 1 LOE 4 study10 demonstrated no American Burn Association benefit to administering syrup of ipecac to a suspected poisoning American College of Emergency Physicians victim. Two LOE 2 studies11,12 demonstrated untoward effects, American College of Occupational and Environmental Medicine such as intractable emesis and delayed charcoal administration, American College of Surgeons when syrup of ipecac was given. One LOE 2 epidemiological American Heart Association study13 showed that the administration of syrup of ipecac is notassociated with decreased healthcare utilization.
American Pediatric Surgical Association American Red Cross American Red Cross Advisory Council on First Aid, Aquatics, Safety and Ipecac syrup should not be used by the lay public as a first aid treatment of acute poisoning.
American Safety and Health Institute Knowledge Gaps Austrian Red Cross What is the role of gastric emptying in poisoning treatment? Canadian Red Cross How does the treatment outcome differ with and without Divers Alert Network stomach emptying? Egyptian Red Crescent European Reference Center for First Aid Education Consensus on Science Grenada Red Cross No evidence was found to suggest that activated charcoal is Hong Kong Red Cross efficacious as a component of first aid for acute poisoning, Hungarian Red Cross although 2 small LOE 5 studies14,15 suggest that it may be safe International Federation of Red Cross and Red Crescent Societies to administer. One LOE 3 study16 demonstrated that the majority of children will not take the recommended dose of activated charcoal.
National Association of EMS Educators National Association of EMS Physicians There is insufficient evidence to recommend for or against National Athletic Trainers' Association the administration of activated charcoal in a first aid setting.
National Safety Council Norwegian Red Cross Knowledge GapsDoes the prehospital administration of charcoal by lay rescu- Occupational Safety and Health Administration ers improve outcome? Does the administration of activated Red Cross Society of China charcoal by a first aid provider cause harm? Resuscitation Council of Asia St. John Ambulance, United Kingdom Recognition of Anaphylaxis by First Aid
coronary event or identify the contraindications to aspirin.
Consensus on Science Aspirin administration should never delay EMS activation.
Four LOE 417–20 and 3 LOE 521–23 studies documented thedifficulty that first aid providers have in assessing and recogniz- ing signs and symptoms of anaphylaxis. Evidence from 1 LOE Dilution With Milk or
4 study24 demonstrated that parents of children with multipleanaphylactic reactions can more accurately begin to recognize Consensus on Science the signs and symptoms indicating the need for administration of There are no human studies on the effect of treating oral an auto-injector, but with a lack of training and experience, they caustic exposure with dilution therapy. One in vitro LOE 5 are unable to provide appropriate care.
chemistry study2 demonstrated no benefit from the additionof large volumes of diluent to either a strong base or a strong acid. Five LOE 5 animal studies3–7 demonstrated histological First aid providers should not be expected to recognize the benefit to the esophagus when a diluent was administered signs and symptoms of anaphylaxis without repeated epi- following exposure to an alkali or acid.
sodes of training and encounters with victims of anaphylaxis.
Knowledge Gaps There is insufficient evidence for or against the administra- How can a first aid provider determine that a witnessed tion of a diluent as a first aid measure for ingestion of a allergic reaction needs epinephrine? Are there anaphylactic caustic substance.
reactions that do not respond to epinephrine? Second Dose of
Knowledge GapsDoes the early administration of milk or water as compared to Consensus on Science nothing by mouth improve outcome in patients with poison- One small, retrospective LOE 4 chart review,25 1 LOE 4 ing with caustic substances? retrospective patient survey,26 and 1 LOE 4 retrospective October 19, 2010
chart review of children with food allergy27 found that 12% to Chest Discomfort – Aspirin
36% of patients with anaphylactic reactions received a second dose of epinephrine because the first dose did not relieve Consensus on Science symptoms. Two LOE 428,29 and 2 LOE 5 studies30,31 docu- Evidence from 2 large, randomized LOE 1 trials38,39 clearly mented adverse reactions, including fatalities, due to misdi- demonstrated that administration of aspirin within the first 24 agnosis of an anaphylactic reaction, inappropriate route of hours of onset of chest discomfort in patients with acute administration, or excessive doses of epinephrine. One LOE coronary syndromes reduced mortality. Evidence from an 3 retrospective study32 demonstrated that 20% of anaphylac- LOE 3 retrospective registry40 showed an association be- tic reactions are biphasic, with a mean of 10 hours between 2 tween early prehospital administration of aspirin and lower mortality in patients with acute myocardial infarction. Thereis evidence from an LOE 4 retrospective study41 that prehos- pital administration of aspirin is safe. This study suggested There is insufficient evidence for or against the routine first that prehospital aspirin might facilitate early reperfusion and aid administration of a second dose of epinephrine.
demonstrated the value of early aspirin administration during Knowledge Gaps acute myocardial infarction.
How can a first aid provider determine that a victim needs additional epinephrine? What should the time interval be be- Administration of aspirin is recommended for chest discom- tween doses of epinephrine? How often does someone with an fort if the victim does not have an allergy, a recent episode of anaphylactic reaction respond to a second dose of epinephrine if bleeding, or other contraindications to aspirin, but adminis- they did not respond to the first? Are anaphylactic reactions tration of aspirin should never delay activation of EMS.
biphasic, and if so, how does that influence first aid measures? Knowledge GapsDoes administration of aspirin by first aid providers delay EMS involvement? Can first aid providers recognize contra- Consensus on Science indications to aspirin? What are the clinical results with There is no study that directly addresses the first aid use of treatment versus nontreatment with aspirin by first aid pro- oxygen for breathing difficulty or complaints of chest pain. In 1 viders of patients with subsequently proven coronary events? large LOE 3 retrospective case study,33 underwater divers Positioning of Breathing but
experiencing decompression injury required fewer decompres- sions and had a greater likelihood of complete recovery if firstaid included normobaric oxygen. One small LOE 4 case series34 Consensus on Science reported less ST-segment elevation in patients who received There is no evidence that positioning an unresponsive, oxygen by face mask at 15 L/min and who were admitted to the breathing victim in a recovery position (ie, lateral recumbent CCU for acute transmural myocardial infarction than in those or High Arm IN Endangered Spine [HAINES] position) as
who did not receive oxygen. In 1 LOE 2 randomized controlled compared to a supine position decreases complications. Most trial conducted before the introduction of reperfusion therapy35 evidence comes from LOE 5 studies performed on responsive in 200 patients admitted to the hospital with a suspected acute volunteers that compare the types of lateral positioning only.
myocardial infarction, there was no reduction in frequency of One LOE 542 and 1 LOE 443 study recommended the ventricular tachycardia or in mortality when oxygen was pro- HAINES position for unresponsive persons with potential vided at 6 L/min for 24 hours. One LOE 2 systematic review spinal cord trauma. Two LOE 5 studies44,45 in healthy volunteers showed decreased dependent forearm perfusion found no controlled trials (and only inpatient use) to support the and therefore a greater potential for nerve damage with the routine use of oxygen for acute myocardial infarction patients.
HAINES position. Four LOE 5 studies46–49 supported the One LOE 2 systematic review37 found no randomized controlled lateral recumbent recovery position because it was easier for trials evaluating the benefit of oxygen therapy for acute exacer- the rescuer and more comfortable for the victim. One LOE 450 bation of chronic obstructive pulmonary disease (COPD) pa- and 1 LOE 551 study compared the supine to a lateral position tients in the out-of-hospital setting.
and concluded that there was no difference in heart rate variability or in risk for aspiration pneumonia.
There is no evidence for or against the routine use of oxygen as a first aid measure for victims experiencing shortness of There is no evidence that turning an unresponsive, spontane- breath or chest pain. Oxygen may be beneficial for first aid in ously breathing victim into any side-lying versus a supine divers with a decompression injury.
position is beneficial. If a person with a suspected cervicalspine injury is turned to the side, the HAINES position Knowledge Gaps appears to be safer than the lateral recumbent position.
What is the risk to the victim of providing oxygen (ie, delayin EMS activation)? How does the outcome differ if oxygen Knowledge Gaps is given by first aid providers to patients with chest pain, What are the risks of any position for patients who are not breathing difficulty, or other conditions? responsive but breathing? Markenson et al
Part 13: First Aid
neurological deficit, altered mental status, intoxication, anddistracting injury as the 5 key clinical criteria predicting high risk for spine injury in adults,61 children,62 and the elderly63 Since the 2005 scientific review, new data have become avail-able about the effect of tourniquets to control bleeding. This and demonstrated that elimination of any of these factors experience comes primarily from the battlefields of Iraq and weakened the predictive value.64 The LOE 5 Canadian Afghanistan. There is no question that tourniquets do control C-Spine Rule (CCR) study65 identified age ⱖ65 years, bleeding, but when tourniquets remain in place too long, dangerous injury mechanism, and paresthesia as conditions reported complications include gangrene distal to the applica- that should create a high level of suspicion for cervical spine tion, shock, and death. Protocols for the proper use of tourni- injury. A large LOE 5 study of children younger than 3 years quets to control bleeding exist, but there is no experience with of age66 identified a Glasgow Coma Scale (GCS) score ⬍14, civilian use or how to teach the proper application of tourniquets a GCS Eye Opening score of 1, motor vehicle crash, and age to first aid providers. Studies have shown that not all tourniquets ⱖ2 years as signs that should create a high level of suspicion are the same, and some manufactured tourniquets perform better for cervical spine trauma in young children. One LOE 5 than others and better than improvised ones. This issue will take study67 has validated these risk factors with the possible on increasing importance in this age of terrorism and the exception of injury mechanism, and 11 LOE 5 studies have possibility of mass casualties during disasters.
shown that emergency medical technicians can identify the Because of its importance, the issue of spinal stabilization risk factors in most patients with possible cervical spinal was once again reviewed. Unfortunately, very few new data injury68–70 with excellent reliability71,72 when applied in are available, and it is still not clear whether and how often selective spinal immobilization protocols.73–78 secondary spinal cord injury occurs and whether the methodsthat have been recommended for spinal stabilization or Treatment RecommendationsCervical spine injury should be suspected in traumatic injury movement restriction are effective.
The literature on first aid for snake bites was once again reviewed. Previously, evidence supported pressure immobiliza- Is ⱖ65 years of age tion for neurotoxic snake bites, but it now appears that there is a Is involved as driver, passenger, or pedestrian in a motor benefit to application of pressure even for nonneurotoxic snake vehicle, motorized cycle, or bicycle crash bites. The challenge is that the range of pressure used appears to Falls from a greater than standing height be critical and may be difficult to estimate in the field.
Has tingling in the extremities A new section on jellyfish stings has been added, and new Complains of pain or tenderness in the neck or back recommendations for treatment have been made.
Has sensory deficit or muscle weakness involving the torso Optimal Position in
or upper extremities Is not fully alert or is intoxicated Consensus on Science Has other painful injuries, especially of the head and neck Evidence from 2 LOE 452,53 and 3 LOE 554–56 studies Is a child ⱖ2 years of age, has a GCS score ⬍14, or has a demonstrated that use of passive leg raising or the modified GCS Eye Opening score of 1 Trendelenburg position does not significantly increase meanarterial pressure or cardiac output over a period of 7 min-utes.52 Evidence from 2 LOE 457,58 and 2 LOE 559,60 studies Benefit of Spinal
demonstrated that passive leg raising can increase cardiac Consensus on Science output and volume responsiveness. No studies demonstrated There are no published studies that support or refute the improved patient outcome, but 1 LOE 4 study53 noted benefit of spinal immobilization by first aid providers. One potential harm with the Trendelenburg position.
retrospective, nonrandomized, and probably underpowered LOE 5 study79 of spinal immobilization by emergency med- There is insufficient evidence for or against raising the legs as ical technicians using immobilization devices failed to show a first aid intervention for shock.
any neurological benefit compared with no spinal immobili-zation. Two LOE 4 studies80,81 examined data from before the Knowledge Gaps era of routine spinal immobilization and compared them to What are the relative benefits and risks of supine positioningwith passive leg raising and modified Trendelenburg posi- the era after the introduction of routine spinal immobilization tioning in victims with shock? Is there potential harm of and determined that secondary spinal injury occurred in 3% passive leg elevation in victims with pelvic, abdominal, chest, to 25% of patients suffering a spinal injury. An LOE 5 review of the literature82 estimated that 0.03% to 0.16% of patientsmay be helped by spinal restriction.
When to Suspect Cervical Spine
Consensus on Science There is insufficient evidence for or against spinal immobi- The LOE 5 National X-Radiography Utilization Study lization. It is reasonable to recommend spinal motion restric- (NEXUS) identified midline cervical neck tenderness, focal tion, in victims with risk factors for cervical spine injury.
October 19, 2010
Method for Spinal Motion
Consensus on Science Direct Pressure, Pressure Points, and
There are no studies that support or refute any 1 method of spinal Consensus on Science motion restriction in victims of trauma. One LOE 5 study in There are no studies evaluating the effectiveness of direct healthy volunteers83 concluded that professional rescuer appli- pressure as a first aid for bleeding. One LOE 1 randomized, cation of bilateral sandbags held in place by 3-inch tape placed prospective, but not double-blind study,133 1 LOE 1 meta- across the forehead was more effective than any other method, analysis,134 and 5 LOE 2 studies135–139 showed that hemosta- including extrication collars, in restricting spinal motion. Two sis can be achieved by manual direct pressure over an LOE 5 studies, 1 in cadavers with spinal injury84 and the other arteriotomy site after cardiac catheterization. Three LOE 5 in traumatic cardiac arrest,85 showed that manual stabilization animal studies140–142 showed that increasing intra-abdominal was ineffective in protecting the spinal cord.
pressure by insufflation of air can control intra-abdominal bleeding. Three LOE 4143–145 and 1 LOE 5146 studies showed There is insufficient evidence for or against manual cervical that bleeding from even large wounds can be controlled and spine restriction of motion. The only proven method of hemostatic pressure achieved by application of an adhesive cervical spine immobilization is use of bilateral sandbags elastic bandage over gauze. One LOE 4 study147 in 10 held together with tape over the forehead, thus restricting volunteers showed no effect on distal pulses when pressure both lateral and anterior-posterior neck motion.
was applied over the proximal artery.
Knowledge Gaps Is there a benefit to applying (as compared with not applying) Control of bleeding is best achieved with direct manual spinal motion restriction to all victims of head and neck pressure over the bleeding area. Pressure can be maintained trauma? What is the risk? by applying an elastic adhesive bandage over gauze pads.
There is evidence against using pressure points (indirect Thermal Cutaneous
pressure) but no evidence for or against elevation of the Consensus on Science bleeding part as a method of hemorrhage control.
Evidence from 5 LOE 386–90 and 4 LOE 4 retrospective91–94studies, as well as 28 LOE 5 animal experiments,95–122 demon- Knowledge GapsAll our knowledge about direct pressure hemostasis is extrap- strated that cooling of thermal burns with water at roomtemperature (15°C to 25°C) within 30 minutes of injury reduces olated from cardiac catheterization experience and the battle- pain, depth of injury, and the need for grafting. In 1 LOE 4 case field, and studies of bleeding control in civilian settings by series123 and 5 LOE 5 animal studies,111,121,124,125 cooling of first aid providers are needed. Do first aid providers apply burns with ice or ice water increased tissue damage.
sufficient pressure? Do first aid providers apply pressure fora sufficient amount of time to control bleeding? How often does properly applied pressure fail to control bleeding, and Cooling of thermal burns with tap water is recommended as which alternative method works? soon as possible but no later than 30 minutes after the injury.
Large burns should not be cooled without the ability to Tourniquets – Routine
monitor the victim's core temperature because that may cause Consensus on Science hypothermia, especially in children. Cooling with ice or ice There are no studies of the use of tourniquets to control water is not recommended.
hemorrhage in a civilian setting by first aid providers. Two Knowledge Gaps LOE 5 retrospective studies148,149 and 1 LOE 5 prospective What is the role of cooling in large burns? When is a burn study150 supported the use of a tourniquet to control extremity sufficiently large that cold application creates risk of hypo- hemorrhage on the battlefield. One LOE 4 retrospective case thermia? Is there a benefit to use of water gel versus tap water study145 found that direct pressure was superior to a tourni- in the cooling of a burn? How long should burns be cooled? quet in controlling hemorrhage. One LOE 1 prospective studyin orthopedic patients undergoing surgery that used a tourni- quet to achieve a bloodless field151 showed that metabolic Consensus on Science markers of muscular injury were directly related to the length Evidence from 1 LOE 2 human study,126 2 small LOE 4 of time the tourniquet was in place. One LOE 3 prospective, clinical studies,127,128 1 LOE 5 human volunteer study,129 and controlled study during orthopedic surgery152 showed en- 4 LOE 5 animal studies118,130–132 demonstrated that leaving hanced transendothelial neutrophil migration with potential burn blisters intact improves healing and reduces pain.
for muscle injury while a tourniquet was in place. One LOE4 case report documented paralysis after surgical use of a tourniquet,153 1 LOE 5 retrospective review documented limb Burn blisters should be left intact.
paralysis following use of a tourniquet during surgery,154 and Knowledge Gaps 1 LOE 5 animal study on muscular contraction following Is there an outcome benefit of burn treatment with a modern tourniquet use and its relationship to inflating pressure155 occlusive dressing with and without prior blister debridement? demonstrated potential neurological complications of pro- Markenson et al
Part 13: First Aid
longed tourniquet use. Two of these studies153,154 showed that loosened to reassess or stop bleeding with direct pressure the neurological complication was potentially reversible.
when conditions warrant (eg, scene safety improves, access towounds improves, or additional resources are available)? Treatment RecommendationProperly applied tourniquets do control hemorrhage under surgical and battlefield conditions, but because of potentialcomplications, there are insufficient data for or against Consensus on Science recommending their routine use in civilian first aid.
Evidence from 4 LOE 4 studies in adults165–168 showed asignificant improvement compared with standard treatment for Knowledge Gaps out-of-hospital control of life-threatening bleeding when topical What is the maximum time that a tourniquet can be left in hemostatic agents were used by trained individuals. This bene- place before the benefit/risk ratio reverses? Can first aid ficial outcome was supported by 21 LOE 5 animal studies.168–186 providers be taught how tightly to apply a tourniquet? Are Effectiveness varied substantially among the agents used. Ad- there any advantages/disadvantages to intermittent release of verse effects of some agents included tissue destruction with an applied tourniquet? induction of a proembolic state and potential thermal injury.
Tourniquets – When Should They be
Consensus on Science The out-of-hospital application of a topical hemostatic agent There are no studies on the use of a tourniquet to control to control life-threatening bleeding not controlled by standard bleeding in the civilian setting by first aid providers. One techniques is reasonable, but the best agent and the conditions LOE 4 retrospective study of 11 patients on the use of under which it should be applied are not known.
paramedic application of tourniquets in a community set-ting156 showed that tourniquets are effective and can be used Knowledge Gaps by trained professionals without complications. Two LOE 5 Which hemostatic agents are most effective as a first aid measure? retrospective studies148,149 and 2 LOE 5 prospective stud- Which hemostatic agents have the least side effects when used by ies150,157 documented the effectiveness of tourniquets in first aid providers? How do hemostatic agents compare with controlling extremity hemorrhage on the battlefield.
direct pressure and tourniquets? When should they be used? Two LOE 5 studies,158,159 1 LOE 5 study,160 and 1 LOE 2 prospective randomized study161 tested different tourniquets Straightening an Angulated
for ease of volunteer application and effectiveness and Consensus on Science showed that commercially available devices are safer than One LOE 4 prehospital study187 and 6 LOE 5 hospital studies improvised ones; in 1 study,150 only 25% of improvised and reviews188–193 showed no evidence that straightening of an tourniquets were effective. Three commercially available angulated suspected long bone fracture shortens healing time or tourniquets that have been found to be reliable in combat and reduces pain prior to permanent fixation. One LOE 4194 study experimental situations are the Combat Application Tourni- showed reduced pain with splinting without straightening. One quet (CAT®), the Special Operations Forces Tactical Tour- LOE 5195 study on cadavers suggested that straightening angu- niquet (SOFTT®), and the Emergency and Military Tourni- lated fractures decreases compartment size and might increase quet (EMT®).150,161 compartment pressure. One LOE 5 study196 showed no evidence One LOE 5 prospective but not randomized study162 on that traction splints could have prevented any hemodynamic prolonged tourniquet application during surgery and 2 LOE 5 compromise in isolated long bone leg fractures in children.
animal studies163,164 showed that local hypothermia of theextremity protected against adverse effects of ischemia.
Treatment RecommendationIn general, there should be no attempt to manipulate a Treatment RecommendationIn civilian settings, tourniquets should only be used for suspected extremity fracture.
control of extremity hemorrhage if direct pressure is not Knowledge Gaps adequate or possible (eg, multiple injuries, inaccessible In the first aid setting, what are the benefits/risks of realigning wounds, multiple victims). Specifically designed tourniquets long bones that are angulated and presumed to be fractured? are superior to improvised ones but should only be used with Does travel time to a definitive healthcare facility make a proper training. There is insufficient evidence to determine difference? Does the application of traction reduce blood loss? how long a tourniquet can remain in place safely. Cooling ofthe distal limb should be considered if a tourniquet needs to Stabilizing Suspected Extremity
remain in place for a prolonged period of time.
Consensus on Science Knowledge Gaps There are no published studies that evaluate the change in Which specifically designed tourniquet is best and easiest to pain or functional recovery when a first aid provider stabi- use in a civilian setting? lizes a suspected extremity fracture.
Do improvised tourniquets stop bleeding in a civilian setting? Does cooling of an extremity after application of a tourniquet in humans prolong the safety margin of tourni- There is no evidence for or against manual stabilization or quets? In delayed-help environments, can tourniquets be splinting for a suspected extremity fracture by first aid providers.
October 19, 2010
Knowledge Gaps Irrigation of Superficial
Is there any benefit in terms of pain reduction or healing iffirst aid providers stabilize a suspected fracture? Is there any Consensus on Science harm in stabilizing a suspected fracture as a first aid maneu- Evidence from 6 LOE 1 clinical trials,214–219 1 LOE 2 clinical ver? Does distance from a definitive healthcare facility make trial,220 1 LOE 1 meta-analysis221 of simple traumatic lacer- a difference in effectiveness of stabilization? ations in the emergency department, and 6 LOE 5 animalstudies222–227 demonstrated that irrigation is better than no Musculoskeletal Injury and
irrigation, that higher irrigation pressures are more effective than lower pressures, that higher volumes are better thanlower volumes (within a range of 100 to 1000 mL), and that Consensus on Science tap water is as good as (or better than) any other irrigation In 1 LOE 1 study involving only 30 subjects197 with anklesprains, cold was more effective than heat or alternating cold solution in reducing infection rates. In 1 small LOE 1 clinical and heat for reducing ankle edema within 24 hours following study,228 body temperature saline was more comfortable than a musculoskeletal injury.
cold saline, and in 1 LOE 5 inanimate study,229 soap andwater were more effective than irrigation with saline alone.
Treatment RecommendationThere is insufficient evidence for or against the application of heat to an acute musculoskeletal injury. Cold application Irrigation of acute superficial wounds with a large volume of appears to be superior in the early reduction of edema.
warm or room temperature tap water from a reliable source(with or without soap) is recommended.
Musculoskeletal Injury and Cold
Knowledge Gaps Consensus Science What are the effectiveness and best method of wound In 2 LOE 2 studies198,199 and 1 LOE 5 study,200 cold irrigation in the home? Is there a benefit to using soap in application reduced pain, swelling, edema, and the duration addition to water in cleaning superficial wounds? of disability after musculoskeletal injury. Evidence from 3LOE 5 studies201–203 showed that a mixture of ice and wateris more effective in lowering tissue temperature in the injured Eye Injury –
area than ice alone. Three LOE 5 studies204–206 showed thatthe duration of cryotherapy should not exceed 20 minutes.
Consensus on ScienceThere are no human studies comparing irrigation of eyes with One LOE 1 study207 demonstrated that intermittent 10-minuteapplications of ice and water (melting ice water) were as tap water and irrigation with another substance following eye effective as standard ice application for 20 minutes.
exposure to a toxin. Two LOE 5 studies230,231 support tapwater over saline solution for emergency rinsing of caustic burns of the eyes. Three LOE 5 studies230,232,233 found Musculoskeletal, including joint, injuries should be treated phosphate buffer, borate buffer eye wash, and amphoteric with the application of ice (crushed or cubed) with water.
solutions (Diphoterine®, Previn) to be more effective than Cooling time should be interrupted every 20 minutes. Inter- water in lowering intraocular pH in caustic burns of the eyes.
mittent 10-minute cooling is also acceptable if 20 minutes of In a single LOE 5 study,234 water performed no better than cooling causes discomfort.
normal saline or isotonic magnesium chloride (MgCl2) solu- Topical Agents and
tion when rinsing eyes exposed to hydrofluoric acid. OneLOE 5 study233 found a specialized rinsing solution for Consensus on Science hydrofluoric acid eye burns (Hexafluorine®) to be more Evidence from 2 small, nonrandomized LOE 2 trials in volun- efficient than tap water. One LOE 5 study235 showed little teers208,209 and supportive evidence from 1 LOE 2 human study difference between a single lavage of water or an amphoteric of other wound types210 and 3 LOE 5 well-designed animal solution in removing radioactivity but also found the ampho- studies211–213 demonstrated significantly shorter healing time of teric solution to be significantly more effective than water in abrasions treated with any occlusive dressing or topical antibi- 3 successive lavages and in an eyewash device.
otic versus no dressing or topical antibiotic.
Immediate irrigation of eyes exposed to a toxin with large After cleaning, superficial traumatic abrasions should be amounts of tap water is beneficial.
covered with a clean occlusive dressing and/or a topicalantibiotic that keeps the wound moist and prevents drying.
Knowledge Gaps There are insufficient data to recommend any particular What is the optimal rinsing method for eyes exposed to a dressing or topical antibiotic.
toxin? Does irrigation of ocular hydrofluoric acid burns withwater compared with other substances improve outcome? Knowledge GapsWhat are the best topical agent and dressing in the home How does the effectiveness of water compare with the setting? When should the first aid provider seek additional effectiveness of other emergency rinsing solutions for ocular care for superficial wounds? Markenson et al
Part 13: First Aid
Human and Animal
occurred earlier in the animals treated with suction than in thecontrol animals. The author concluded that "suction may be Consensus on Science conducive to a more rapid invasion of venom." One LOE 4 Irrigation of bite wounds for the prevention of rabies is sup- retrospective case series247 concluded that there was little sup- ported by 2 LOE 5 animal studies236,237 and is supported for the port for the application of suction in the management of snake prevention of bacterial infection by 1 LOE 3 retrospective envenomation. One LOE 5 simulated-snakebite study in human human study.238 Tap water, saline, and soap and water solutions volunteers248 determined that only 0.04% of a venom load was were among the irrigating solutions that were beneficial, al- recovered by a suction device. There was no benefit to applica- though they were not directly compared. Despite multiple tion of a suction device for rattlesnake envenomation in an LOE recommendations in review literature and common clinical 5 porcine study,249 and the suction may have caused injury. An practice, no evidence was found that application of povidone- LOE 4 case report250 of the application of suction to a snake iodine is beneficial for the treatment of human or animal bites.
envenomation victim demonstrated visual harm to tissue in the region of the application of the suction device.
Irrigation of human and animal bite wounds with a copious amount of fluid (water or saline) is recommended to mini- Suction should not be applied to treat snake envenomation; it mize the risks of bacterial and rabies infections. There is no is ineffective and may be harmful.
evidence for or against any specific irrigation fluid.
Knowledge Gaps Snake Bite
No further studies on suctioning following snake bite are warranted.
Consensus on Science Topical Applications to Prevent Nematocyst
One LOE 5 monkey study239 showed that application of apressure bandage to create ⬇55 mm Hg of pressure and Consensus on Science simultaneous immobilization of the bitten extremity with a splint In 2 LOE 5251,252 animal studies of jellyfish stings, vinegar are effective and safe in retarding snake venom uptake into the prevented further nematocyst discharge. One of these studies251 systemic circulation. One LOE 2 human study240 and 1 LOE 5 supported vinegar use for Olindias sambaquiensis, and the animal study241 demonstrated that lymphatic flow and "mock second252 for the Portuguese man-of-war (Physalia physalis).
venom" uptake can be significantly or almost completely re- One LOE 5 animal study252 supported the use of a baking soda duced by proper application of pressure and immobilization but slurry to decrease further nematocyst release. One LOE 1 that either pressure or immobilization alone was ineffective. No study253 and 1 LOE 2 study254 concluded that pain cannot be adverse effects were observed within certain prescribed pressure diminished with use of a commercial aerosol spray, meat ranges (between 40 and 70 mm Hg for upper, and 55 to tenderizer, or freshwater wash and that papain, meat tenderizer, 70 mm Hg in lower limbs); a useful and practical field estima- and vinegar are less effective than heat in relieving pain from tion for this pressure range is the application of a comfortably acute jellyfish stings.
tight bandage that allows the insertion of a finger under it.
Theoretically, if a venom produces more local tissue effects than Treatment RecommendationJellyfish stings should be liberally washed with vinegar (4% systemic effects, damage may be increased if the venom is to 6% acetic acid solution) as soon as possible for at least 30 "trapped" in 1 place with use of pressure and immobilization.
seconds to prevent further envenomation and/or to inactivate One LOE 5 animal study242 demonstrated the effectiveness of nematocysts. If vinegar is not available, baking soda slurry pressure and immobilization on survival from the venom of non- may be used instead. Topical application of aluminum sulfate neurotoxic North American snakes. Two LOE 5 studies243,244 using or meat tenderizer is not recommended for the relief of pain.
volunteer first aid providers showed that retention of the ability toperform proper pressure/immobilization application is poor.
Heat or Cold
Consensus on Science Properly performed pressure immobilization of extremities In 2 LOE 2254,255 and 2 LOE 3 studies,256,257 hot-water immer- should be considered in first aid following snake envenomation.
sion was effective for first aid treatment of pain of jellyfishstings. One LOE 2 study258 concluded that there is a statistically Knowledge Gaps significant but possibly clinically unimportant reduction in pain Does first aid provider compressive wrapping of an extremity with application of dry hot or cold packs in comparison with dry bitten by a venomous snake improve outcome? What is the best thermo-neutral packs for box jellyfish stings. The response was method to teach the optimal way to apply a compressive greatest with hot versus cold packs. In 1 LOE 4 study,259 cold dressing? How often does this need to be refreshed for retention? packs reduced pain, but in 2 LOE 2 studies,255,258 the use of cold packs produced no significant relief of pain.
Consensus on Science In 1 LOE 4 case series descriptive report,245 suction was After the nematocysts are removed or deactivated, the pain effective in treating snake envenomation. In 1 LOE 5 controlled caused by jellyfish stings should be treated with hot-water animal study,246 suction provided no clinical benefit, and death immersion when possible. The victim should be instructed to October 19, 2010
take a hot shower or immerse the affected part in hot water with intravenous or intra-arterial tissue plasminogen activator (temperature as hot as tolerated, or at 45°C if there is the capability (tPA), the amputation rate was decreased significantly when to regulate temperature) as soon as possible. The immersion should treatment was performed within 24 hours of injury.
continue for at least 20 minutes, or for as long as pain persists. If hot water is not available, dry hot packs or, as a second choice, dry cold When providing first aid to a victim of frostbite, rewarming packs may also be helpful in decreasing pain.
of frozen body parts is only beneficial if there is no risk of Pressure Immobilization
refreezing. For severe frostbite, rewarming should be accom-plished within 24 hours.
Consensus on Science Rewarming is best achieved by immersing the affected part Two LOE 5 animal studies260,261 showed fair to good evi- in water between 37°C and 40°C (ie, body temperature) for dence that the application of pressure with an immobilization 20 to 30 minutes. Chemical warmers should not be placed bandage causes further release of venom, even from already directly on frostbitten tissue because they can reach temper- fired nematocysts.
atures that can cause burns. Following rewarming, effortsshould be made to protect frostbitten parts from refreezing and to quickly evacuate the victim for further care.
Pressure immobilization bandages are not recommended forthe treatment of jellyfish stings.
Knowledge GapsAt what interval from injury (eg, 24, 48, or 72 hours) is Knowledge Gaps rewarming at the site of injury no longer beneficial? If a Almost all evidence-based research on the best first aid treat- warm-water bath is not available, but chemical hand warmers ment for jellyfish stings involves species of jellyfish found in are, how long should they be applied to frostbitten tissue? Indo-Pacific waters. More research is needed on species found inother waters (eg, Atlantic Ocean). More specific research on the best first aid treatment of jellyfish stings is needed.
Consensus on ScienceEvidence from 1 LOE 2 cohort study275 showed a significant reduction in morbidity, a reduction in tissue loss, and a decrease in hospital stay for victims of localized cold injury treated with The literature on the first aid treatment of frostbite was ibuprofen 12 mg/kg per day and topical aloe vera (n⫽56) versus reviewed. There continues to be evidence against thawing of standard treatment (n⫽98). Groups were not matched for size or a frozen body part if there is any chance of refreezing. The degree of injury. Evidence from 1 LOE 3 bench study276 evidence is not clear at this time regarding the benefit of demonstrated elevated levels of inflammatory mediators in nonsteroidal anti-inflammatory agents as a first aid treatment blister fluid of frostbite patients. In 6 LOE 5 animal stud- for frostbite. There is evidence against the use of chemical ies,264,277–281 frostbite treatment that included administration of a warmers since they have been demonstrated to be capable of nonsteroidal anti-inflammatory drug (NSAID) either before or reaching temperatures that could damage tissues.
following injury was beneficial. Two LOE 4 case series273,282 Oral fluid replacement has been found to be as effective as reported healing without major tissue loss when an NSAID was intravenous fluid in exercise- or heat-induced hypohydration.
included in treatment protocols, while 2 LOE 4 studies271,283 did The best fluid appears to be a carbohydrate-electrolyte mixture.
not clearly describe outcomes. One LOE 4 case series273 and 1LOE 3 cohort study274 found dramatic reductions in amputation Cold Injury
rates (33/174 digits at risk273 and 10% versus 41%,274 respec-tively) following use of intravenous or intra-arterial tPA plus heparin within 24 hours of injury for severe frostbite with absent Consensus on Science pulses following rewarming.
Seven LOE 5 animal studies262–268 of frostbite injury demon- strated a beneficial effect of rapid rewarming in water baths There is insufficient evidence for or against the use of ibuprofen or between 37°C and 42°C for 20 to 30 minutes. Beneficial other NSAIDs as a first aid measure for victims of frostbite.
outcomes included the return of venous circulation, arterialcirculation, and/or microcirculation, as well as decreased tissue Knowledge Gaps loss (as measured by paw volume, level of tissue necrosis, or Good-quality research is needed to establish whether there is amputation). Three LOE 4 case series of frostbite victims269–271 a true benefit from the use of NSAIDs for frostbite in humans, treated with rewarming protocols demonstrated a trend toward both in the prethaw and postthaw phases of injury. Does the improved outcome (ie, reduced tissue loss) when rewarming was early use of NSAIDs for frostbite lead to an increase in rapid versus gradual or at room temperature. Two LOE 4 case bleeding complications in patients treated with tPA for series269,270 also described severe tissue loss when frostbitten ongoing (warm) ischemia following thawing? tissue was thawed and then refrozen or was rewarmed with a dry Heat Injury
heat source. One LOE 5 bench study272 of commerciallyavailable disposable chemical hand and foot warmers found that Fluid Treatment of
temperatures created by these chemical warmers reached 69°C Consensus on Science to 74°C. In 1 LOE 4 case series273 and 1 LOE 4 cohort study274 The level of evidence regarding the treatment of hypohy- of severe frostbite without perfusion after rewarming treatment dration is extremely low because studies have been per- Markenson et al
Part 13: First Aid
formed in volunteers and are underpowered, and the target testing. Five LOE 1300–304 and 10 LOE 2305–314 studies of hypohydration is generally less than 2% dehydrated.
showed the benefit of using simulations as an educational One LOE 2284 and 1 LOE 5285 study showed that oral tool. One LOE 1 study315 showed the benefit of using rehydration is as effective as intravenous rehydration. In a simulation as an evaluative tool.
model of exercise- and heat-induced mild hypohydration, 1 One LOE 1 study,300 4 LOE 2 studies,308,311,313,314 2 LOE 3 LOE 1 study286 and 8 LOE 2 studies284,287–293 demonstrated studies,316,317 and 1 LOE 5 study318 showed that use of that oral carbohydrate/electrolyte solutions were more simulation in medical education improved learning outcomes.
effective than water in restoring intravascular volume. One Two LOE 2 studies300,319 showed that ACLS training using LOE 2 study293 showed that the volume consumed must simulation is an effective training method for initial patient exceed the volume lost in sweat. In 1 LOE 2 study,287 management skills. In these studies, simulation tools and fluids containing a mixture of glucose and fructose led to simulated patients produced identical or better educational a more rapid hydration that those containing only glucose, outcomes than either traditional lecture-based or clinical- but 1 LOE 2 study288 showed that carbohydrate concentra- based learning for ACLS, advanced trauma life support, or tion above 6% compromised fluid absorption. One LOE 2 the equivalent.
study294 showed that milk is more effective than water forfluid replacement for hypohydration.
Treatment RecommendationIn first aid training, the use of simulation appears to improve participant learning if it is accompanied by other effective Exercise-related hypohydration should be treated with an oral teaching methods.
carbohydrate/electrolyte solution. Milk is an acceptable alter-native. The volume consumed should exceed the volume lost Knowledge Gaps Well-designed studies to compare training using simulationwith didactic lectures and other pedagogic methods are Knowledge GapsWhat is the best fluid composition for oral rehydration? Are there needed. Well-designed studies on the efficiency of first aid benefits of cooling with water immersion versus water spray? providers trained using simulation versus other pedagogicmethods are also needed.
Because education in first aid continues to be undocumented in Frequency of First Aid
a scholarly way, many questions remain. What is the best way to Consensus on Science teach first aid skills? Evidence shows a deterioration of skills There are no data to support a recommendation for the frequency almost from the moment that a course is completed. How does needed for first aid retraining. Four LOE 1 studies320–323 and 1 one ensure that the skills, once learned, are retained so they are LOE 2 study299 demonstrated a loss of skills between 3 and 6 available when needed? The progress in technology has un- months following BLS training. Evidence from 1 study299 leashed an ever-growing number of attractive simulation tech- suggested that video retraining in first aid at 1 week, 1 month, niques but no data that they improve knowledge or skillcompetencies. An evaluation of the literature only raises more and 13 months after initial training produces better retention of questions but does not provide any definitive answers.
skills than no retraining over this period.
Evaluation of Progress and
There are insufficient data to recommend a specific frequency of Consensus on Science retraining in first aid in order to retain skills and knowledge.
There are no data regarding the optimal method to evaluate and Knowledge Gaps monitor progress in first aid education. Four LOE 1 studies295–298 Well-designed studies are needed to help define the optimal and 1 LOE 2 study299 with well-defined populations explored retraining/update strategy (timing, duration, etc). Well- evaluation during resuscitation training, but no conclusions can designed studies are needed to evaluate self-instruction ver- be drawn because a variety of methods were used.
sus a traditional first aid refresher course.
Treatment RecommendationThere are no data for or against any method of evaluating or monitoring a first aid provider trainee's educational progress.
We thank the following individuals (the First Aid Chapter Knowledge Gaps Collaborators) for their collaborations on the worksheets con- Well-designed studies are needed to evaluate the optimal eval- tained in this section: Olav Aasland; Juan Acosta; Kristian L.
Arnold; David Berry; Richard N. Bradley; Rick Caissie; Barbara uation strategy (method, timing, duration) of first aid courses.
Caracci; Arthur Cooper; Cara B. Doughty; Jonathan I. Groner;Jeffrey Guy; Christopher P. Holstege; Vincent Hubert; Keiichi Simulation in First Aid Education
Ikegami; Lisa S. Jutte; Sue O. Kell; Blaine C. Long; AndrewMacPherson; Daniel Meyran; Neal Pollock; Jeanette Previdi; Consensus on Science William Raynovich; Karyl Reid; Samantha Roberts; Paul Satter- There are no studies evaluating the effect of simulation in first lee; Susanne Schunder-Tatzber; Hong Shen; Ralph Shenefelt; aid education. In other medical educational settings, simula- Eunice M. Singletary; William Smith; Jeff Woodin; Brad tions have been used successfully both in education and in Yeargin; and Susan W. Yeargin.
October 19, 2010
CoSTR Part 13: Writing Group Disclosures
New York Medical College—Interim Chairman Brody School of Medicine at East Carolina *Currently functioning as expert witness in two trial/resolution. Total fees to date are less than $10 000 in the past Emeritus Director Pediatric Cardiology Connecticut Children's Medical Center Clinical Professor University of Connecticut French Red Cross/International federation of *Coordinator of the RC/RC—Coordinator of the European Scientific Committee of Reference Centre for First Aid Education— the National First Aid National Medical Advisor of the French Red Commission for the Interior Ministry inFrance (No payed) Hong Kong Hospital Authority Hospital Chief *Chairman of Board of Association of Hong NorthEast Emergency Medical Services, Inc.: *American Red Cross Regional EMS Council—EMS System Advisory Council for Oversight and Training Center (CPR/AED/First First Aid, Aquatics, Aid)—Executive Director; Isis Maternity: Pre-Natal and Post-Partum Retail and Educational Company—CPR and First Aid City of Austin/Travis County EMS System: Office of the Medical Director—Performance Management & Research Coordinator *Consultant—Senior Science Editor for the American Heart Association Vanderbilt University School of Nursing—Professor; AHA ECC Product Development—Senior Science Editor †The significant compensation that I receive is for my writing and editorial responsibilities for the 2010 CoSTR document and the 2010 AHA Guidelines for CPR and ECC CVS/Minute Clinic—Family Nurse Practitioner Kent State University—Assistant Director †StayWell Publishing, Faculty Professional Development Center Expert, wilderness author of Wilderness First Aid Instructor Bloomington Hospital Promptcare—Adult NP Stony Brook University—Physician 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 personreceives $10 000 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 shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under thepreceding definition.
Markenson et al
Part 13: First Aid
CoSTR Part 13: Worksheet Collaborator Disclosures
Ownership Interest Norwegian Red Cross NGO; First Aid Advisor Yakima Regional Medical and Cardiac Center Attending Kristian L. Arnold Occupational and Emergency Medicine consulting Chief Weber State University The University of Texas Health Science Center at Professor of Emergency Medicine; Texas Air National *I served as an expert witness in a coroners Injury Prevention Programs inquest relating to CPR drowning of a twelve given. I was also asked to provide an expert opinion in a lawsuit, in which a twenty year old male struck a light pole while skiing and became paralized.
The law firm paid distance phone calls, photocopying etc.). No Council—Director of Program Development and Training †I am a salaried employee of the National Safety Council.
My salary comes from work I do with the emergency care product line. This includes making sure our student and instructor materials are *Clinical Decision Rule to *Symposium Lecture, Identify Children with Carilion Clinic (directly) Abdominal Injuries, CDC EMSC Stakeholder's (consultant, directly) Car Group, HRSA (directly) Seats for Kids at Harlem Commissioned Paper, Vulnerable Populations, (principal investigator, Forum on Medical and none) EMSC Network Preparedness, IOM Demonstration Project, (directly) Pediatric HRSA (co-principal Preparedness Consensus investigator, none) Conference, Children's Pediatric Disaster Health Fund (directly) Coalition, NYCDOHMH (consultant, directly) Neonatal Transport Ventilator, Friends of (principal investigator, Baylor College of Medicine; Assistant Professor October 19, 2010
CoSTR Part 13: Worksheet Collaborator Disclosures, Continued
Ownership Interest The Ohio State University College of Medicine, non-profit state university; Professor of Clinical Surgery; Nationwide Children's Hospital Non-profit pediatric hospital (501–3(c)) ;Trauma Vanderbilt University School of Medicine Director Burn Center; Associate Professor medical liability cases as well as medical malpractice defense Christopher P.
Physician, Necker Hospital, Dokkyo Medical University Ball State University Assistant Professor of Athletic Training University of Virginia Health Programs Coordinator Oklahoma State University Assistant Professor Vancouver Island Health Authority Emergency Physician BC Ambulance Service Medical Director Bergen Regional Medical Currently serve as Center, 230 E. Ridgewood volunteer on BLS & Ave., Paramus, NJ ACLS Regional Faculty 07652—Health & Education Coordinator/Life Support Training Center Coordinator Association (AHA), and as volunteer member Duke University Medical Center University Research Associate Divers Alert Network Diving safety and emergency support organization Research Creighton University *Expert Witness: My University Associate Professor Hackensack Univversity Medical Center—APN-C Pediatric Emergency Dept.
Government of Grenada Allina Hospitasl and *Ridgewater Community †Enova Medical Technologies—medical †National Safety †Medical Director, College paramedic manufacturing company emphasizing Council I have been Director, medical headlamps and splint/cast material. My the medical advisor Paramedic Program. I wife and I are one of over 25 investors for their Emergency Care Consultants: Private in the company that is located in our Care products for 4 director for the EMS community. Our investment was education programs for this state college OMV Oilcompany Coporate Chinese PLA.general hospital; public health hospital and institute; emergency physician, professor Markenson et al
Part 13: First Aid
CoSTR Part 13: Worksheet Collaborator Disclosures, Continued
Ownership Interest Health and Safety Institute: †Shareholder. Health and Safety educational services— Institute, Inc. Health & Safety Institute occasional income is an affiliate of ASHI Holding Company.
HSI, Health & Safety Institute, MEDIC HEALTH & SAFETY, MEDIC FIRST AID, Children's Hospital 801 MEDIC FIRST AID logo, American Safety 6th St. South St.
& Health Institute, and the ASHI logo Petersburg, FL 33701 are registered trademarks of Medic First Aid International, Inc. or ASHI Holding Company. Corporate Headquarters: Health & Safety Institute,1450 Westec Drive, Eugene, OR 97402 University of Virginia Health Sciences Foundation Also holds an academic appointment as Associate Clinical Professor for the Dept. of Emergency Medicinewith the University of Virginia medical center. Attending Physician, Dept. of Emergency Medicine The Medical Clinic of Big Sky, Montana—Attending Emergency Medicine of *Chinook Board of *Limited Consulting for Jackson Hole—Clinical ED for multiple EMS, Wilderness Expert Witness for Physician, Resident Rotation Medicine, and Hospital volunteer National Supervisor; University of groups: Wilderness Medical Park Service—EMS Washington School of *Personal Consulting (Wilderness Advanced Life business (Wilderness Faculty; Stanford Wilderness Support) Course Wilderness Medicine Fellowship— Medical Society, Snowmass, Rotation Supervisor for Grand CO, Park City, UT Wilderness Teton National Park; Jackson Medicine Conference— LLC) Jackson, WY. I'm Hole Fire/EMS—Medical Mountain Destinations, Santa Director; National Park Fe, NM, Big Sky, MT Director, and provide Service and Grand Teton Colorado Symposium on National Park—NPS EMS Emergency Care, Telluride, wilderness medicine Advisory Committee, Medical CO NAEMSP (National consulting in many Advisor for Grand Teton Association of EMS forms from providing National Park; United States Physicians) plus other Army Reserve-Emergency teaching to other less common presentations business opportunities Sky, MT Wilderness MedicalAssociates—WALS Colorado Symposium on Emergency Tualatin Valley Fire & Rescue: Emergency Medical and Fire Paramedic; PortlandCommunity College: Indiana State University Indiana State University Assistant Professor This table represents the relationships of worksheet collaborators that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all worksheet collaborators are required to complete and submit. A relationship is considered to be "significant" if (a) the personreceives $10 000 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 shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under thepreceding definition.
October 19, 2010
CoSTR Part 13: Worksheet Appendix
In victims of a venomous snakebite (P) does pressure Compression wrapping Christopher P.
immobilization (I) of an extremity, when compared to no therapy (C), improve outcome (O)? In victims of a venomous snakebite (P) does application Suction for snake bite Christopher P.
of suction (I) to the envenomation site, when compared to no therapy (C), improve outcome (O)? Does the use of cooling (I) improve healing and pain Cooling of thermal control (O) in patients after thermal injuries (P)? In patients with burns (P), does leaving the burn Burn blister treatment blister intact (I), compared with removing the blister (C), improve healing and pain control (O)? Does the use of wet dressings (I) compared with dry Application of dressing dressings (C) improve healing and pain control (O) in patients after thermal injuries (P)? In a patient (P) experiencing difficulty breathing, does administration of a bronchodilator (I) compared with not administration (C) improve outcome (O)? In patients with chest pain (P), does helping Lay rescuer medication administer aspirin (I), compared with not administering aspirin (C), improve outcomes (O)? In patients with chest pain (P), does helping Lay rescuer medication administer aspirin (I), compared with not administering aspirin (C), improve outcomes (O)? Does irrigation of eyes exposed to a toxin with water Irrigation of eyes compared to other substances improve outcome? In persons with acute skin exposure to potentially Irrigation of skin for Kristian L. Arnold toxic substances, does irrigation with ambient temperature, not specifically sterilized water compared with no irrigation lead to less morbidity and/or mortality? What is the optimal position for a person in shock? Optimal position for Jonathan L. Epstein Does elevating the legs improve outcome? What is the optimal position for a person in shock? Optimal position for Does elevating the legs improve outcome? In hypohydrated individuals (P) does providing fluids (I) as compared to providing no fluids (C) decrease electrolyte vs water in symptoms (O)? In hypohydrated individuals (P) does a carbohydrate-electrolyte beverage (I) compared to water (C) rehydrate individuals (O)? In victims with heat exhaustion or heat syncope (P) Best fluid for oral what treatment (I) as opposed to no treatment (C) decreases/resolves symptoms (O)? Is there a treatment for human or animal bites that First aid for human Jeffrey D. Ferguson improves outcome? In individuals who have received a jellyfish sting (P), Temperature treatment does the application of heat or cold (I) decrease pain for jellyfish sting Jeanette Previdi, or prevent worsening (O) as compared to not applying heat or cold (C)? In individuals who have received a jellyfish sting (P), Topical application for does the application of a topical (i.e. vinegar, baking Jeanette Previdi, soda, meat tenderizer, or commercial product) (I) decrease pain or prevent worsening (O) as compared to not applying a topical (C)? In individuals who have received a jellyfish sting (P), Pressure immobilzation does the application of a pressure immobilization bandage for jellyfish Jeanette Previdi, bandage (I) decrease pain or prevent worsening (O) as compared to not applying a pressure immobilization bandage (C)? In breathing but unresponsive victims (P), does Positioning breathing Jeanette Previdi, positioning the victim in a lateral, side-lying, recovery position (i.e. lateral recumbent or modified HAINES) (I) decrease complications (O) as compared to leaving them in a supine position (C)? In a patient who ingests a potentially poisonous Christopher P. Holstege, substance (P), does the administration of activated Jeffrey D. Ferguson charcoal (I), when compared to no administration (C), improve that patient's outcome (O)? Markenson et al
Part 13: First Aid
CoSTR Part 13: Worksheet Appendix, Continued
In victims with oral caustic substance poisoning, does Use of milk or water Christopher P. Holstege the early administration of milk or water as compared to nothing by mouth, improve outcome? In victims with oral poisoning does the administration of syrup of ipecac by lay public improve outcome? administration in oral Christopher P. Holstege In First Aid Training (P), does the use of simulation (I) Simulated patients in when compared with not using simulation (C) First Aid training improve the participant effectiveness (O)? In First Aid Training (P), does the use of simulation (I) Simulated patients in when compared with not using simulation (C) First Aid training improve the participant effectiveness (O)? In First Aid Training, which techniques of monitoring and evaluation of progress and performance is able evaluation of First Aid to show the improvement of the participant skills? In First Aid Training (P) how frequently are retraining/ First Aid retraining update sessions required (I) in order to maintain the participant's skills (O).
Helmet removal after motorcycle accident–When? Motorcycle helmet How? One–helper/ two helper techniques? Which position might be the best for victims of Positioning possible possible head injury if they are unconsciousness? What is the best first aid treatment of an open chest First aid treatment for Does the administration of a second dose of Kristian L. Arnold injectable epinephrine improve outcome from a injectable epinephrine severe allergic reaction? Does the administration of a second dose of injectable epinephrine improve outcome from a injectable epinephrine severe allergic reaction? Can the first aid provider appropriately recognize the Jonathan L. Epstein, signs and symptoms of anaphylaxis? In a bleeding victim do direct pressure, indirect Control of bleeding pressure (pressure points), or elevation of the bleeding part help control bleeding as compared to Jeffrey L. Pellegrino When direct pressure fails to stop bleeding does the Tourniquet if direct administration of a tourniquet improve outcome? Jeffrey L. Pellegrino When direct pressure fails to stop bleeding does the Tourniquet if direct administration of a tourniquet improve outcome? In which circumstances are the application of a tourniquet appropriate? circumstances for Jeffrey L. Pellegrino In which circumstances are the application of a tourniquet appropriate? circumstances for In patients with severe external bleeding (P), does the Topical hemostatic application of topical haemostatic agents (I) when compared with usual care (C) improve outcome? (O).
In patients with severe external bleeding (P), does the Topical hemostatic Richard N. Bradley application of topical haemostatic agents (I) when compared with usual care (C) improve outcome? (O).
In patients with severe external bleeding (P), does the Topical hemostatic application of topical haemostatic agents (I) when compared with usual care (C) improve outcome? (O).
In victims with suspected cervical spinal injury does Spine immobilization spinal immobilization benefit the patient over doing nothing in outcome? In victims with suspected cervical spinal injury does Spine immobilization spinal immobilization benefit the patient over doing nothing in outcome? In victims with trauma, when should one suspect Cervical spine injury Jonathan I. Groner, cervical spinal injury? October 19, 2010
CoSTR Part 13: Worksheet Appendix, Continued
In victims suspected to have spinal injury, what method(s) should be used for spinal motion restriction restriction methods in William Raynovich, by the first aid provider? Which are effective methods suspected cervical of spinal motion restriction in persons with suspected cervical spinal injury? In a patient with a closed joint injury (P), does the Compression bandage application of a compression bandage by a lay rescuer (I) decrease pain and swelling as compared to not applying a compression bandage (O)? In a patient with a closed joint injury (P), does the Compression bandage application of a compression bandage by a lay rescuer (I) decrease pain and swelling as compared to not applying a compression bandage (O)? Does straightening angulated suspected long bone Suspected long bone Jeffrey L. Pellegrino fractures when compared with immobilizing in found position, improve the (management of pain; safer transport; prognosis)? Does straightening angulated suspected long bone Suspected long bone Kristian L. Arnold fractures when compared with immobilizing in found position, improve the (management of pain; safer transport; prognosis)? Does cooling of a musculoskeletal injury improve outcome? And if so, what is the optimal method of musculoskeletal injury In individuals with musculoskeletal injury (P) does heat application (I) as opposed to no treatment (C) musculoskeletal injury improve tissue healing? In individuals with musculoskeletal injury (P) which type of heat application (I) compared to other methods is more effective (C) and improves healing better (O)? In individuals with musculoskeletal injury (P) does heat application (I) as opposed to no treatment (C) musculoskeletal injury improve tissue healing? In individuals with musculoskeletal injury (P) which type of heat application (I) compared to other methods is more effective (C) and improves healing better (O)? In patients with suspected extremity fractures (P), Stabilizing extremity Richard N. Bradley does stabilization (I) compared to no stabilization (C) reduce pain and lead to better functional recovery (O)? What is the appropriate method of preservation of the Andrew MacPherson amputated body part In patients with difficulty breathing or complaints of Oxygen administration chest pain, does administration of oxygen improve Does the use of a topical agent and/or dressing (I) for superficial wounds (I) improve healing (O) when compared to no topical therapy (C)? Does the use of irrigation (I) compared with no irrigation (C) improve healing (O) in patients with superficial wound superficial wounds (P)? Does rewarming of a localized cold injury (frostbite) Rewarming frostbite Eunice M. Singletary, In patients with frostbite, does the use of an Anti-inflammatory and Eunice M. Singletary, anti-inflammatory, when compared with usual care, 6. Homan CS, Singer AJ, Henry MC, Thode HC Jr. Thermal effects of 1. 2005 International Consensus on Cardiopulmonary Resuscitation And neutralization therapy and water dilution for acute alkali exposure in Emergency Cardiovascular Care Science With Treatment Recommen- canines. Acad Emerg Med. 1997;4:27–32.
dations, Section 2 Part 10: First Aid. Circulation. 2005;112:III- 7. Homan CS, Singer AJ, Thomajan C, Henry MC, Thode HC Jr. Thermal characteristics of neutralization therapy and water dilution for strong acid 2. Maull KI, Osmand AP, Maull CD. Liquid caustic ingestions: An in vitro ingestion: An in-vivo canine model. Acad Emerg Med. 1998;5:286 –292.
study of the effects of buffer, neutralization, and dilution. Ann Emerg 8. Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of Med. 1985;14:1160 –1162.
acutely poisoned patients without gastric emptying. Ann Emerg Med.
3. Homan CS, Maitra SR, Lane BP, Geller ER. Effective treatment of acute alkali injury of the rat esophagus with early saline dilution therapy. Ann 9. Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW.
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KEY WORDS: arrhythmia 䡲 cardiac arrest 䡲 cardiopulmonary resuscitation 2000;28:550 –554.
䡲 resuscitation In the article by Markenson et al, "Part 13: First Aid: 2010 American Heart Association andAmerican Red Cross International Consensus on First Aid Science With Treatment Recommen-dations," which published online October 18, 2010, and appeared with the October 19, 2010, issueof the journal (Circulation. 2010;122(suppl 2):S582–S605), several corrections were needed.
On page S583, in the Table, the American Safety and Health Institute and Medic First Aid should be listed as members of the International First Aid Science Advisory Board MemberOrganizations. The word "(Observer)" has been deleted from both entries.
The American Heart Association and the American Red Cross regret listing these organizations as observers.
These corrections have been made to the current online version of the article, which is available (Circulation. 2010;122:2227.)
2010 American Heart Association, Inc., and American Red Cross.
Circulation is available at
In the article by Markenson et al, "Part 13: First Aid: 2010 American Heart Association andAmerican Red Cross International Consensus on First Aid Science With Treatment Recommen-dations," which published online October 18, 2010, and appeared with the October 19, 2010, issueof the journal (Circulation. 2010;122[suppl 2]:S582–S605), a correction was needed: On page S589, in the left column, in the paragraph under "Snake Bite," line 18, the sentence read, "Two LOE 5 animal studies241,242 demonstrated …." It has been changed to read, "One LOE5 animal study242 demonstrated …." Worksheet FA-1001A has been updated. Its callout is listed on page S589 in the left column under the heading "Snake Bite" and in the Appendix on page S596. A direct link to it is: The correction to the text has been made to the current online version of the article, which is (Circulation. 2012;125:e585.)
2012 American Heart Association, Inc.
Circulation is available at
Circulation 2012, 125:e586 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX Copyright 2012 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online The online version of this article, along with updated information and services, is located on the World Wide Web at: Subscriptions: Information about subscribing to Circulation is online at Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. 410-528-8550. E-mail: Reprints: Information about reprints can be found online at In the article "Appendix: Evidence-Based Worksheets: 2010 International Consensus on Cardio-pulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recom-mendations and 2010 American Heart Association and American Red Cross InternationalConsensus on First Aid Science With Treatment Recommendations" which published onlineOctober 18, 2010, and appeared with the October 19, 2010, issue of the journal (Circulation.
2010;122[suppl 2]:S606 –S638), several corrections were needed in the worksheet by Holstege,No. FA-1001A: 1. On page 4, first paragraph, line 5: ". . (i.e. German 2004, LOE 5) . ." has been changed to ". . (i.e. German 2005, LOE 5). . " 2. On page 4, second paragraph, line 3: ". . (German 2005, LOE 5; Bush 2004, LOE 5) . ." has been changed to ". . (Bush 2004, LOE 5). . " The worksheet is listed in the table on page S636 of the article.
These corrections have been made to the current online version of the worksheet, which is (Circulation. 2012;125:e586.)
2012 American Heart Association, Inc.
Circulation is available at


Mach Learn (2010) 81: 333–357DOI 10.1007/s10994-010-5185-8 Learning to rank on graphs Received: 31 July 2008 / Revised: 27 December 2009 / Accepted: 28 March 2010 /Published online: 29 May 2010© The Author(s) 2010 Abstract Graph representations of data are increasingly common. Such representationsarise in a variety of applications, including computational biology, social network analysis,web applications, and many others. There has been much work in recent years on developinglearning algorithms for such graph data; in particular, graph learning algorithms have beendeveloped for both classification and regression on graphs. Here we consider graph learningproblems in which the goal is not to predict labels of objects in a graph, but rather to rankthe objects relative to one another; for example, one may want to rank genes in a biologicalnetwork by relevance to a disease, or customers in a social network by their likelihood ofbeing interested in a certain product. We develop algorithms for such problems of learningto rank on graphs. Our algorithms build on the graph regularization ideas developed in thecontext of other graph learning problems, and learn a ranking function in a reproducing ker-nel Hilbert space (RKHS) derived from the graph. This allows us to show attractive stabilityand generalization properties. Experiments on several graph ranking tasks in computationalbiology and in cheminformatics demonstrate the benefits of our framework.

Aesth Plast Surg (2012) 36:458–463 Control of Postoperative Pain with a Wearable ContinuouslyOperating Pulsed Radiofrequency Energy Device:A Preliminary Study Ian M. Rawe • Adam Lowenstein • C. Raul Barcelo •David G. Genecov Received: 18 May 2011 / Accepted: 29 September 2011 / Published online: 25 October 2011Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011