Editor’s Note: This is part one of a four-part series.
The International Liaison Committee on Resuscitation (ILCOR) defines first aid as “helping behaviors and initial care provided for an acute illness or injury.” Noting the paucity of evidence regarding these treatments, in 2013, ILCOR appointed a task force to prepare recommendations regarding initial care by trained or untrained rescuers for the 2015 American Heart Association (AHA) and American Red Cross Guidelines Update for First Aid, which were released with the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
The task force included emergency physicians from throughout the world. 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. These first aid competencies include, at any level of training:
- Recognizing, assessing, and prioritizing the need for first aid
- Providing care by using appropriate knowledge, skills, and behaviors
- Recognizing limitations and seeking additional care when needed
In order to review these recommendations, 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.
Panel Commentators:
Howard Mell, MD, MPH, CPE, FACEP, assistant professor, Wake Forest Baptist Medical Center, Department of Emergency Medicine 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.
Aspirin for Chest Pain (FA 871)
Recommendation Author: Erika M. McMahon, MD
Dr. McMahon 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 experiencing chest pain due to suspected myocardial infarction (P), does administration of aspirin (I) compared with no administration of aspirin (C) change cardiovascular mortality, complications, adverse effects, incidence of cardiac arrest, cardiac functional outcome, infarct size, or hospital length of stay (O), and does early administration of aspirin change these outcomes or chest pain resolution compared with late administration?
Results: High-quality evidence was identified from one randomized controlled trial (RCT) regarding aspirin’s effect on mortality, complications, adverse effects due to bleeding, and incidence of cardiac arrest. Low- to very-low-quality evidence was identified from four other studies regarding the effect, but not timing, of aspirin administration on infarction size and early administration on cardiovascular mortality. No evidence was found regarding cardiac functional outcome or hospital length of stay.
Outcomes: Aspirin use showed benefits on mortality, complications, and cardiac arrest. No effect was noted on infarct size. Early administration (defined as prehospital or within the first hours of symptoms) showed a positive mortality benefit. Aspirin was found to increase minor bleeding risk.
Discussion: High-quality evidence supports administering aspirin to patients with chest pain due to suspected myocardial infarction (MI). Aspirin has been shown to decrease cardiovascular mortality, rates of complication secondary to MI, and cardiac arrest occurrence. While only low-quality evidence was found in regard to optimal timing of aspirin administration, early administration demonstrated a positive mortality benefit.
Recommendation: Early aspirin administration is recommended for all adults with chest pain due to suspected MI (weak recommendation, very-low-quality evidence).
Comment:
Dr. Sztajnkrycer: It must be clarified that the current recommendation (weak, very-low-quality evidence) solely examines the issue of timing of aspirin administration. The administration of aspirin in adults with chest pain suggestive of MI is a strong recommendation based upon high-quality evidence.
Stroke Recognition (FA 801)
Recommendation Author: Ann B. Smith, MD
Dr. Smith is a member of the Emergency Medicine Residency Training Class of 2018 at the Wake Forest School of Medicine.
Question: Among adults with suspected acute stroke (P), does the use of a rapid stroke scoring system or scale (I), compared with standard first aid assessment (C), change outcomes (O)?
Results: Six observational studies identified evaluated stroke systems on the outcome of time to treatment. For the outcome of recognition of stroke defined as diagnosis of stroke or administration of tissue plasminogen activator (tPA), four observational studies were identified. For the outcome of recognition of stroke defined as correct stroke diagnosis, 22 studies were evaluated to determine sensitivity and specificity of stroke scales. All studies but one (Harbison, 2003) were deemed low-quality evidence.
Outcomes: Two scales, Functional Assessment Staging Test (FAST) and Kurashiki Prehospital Stroke Scale (KPSS), resulted in decreased time from symptom onset to hospital arrival. Application of FAST resulted in increased stroke identification. Patients who had FAST or KPSS applied were more likely to receive thrombolytics. Inclusion of glucose measurement increased specificity of stroke assessment scales. All scales studied had a similar sensitivity, while scales that use glucose measurement (Los Angeles Prehospital Stroke Screen [LAPSS], Ontario Prehospital Stroke Screening [OPSS], KPSS, Recognition of Stroke in the Emergency Room [ROSIER]) had a higher specificity when compared with scales that do not (FAST, Melbourne Ambulance Stroke Screen [MASS], Los Angeles Motor Scale [LAMS], CPSS, Medical Priority Dispatch System [MPDS]).
Discussion: Stroke assessment systems are simple, low-risk methods for promoting early stroke recognition among first aid providers and have the potential to improve patient outcomes.
Recommendation: The use of a stroke assessment system by first aid providers is recommended. FAST or KPSS are preferred as these are the simplest tools with the highest sensitivity. If a glucometer is available, use of LAPSS, OPSS, KPSS, or ROSIER may increase specificity.
Comment:
Dr. Stopyra: Further training to improve stroke identification is an extremely valuable step in improving access to health care and outcomes for patients. Emergency physicians can use simple scales outside of the hospital to describe stroke patients.
Toxic Eye Injury (FA 540)
Recommendation Author: G. Mike Hunihan, MD
Dr. Hunihan is a member of the Emergency Medicine Residency Training Class of 2018 at Warren Alpert Medical School of Brown University.
Question: Among adults and children with toxic exposure to the conjunctiva (P), does irrigation with isotonic saline, balanced salt solution, or commercial eye solution (I), compared to water (C), improve outcomes (O)?
Results: Although it features low-quality evidence, one animal in vivo observational study was deemed appropriate in addressing pH in the PICO. In this study, sodium hydroxide was applied to 16 rabbit corneas, irrigation trials were performed comparing different and equal escalating volumes of normal saline and water, and the pH was compared.
Outcomes: Irrigation with 0.5 L of water was found to significantly lower the initial pH versus 0.5 L of normal saline, but when 1.5 L of each were used, the difference disappeared. Importantly, pH remained elevated three hours after 1.5 L irrigation with either solution, indicating the dangers of alkali exposure. There was no evidence addressing the outcomes of intraocular penetration, corneal edema, intraocular pressure, or secondary glaucoma.
Discussion: Toxic exposure to the eye can result in severe morbidity if not treated quickly. It’s generally acceptable to irrigate until pH normalizes, but there’s no clear consensus on the optimal irrigation solution or volume. One paper was identified suggesting that water might lower the initial pH faster than saline, but at the large volumes required to normalize the pH, the difference disappears.
Recommendations: After chemical eye injury, first aid providers should continuously irrigate with large volumes of clean water and seek a professional health care provider. The local poison center should help identify chemicals involved in ocular injury.
Comment:
Dr. Smith: The caustic nature of alkali exposure to the cornea remains a threat to vision hours after irrigation. Large-volume irrigation and immediate evaluation in the emergency department are critical.
Control of Bleeding (FA 530)
Recommendation Author: Zachary Lipsman, MD
Dr. Lipsman is a member of the Emergency Medicine Residency Training Class of 2019 at Warren Alpert Medical School of Brown University.
Question: Among adults and children with bleeding, (P), does ice, elevation, and/or proximal pressure (I) versus direct pressure (C) change mortality, hemostasis, major bleeding, complications, or hospital length of stay (O)?
Results: For cold compression versus compression alone, there was very-low-quality evidence: One RCT was identified for the outcome of hemostasis comparing femoral hematoma after percutaneous coronary intervention (PCI), and one RCT was identified for the outcome of major bleeding following total knee arthroplasty. This study also addressed deep vein thrombosis formation and was deemed very-low-quality evidence. No evidence was identified addressing mortality or hospital length of stay.
Outcomes: Significant hematoma reduction was found using cold-pack compression versus compression alone following PCI. A significant decrease in total blood loss and extravasation volumes, and a nonsignificant decrease in DVT, was found using cold compression versus compression alone following knee arthroplasty.
Discussion: Caution must be used when applying postsurgical principles to first aid settings. Hypothermia is unlikely from using cold therapy, even in children, when applied to a small, closed area of bleeding.
Recommendation: Localized cold therapy with or without pressure may be beneficial in hemostasis for closed bleeding in extremities. There’s inadequate evidence to recommend the use of proximal pressure points, cold therapy for external bleeding, or elevation for control of bleeding.
Comment:
Dr. Mell: You can use ice for small bruises, but the idea of controlling bleeding with elevation or pressure points isn’t recommended. Direct pressure is the best method overall. A separate recommendation (FA 768) advocates tourniquet use when conventional methods fail to control bleeding.
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