Part 9: First aid: 2015 International Consensus on First Aid Science with Treatment Recommendations

Medical ID use by international patients with Aspirin-Exacerbated Respiratory Disease

BACKGROUND

Patients widely use medical identification (ID) to indicate their food and drug allergies, and chronic medical conditions. One chronic condition for which patients are recommended to use a form of medical ID is Aspirin-Exacerbated Respiratory Disease (AERD), a disease characterized by the presence of asthma, chronic rhinosinusitis with nasal polyps and sensitivity to aspirin and other COX-1 inhibitors, including nonsteroidal anti-inflammatory drugs (NSAIDs). The uptake of medical ID use in AERD is unknown and has not been widely studied in this population.

METHODS

We conducted a cross-sectional survey study to measure the perception of the need to use a medical ID and its use by patients with AERD internationally.

RESULTS

245 members of an online AERD support group completed an online survey. The majority (80%, n = 198) of the participants did not use any form of medical ID. The participants reported that the lack of knowledge and awareness about the importance of using a medical ID was the most common reason for not using it.

CONCLUSION

This international survey found that the majority of the AERD patient respondents did not use a medical ID. The most common reasons for nonuse were not knowing that it is recommended for their condition and that the patients did not consider it necessary. The results highlight the need for further patient and health care provider education.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Duration of cooling with water for thermal burns as a first aid intervention: A systematic review

BACKGROUND

Cooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations.

AIM

To perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 min or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications?

METHOD

We searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 min or more. We found no benefit for a duration of 20 min or more of cooling when compared with less than 20 min of cooling for the outcomes of size and depth of burn, re-epithelialization, or skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness.

CONCLUSION

The optimal duration of cooling for thermal burns remains unknown and future prospective research is indicated to better define this treatment recommendation.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Assessment Framework for Recognizing Clinical Deterioration in Patients With ACS Undergoing PCI

TOPIC

Patients with acute coronary syndrome undergoing primary percutaneous coronary intervention are at risk of clinical deterioration that results in similar general signs and symptoms regardless of its cause. However, specific causes and forms of clinical deterioration are associated with key differences in assessment findings. Focused clinical assessments using a modified primary survey enable nurses to rapidly identify the cause and form of clinical deterioration, facilitating targeted treatment.

CLINICAL RELEVANCE

Clinical deterioration during percutaneous coronary intervention is associated with increased mortality and morbidity. Previous studies identified nursing inconsistencies when recognizing clinical deterioration, with inconsistent collection of cues and prioritization of cues related to cardiac performance over more sensitive indicators of clinical deterioration.

PURPOSE OF PAPER

To describe a framework to help nurses optimize physiological cue collection to improve recognition of clinical deterioration during periprocedural care of patients undergoing percutaneous coronary intervention for unstable acute coronary syndrome.

CONTENT COVERED

Literature analysis revealed 7 forms of clinical deterioration in patients undergoing percutaneous coronary intervention: coronary artery occlusion, stroke, ventricular rupture, valvular insufficiency, lethal cardiac arrhythmias, access-site and non-access-site bleeding, and anaphylaxis. Evidence for the pathophysiology, incidence, severity, and clinical features of each form of clinical deterioration is identified. A framework is proposed to help nurses conduct highly focused patient assessments, enabling prompt recognition of and response to the specific forms of clinical deterioration that occur in patients undergoing percutaneous coronary intervention.

A Rapid Review of Burns First Aid Guidelines: Is There Consistency Across International Guidelines?

We conducted a rapid review of current international and Australian/New Zealand guidelines on first aid for burns to identify any critical variation and any recent major changes in the literature that would warrant a significant change to current recommendations. A search was conducted to identify Australian/New Zealand and international first aid guidelines for burn care using guideline databases, and we compared key recommendations from each guideline relating to burns first aid. A literature search of relevant databases (Medline, Embase, Cochrane Database of Systematic Reviews, PROSPERO international register of systematic reviews, and ClinicalTrials.gov databases) was conducted to identify existing and in-progress research published on the topic of first aid for burn injuries. Seven guidelines were identified from the Australia/New Zealand region, and 11 international guidelines were identified from the United States of America and Europe. All Australian and New Zealand guidelines recommended a cooling duration of 20 minutes and made some mention of when to refer a burn for medical evaluation, while international guidelines saw cooling duration variation, a number of guidelines failed to mention referral criteria. The review of published systematic reviews and clinical trials revealed a lack of new evidence in the last six years. Our rapid review identified key variation between first aid guidelines for burns that would benefit from the development of an international consensus on management. We identified no new significant evidence that would alter guideline recommendations and did not identify any upcoming reviews or clinical trials on this subject.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Second Dose of Epinephrine for Anaphylaxis in the First Aid Setting: A Scoping Review

Anaphylaxis is a life-threatening hypersensitivity reaction where rapid, early administration of epinephrine (adrenaline) can be lifesaving in the first aid setting. There are instances where a single dose of epinephrine does not relieve symptoms and a second dose may be required to further mitigate symptoms and preserve life. We performed a scoping review as part of an update to a previously conducted International Liaison Committee on Resuscitation First Aid Task Force (ILCOR) review. PubMed and Embase were searched using the strategy from the 2015 ILCOR review (dates January 1, 2015 to October 22, 2019) and a review of the grey literature (all dates up to November 18, 2019) was performed to identify data on the requirement, use, and effectiveness of a second dose of epinephrine. Each search was rerun on June 26, 2020. We included all human studies of adults and children with an English abstract. Critical outcomes included resolution of symptoms, adverse effects, and complications of second dosing of epinephrine in the treatment of acute anaphylaxis. Included studies are presented descriptively. Our updated search identified 909 potential sources, 890 from the published literature and 19 from the grey literature. After full text review, two studies met our eligibility criteria (Campbell et al. and Akari et al.). For the outcome of resolution of symptoms, both studies found that two or more doses of epinephrine were required in 8% of 582 patients and 28% of 18 patients, respectively, with anaphylaxis requiring treatment with epinephrine. The other a priori outcomes were not reported. This scoping review identified limited evidence regarding the use of a second dose of epinephrine for anaphylaxis in the first aid setting, however, due to the potential benefit, it is reasonable to administer a second dose when symptoms of severe anaphylaxis fail to resolve following an initial dose. Given the potential mortality associated with anaphylaxis, further research is needed to better identify individuals who may benefit from a second dose of epinephrine.

Stroke Recognition for First Aid Providers: A Systematic Review and Meta-Analysis

Aim

To perform a systematic review of the literature on the effectiveness of existing stroke recognition scales used in a prehospital setting and suitable for use by first aid providers. The systematic review will be used to inform an update of international first aid guidelines.

Methods

We followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We searched Medline, Embase and CENTRAL on May 25, 2020 for studies of stroke recognition scales used by first aid providers, paramedics and nurses for adults with suspected acute stroke in a prehospital setting. Outcomes included change in time to treatment, initial recognition of stroke, survival and discharge with favorable neurologic status, and increased layperson recognition of the signs of stroke. Two investigators reviewed abstracts, extracted and assessed the data for risk of bias. The certainty of evidence was evaluated using GRADE methodology.

Results

We included 24 observational studies with 10,446 patients evaluating 10 stroke scales (SS). All evidence was of moderate to very low certainty. Use of the Kurashiki Prehospital SS (KPSS), Ontario Prehospital SS (OPSS) and Face Arm Speech Time SS (FAST) was associated with an increased number of suspected stroke patients arriving to a hospital within three hours and, for OPSS, a higher rate of thrombolytic therapy. The KPSS was associated with a decreased time from symptom onset to hospital arrival. Use of FAST Emergency Response (FASTER) was associated with decreased time from door to tomography and from symptom onset to treatment. The Los Angeles Prehospital Stroke Scale (LAPSS) was associated with an increased number of correct initial diagnoses. Meta-analysis found the summary estimate sensitivity of four scales ranged from 0.78 to 0.86. The FAST and Cincinnati Prehospital Stroke Scale (CPSS) were found to have a summary estimated sensitivity of 0.86, 95% CI [0.69-0.94] and 0.81, 95% CI [0.70-0.89], respectively.

Conclusion

Stroke recognition scales used in the prehospital first aid setting improves the recognition and diagnosis of stroke, thereby aiding the emergency services to triage stroke victims directly down an appropriate stroke care pathway. Of those prehospital scales evaluated by more than a single study, FAST and Melbourne Ambulance Stroke Screen (MASS) were found to be the most sensitive for stroke recognition, while the CPSS had higher specificity. When blood glucose cannot be measured, the simplicity of FAST and CPSS makes these particular stroke scales appropriate for non-medical first aid providers.

2020 International Consensus on First Aid Science With Treatment Recommendations

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.

2020 International Consensus on First Aid Science With Treatment Recommendations

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life-threatening bleeding through the use of tourniquets, hemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research.

Early or First Aid Administration Versus Late or In-hospital Administration of Aspirin for Non-traumatic Adult Chest Pain: A Systematic Review

Chest pain is a common symptom of acute coronary syndrome, including myocardial infarction (MI). Treatment with antiplatelet agents, such as aspirin, improves survival, although the ideal dose is uncertain. It is unknown if outcomes can be improved by giving aspirin early in the course of MI as part of the first-aid management as opposed to late or in-hospital administration. We searched the Medline, Embase, and Cochrane databases and used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for determining the certainty of evidence. We included studies in adults with non-traumatic chest pain, where aspirin was administered early (within two hours) following the onset of chest pain as part of first-aid management as compared with late or in-hospital administration (The International Prospective Register of Systematic Reviews (PROSPERO) registration number: CDR153316). From 1470 references, we included three studies (one randomized controlled trial (RCT) and two non-RCTs). Early administration (median 1.6 hours or pre-hospital) was associated with increased survival as compared with late administration (median 3.5 hours or in-hospital) at seven days; risk ratio (RR) 1.04 (95% CI 1.03-1.06), 30 days RR 1.05 (95% 1.02-1.07), and one-year RR 1.06 (95% CI1.03-1.10). The evidence is of very low certainty due to limitations in study design and the imprecision of the evidence. This systematic review would suggest that the early or first-aid administration of aspirin to adults with non-traumatic chest pain improves survival as compared with late or in-hospital administration.

Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial

Importance

Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established.

Objective

To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training.

Design, Setting, and Participants

This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing.

Interventions

Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention.

Main Outcomes and Measures

Correct tourniquet application in a simulated scenario.

Results

Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [n = 122]; P < .001) was superior to control (n = 104 [16%]) while instructional flashcards (n = 117 [19.6%]) and audio kit (n = 122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (n = 58; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (n = 107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (n = 138).

Conclusions and Relevance

In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical.

Trial Registration

ClinicalTrials.gov Identifier: NCT03479112.

Knowledge, attitude, and practice of first aid among the commercial drivers in the Kumaon region of India

Background

First aid assistance is one of the important life-saving skills. According to World Health Organization, over 50 million people are injured or disabled and over 1.2 million people die following Road Traffic Accident (RTA) every year. Providing the basic care until emergency medical services arrive is the essence of first aid, which will prevent a number of RTA-related mortality and morbidity.

Aim

To assess the knowledge, attitude, and practice regarding first aid among the commercial vehicle drivers operating in and from Haldwani.

Method

This was a cross-sectional study conducted among the commercial drivers operating in and from Haldwani Block of Uttarakhand, from November 2018 to January 2019. Participants were selected using consecutive sampling technique. The questionnaire used for data collection was semistructured and pretested.

Results

All participants were male with the mean age (standard deviation) of 40.4 (8.7) years. Overall 96.4% and 81.7% had heard about first aid and the "Good Samaritan" law. Among participants, 96% knew that first aid should be provided immediately and 90.5% were willing to be trained in first aid. First aid kit was available in 84.9% of the vehicles. In total, 211 (91%) participants had attended RTA victim/s in the past, and 192 (91%) of them provided assistance to RTA victims.

Conclusions

Although the study showed a positive attitude toward giving first aid to RTA victims, the knowledge and practice of first aid was not universal.

First aid glucose administration routes for symptomatic hypoglycaemia

BACKGROUND

Hypoglycaemia is a common occurrence in people with diabetes but can also result from an imbalance in glucose homeostasis in the absence of diabetes. The best enteral route for glucose administration for suspected hypoglycaemia in a first aid situation is unknown.

OBJECTIVES

To assess the effects of first aid glucose administration by any route appropriate for use by first-aid providers (buccal, sublingual, oral, rectal) for symptomatic hypoglycaemia.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL as well as grey literature (records identified in the WHO ICTRP Search Portal, ClinicalTrials.gov and the EU Clinical Trials Register) up to July 2018. We searched reference lists of included studies retrieved by the above searches.

SELECTION CRITERIA

We included studies involving adults and children with documented or suspected hypoglycaemia as well as healthy volunteers, in which glucose was administered by any enteral route appropriate for use by first-aid providers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated trials for overall certainty of the evidence using the GRADE instrument. We used the Cochrane 'Risk of bias' tool to assess the risk of bias in the randomised controlled trials (RCTs), and the 'risk of bias In non-randomised studies of interventions' (ROBINS-I) tool, in addition to the Cochrane Handbook for Systematic Reviews of Interventions recommendations on cross-over studies, for the non-RCTs. We reported continuous outcomes as mean differences (MD) with 95% confidence intervals (CIs) and dichotomous outcomes as risk ratios (RR) with 95% CIs. All data on glucose concentrations were converted to mg/dL. We contacted authors of included studies to obtain missing data.

MAIN RESULTS

From 6394 references, we included four studies evaluating 77 participants, including two RCTs, studying children and adults with hypoglycaemia, respectively, and two non-RCTs with healthy volunteers. The studies included three different routes of glucose administration (sublingual, buccal and a combination of oral and buccal administration). All studies had a high risk of bias in one or more 'Risk of bias' domain.Glucose administration by the sublingual route, in the form of table sugar under the tongue, resulted in a higher blood glucose concentration after 20 minutes compared with the oral route in the very specific setting of children with hypoglycaemia and symptoms of concomitant malaria or respiratory tract infection (MD 17 mg/dL, 95% CI 4.4 to 29.6; P = 0.008; 1 study; 42 participants; very low-quality evidence). Resolution of hypoglycaemia at 80 minutes may favour sublingual administration (RR 2.10, 95% CI 1.24 to 3.54; P = 0.006; 1 study; 42 participants; very low-certainty evidence), but no substantial difference could be demonstrated at 20 minutes (RR 1.26, 95% CI 0.91 to 1.74; P = 0.16; 1 study; 42 participants; very low-certainty evidence). A decrease in the time to resolution of hypoglycaemia was found in favour of sublingual administration (MD -51.5 min, 95% CI -58 to -45; P < 0.001; 1 study; 42 participants; very low-certainty evidence). No adverse events were reported in either group. No data were available for resolution of symptoms and time to resolution of symptoms, and treatment delay.Glucose administered by the buccal route in one study resulted in a lower plasma glucose concentration after 20 minutes compared with oral administration (MD -14.4 mg/dL, 95% CI -17.5 to -11.4 for an imputed within-participants correlation coefficient of 0.9; P < 0.001; 1 trial; 16 participants; very low-quality evidence). In another study there were fewer participants with increased blood glucose at 20 minutes favouring oral glucose (RR 0.07, 95% CI 0.00 to 0.98; P = 0.05; 1 study; 7 participants; very low-certainty evidence). No data were available for resolution of symptoms and time to resolution of symptoms, resolution of hypoglycaemia and time to resolution of hypoglycaemia, adverse events, and treatment delay.For the combined oral and buccal mucosal route (in the form of a dextrose gel) the MD was -15.3 mg/dL, 95%CI -33.6 to 3; P = 0.09; 1 study; 18 participants; very low-quality evidence . No improvement was identified for either route in the resolution of symptoms at 20 minutes or less following glucose administration (RR 0.36, 95% CI 0.12 to 1.14; P = 0.08; 1 study; 18 participants; very low-certainty evidence). No data were available for time to resolution of symptoms, resolution of hypoglycaemia and time to resolution of hypoglycaemia, adverse events, and treatment delay.

AUTHORS' CONCLUSIONS

When providing first aid to individuals with hypoglycaemia, oral glucose administration results in a higher blood glucose concentrations after 20 minutes when compared with buccal administration of glucose. A difference in plasma glucose concentration could not be demonstrated, when administering a dextrose gel, defined as "a combined oral and buccal mucosal route" compared to oral administration of a glucose tablet or solution. In the specific population of children with concomitant malaria and respiratory illness, sublingual sugar results in a higher blood glucose concentration after 20 minutes when compared with oral administration.These results need to be interpreted cautiously because our confidence in the body of evidence is very low due to the low number of participants and studies as well as methodological deficiencies in the included studies.

Guidelines for the public on how to provide mental health first aid: narrative review

BACKGROUND

Expert-consensus guidelines have been developed for how members of the public should assist a person with a mental health problem or in a mental health crisis.

AIMS

This review aimed to examine the range of guidelines that have been developed and how these have been implemented in practice.

METHOD

A narrative review was carried out based on a systematic search for literature on the development or implementation of the guidelines.

RESULTS

The Delphi method has been used to develop a wide range of guidelines for English-speaking countries, Asian countries and a number of other cultural groups. The primary implementation has been through informing the content of training courses.

CONCLUSION

Further work is needed on guidelines for low- and middle-income countries.

DECLARATION OF INTEREST

A.F.J. is an unpaid member of the Board of Mental Health First Aid International (trading as Mental Health First Aid Australia), which is a not-for-profit organisation.

The Contribution of Taiwan in International Liaison Committee on Resuscitation Consensus on Science and Treatment Recommendation 2015 (ILCOR CoSTR 2015)

Taiwan has begun its board certification of emergency medicine since 1998. The scholars have also devoted themselves to research in the related fi elds including resuscitation for decades. On the other hand, International Liaison Committee on Resuscitation (ILCOR) was established to build up international expert consensus on resuscitation science in 1992. The National Resuscitation Council of Taiwan (NRCT) is a multidisciplinary organization and becomes one of the founding members of the Resuscitation Council of Asia (RCA) in 2005, whereas the RCA has also become currently the final regional member of ILCOR. Under these international platforms, the experts from Taiwan have significant contributions in establishment of evidence review and clinical guidelines on resuscitation such as ILCOR Consensus on Science and Treatment Recommendation (CoSTR). This brief review will introduce explicitly these important Taiwan investigations cited in ILCOR CoSTR 2015.

Guidelines for Bystander First Aid 2016

Cardiac life support is a form of first aid for cardiac emergencies. However, research and evidence in this field is lacking compared with other forms of first aid. Having identified the common emergencies that are encountered in the hospital, based on the available evidence, we have put together what could be an evidence-based approach to the first aid management of some of these common emergencies, viz. breathlessness, chest pain, allergies, stroke, heat injury, poisoning, unconsciousness, seizures, and trauma situations such as bleeding, wounds, contusions, head injury, burns and fractures. Educating the public is the key to developing a first responder bystander. These guidelines could become the basis for training of the public.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

The effect and associated factors of dispatcher recognition of stroke: A retrospective observational study

BACKGROUND/PURPOSE

Details of the communication between the caller and dispatcher have not been reported previously in Taiwan. This study aimed to: (1) understand the details of the communication between the caller and dispatcher among the calls for stroke patients, (2) identify factors associated with stroke recognition by dispatchers, and (3) evaluate the association between stroke recognition by dispatchers and stroke management.

METHODS

We conducted a retrospective observational study involving patients with stroke or transient ischemic stroke transported by the emergency medical service, and arriving at 9 hospitals in Taipei within 3 h of symptom onset from January 1, 2013 to February 28, 2014. Patients were excluded if tape-recording data or prehospital information were not available. Data of the enrolled patients were reviewed. We used stroke dispatch determination as the surrogate for stroke recognition by dispatchers. Multivariable logistic regression was used to identify the factors associated with stroke dispatch determination.

RESULTS

A total of 507 patients were included. In approximately 50% of cases, callers were close family members. Ninety-one patients (17.9%) had stroke dispatch determination. After adjustment, stroke reported spontaneously, any symptom included in the Cincinnati Prehospital Stroke Scale reported spontaneously, and dispatcher adherence to the protocol, were associated with stroke dispatch determination significantly. Stroke dispatch determination was associated with receiving pre-arrival notification, shorter door-to-computed tomography time, and thrombolytic therapy.

CONCLUSION

The dispatchers should spend more time identifying stroke patients by following the dispatch protocol. Recognition of stroke by dispatchers was associated with improved stroke care.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Emergency treatment of hypoglycaemia: a guideline and evidence review

AIM

To examine the current treatment guidelines for the emergency management of hypoglycaemia and the evidence underpinning recommendations.

METHODS

International diabetes agencies were searched for hypoglycaemia treatment guidelines. Guidelines were assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. An electronic database search was conducted for evidence regarding emergency treatment of hypoglycaemia in adults, and relevant articles were critically appraised.

RESULTS

Of the international diabetes agencies, six sets of guidelines were deemed relevant and of sufficient detail for appraisal by AGREE II. The evidence search returned 2649 articles, of which 17 pertaining to the emergency management of hypoglycaemia were included. High-quality evidence for the management of hypoglycaemia was lacking, limiting treatment recommendations. In general, guidelines and studies were somewhat concordant and recommended 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult. No evidence was found for other treatment approaches.

CONCLUSION

Evidence for the emergency treatment of hypoglycaemia in adults is limited, is often low grade and mostly pre-dates contemporary management of diabetes. Guideline recommendations are limited by the lack of randomized trials. Further high-quality studies are required to inform the optimum management of this frequently occurring emergency condition.