Levels of Evidence (LOE) (1-8) are defined at the end of the "Major Recommendations" field.
Medical Emergencies
Oxygen Administration
There is insufficient evidence to recommend for or against the use of oxygen by the first aid provider.
Assistance With Use of Inhalers
Because the frequency and mortality from severe asthma is increasing (Mannino et al., 1998) and bronchodilator therapy is safe and can be effective during episodes of severe asthma, the first aid rescuer should assist with administration of bronchodilator therapy.
Epinephrine Autoinjector
Given the widespread use of epinephrine autoinjectors and their documented efficacy in the rapid delivery of epinephrine (Simons et al., 1998), first aid providers may be trained to assist in the use of an epinephrine autoinjector for a victim of anaphylaxis when the victim has a prescribed autoinjector and the victim is unable to use it.
Recovery Position
The use of the recovery position with the victim lying on his or her side with the dependent hand placed in front of the body is recommended for the unconscious victim with an intact airway, spontaneous respiration, and signs of circulation. This position is easy to teach, but conscious volunteers who were placed in the position developed some vessel and nerve compression (LOE 3) (Rathgeber et al., 1996; Fulstow & Smith, 1993). Nerve and vessel injury can develop, particularly if the victim remains in the position for a long period of time.
The preferred position for the victim with known or suspected spinal injury is to stabilize the spine in the supine position and minimize movement of the victim. Use of the recovery position may be necessary if it is difficult to maintain a patent airway in the supine position, if the victim has secretions or emesis, or if the rescuer must leave the victim and there is no provider trained in spinal stabilization. If use of the recovery position is absolutely necessary, use the HAINES (High Arm In Endangered Spine) recovery position: extend the victim's arm above the head and roll the victim to the side so that the victim's head rests on that arm. Bend both legs to stabilize the victim.
Injury Emergencies
Cervical Spine Injuries
Cervical Spine Stabilization
Considering the serious consequences of spinal cord injury, most experts agree that spinal motion restriction should be the goal of early treatment of all patients at risk for spinal injury. The first aid provider should restrict spinal motion by manual spinal stabilization if there is any possibility of spinal injury.
In the absence of any evidence supporting the first aid use of immobilization devices and with some evidence suggesting potential harm even when these devices are used by healthcare providers, the first aid provider should refrain from use of spinal immobilization devices.
Severe Bleeding
Application of Pressure and Tourniquets
The first aid provider should try to control external bleeding by applying direct pressure.
There is insufficient evidence to recommend for or against the first aid use of pressure points or extremity elevation to control bleeding.
Tourniquets may be useful under some unique conditions (e.g., battlefield conditions when rapid evacuation is required and ischemic time is carefully monitored). Additional studies are needed to identify those conditions and the indications and procedures for use. The method of application and best design of tourniquets is still under investigation (Calkins et al., 2000). There is insufficient evidence about the effectiveness, feasibility, and safety of tourniquets to recommend for or against their use by first aid providers to control bleeding.
Wounds and Abrasions
Wound Irrigation
Superficial wounds and abrasions should be irrigated with clean tap water.
Use of Antibiotic Ointment
Lay rescuers should apply antibiotic ointment or cream to cutaneous abrasions and wounds to promote faster healing with less risk of infection. The use of triple antibiotic ointment may be preferable to double- or single-agent antibiotic ointment or cream.
Thermal Burns
Cooling With Water
Cooling of burns with cold water as soon as possible is safe, feasible, and effective as a first aid treatment. First aid providers should avoid cooling burns with ice or ice water for >10 minutes, especially if burns are large (>20% total body surface area).
First Aid for Burn Blisters
Because the need for blister debridement is controversial and requires equipment and skills that are not consistent with first aid training, first aid providers should leave burn blisters intact and cover them loosely.
Musculoskeletal Injuries (Fractures, Sprains, and Contusions)
Stabilization
The first aid provider should assume that any injury to an extremity can include a potential bone fracture. The first aid provider may manually stabilize the injured extremity but should not attempt to straighten it.
Compression
There is inadequate evidence to recommend for or against the use of a circumferential bandage to compress a closed soft-tissue injury and reduce formation of edema (Class Indeterminate).
Application of Cold
Cooling is generally safe, effective, and feasible in first aid for a sprained joint and soft-tissue injury. Cold applied for >20 minutes may be detrimental, although there are several reports that suggest that longer application may continue to cool the joint without additional complications (Merrick, Jute, & Smith, 2003).
There is insufficient information to make recommendations on optimal frequency, duration, and initial timing of cryotherapy after an acute injury (MacAuley, 2001; Bleakley, McDonough, & MacAuley, 2004). Many textbooks are not consistent in their recommendations related to duration, frequency, and length of ice treatment (MacAuley, 2001).
To prevent cold injury to the skin and superficial nerves, it is best to limit ice to periods <20 minutes at a time with a protective barrier (Bassett et al., 1992; Graham & Stevenson, 2000). A damp cloth or plastic bag barrier may be ideal, whereas cold is not conducted as well through padded elastic bandages (MacAuley, 2001). Caution should be exercised when applying ice to an injury in a person with little subcutaneous fat, especially over areas of superficial peripheral nerves (Bassett et al., 1992; Otte et al., 2002).
Dental Injuries
Tooth Avulsion
The consensus of the experts is that the potential harm from attempted reimplantation of an avulsed tooth outweighs the potential benefit, and that avulsed teeth should be stored in milk and transported with the injured victim to a dentist as quickly as possible.
Environmental Injuries
Snakebite
First aid providers should not apply suction to snakebite envenomation sites.
Properly performed pressure immobilization is recommended for first aid treatment of elapid snakebites. The first aid provider creates this pressure by applying a snug bandage that allows a finger to slip under the bandage.
Cold Injuries
Hypothermia
The first aid provider should provide passive warming (using blankets) as feasible for victims of hypothermia. Victims should be transported to a facility where active rewarming can be initiated. If the victim is in a remote location far from medical help, the first aid rescuer may initiate active rewarming.
Frostbite
The first aid provider should rewarm a frostbitten body part unless there is a possibility that it might refreeze.
Toxic Exposure and Chemical Burns
Water Irrigation
To treat skin or eye exposure to acid or alkali, the first aid provider should immediately irrigate the skin or eye with copious amounts of tap water.
Ingested Poisons
Water and Gastrointestinal Decontamination
The administration of water or milk to the victim of ingested poison is not recommended.
Based on lack of evidence of benefit and documentation of potential harm, syrup of ipecac is not recommended for toxic ingestions.
There is insufficient evidence to recommend for or against the use of activated charcoal in first aid.
Definitions:
Levels of Evidence
Level 1: Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
Level 2: Randomized clinical trials with smaller or less significant treatment effects
Level 3: Prospective, controlled, nonrandomized cohort studies
Level 4: Historic, nonrandomized cohort or case-control studies
Level 5: Case series; patients compiled in serial fashion, control group lacking
Level 6: Animal studies or mechanical model studies
Level 7: Extrapolations from existing data collected for other purposes, theoretical analyses
Level 8: Rational conjecture (common sense); common practices accepted before evidence-based guidelines
