DRAFT - DRAFT GUIDELINES FOR PUBLIC COMMENT OPEN FOR COMMENT UNTIL 21ST OCTOBER 2020
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DRAFT
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10 DRAFT GUIDELINES FOR PUBLIC COMMENT
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13 21ST OCTOBER 2020
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17 OPEN FOR COMMENT
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20 UNTIL
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24 5TH NOVEMBER 2020
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27 Draft 2020 European Resuscitation Council First Aid Guidelines
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29 Introduction and Scope
30 In 2015 the European Resuscitation Council published its first First Aid guidelines
31 (Zideman 2015, 278) based on the International Liaison Committee on Resuscitation
32 (ILCOR) consensus on International Consensus on Cardiopulmonary Resuscitation
33 and Emergency Cardiovascular Care Science with Treatment Recommendations
34 published in the same year (Zideman 2015, e225) (Singletary 2015, S269). In 2015
35 ILCOR modified its consensus on science review process from a five-year cycle to a
36 continuous evidence evaluation process. This is reflected in the 2020 ILCOR
37 Consensus on Science and treatment recommendations (CoSTRs) (ILCOR 2020
38 ref).
39 In 2016 the ILCOR First Aid Task Force assessed all the topics reviewed by the
40 American Heart Association and American Red Cross in the 2010 evidence review
41 (Markenson 2010, S934) and the 13 medical PICO questions and ten trauma PICO
42 questions and 1 education PICO examined in the ILCOR 2015 CoSTR review
43 (Singletary 2015, S269; Zideman 2015, e225). 38 PICO topics were selected for
44 scoring and ranking by the task force members. Scoring was orientated as to
45 whether there was any published new evidence that would modify the 2015 CoSTRs.
46 The top twenty ranked topics were selected and submitted by the ILCOR Continuous
47 Evidence Evaluation group, the constituent ILCOR councils for ratification and then
48 opened for public comment. The First Aid task force then evaluated each selected
49 topic. Some topics were combined into a mega-PICOST for full systematic review
50 (control of bleeding). The task force selected topics where they believed that there
51 was new published evidence (since 2015) and submitted these for systematic review.
52 For some topics the PICO question was changed to address gaps identified by
53 previous reviews and these were also submitted for systematic review. Where the
54 task force were uncertain that there was sufficient new published evidence to support
55 a systematic review the PICO was submitted to a scoping review process. Scoping
56 reviews are based on a broader search strategy, including grey literature, and
57 provide a narrative report of their findings rather than the critical appraisal of a
58 systematic review. The resulting manuscripts for both the systematic reviews and
59 scoping reviews were subject to public comment and published on the ILCOR
60 CoSTR website and in the 2020 CoSTR summary (submitted for publication). A
61 number of the systematic reviews have been directly published including ‘Immediate
62 interventions for presyncope’ (Jensen, 2020 64), ‘Management of hypoglycaemia’
63 (De Buck 2019 CD013283), ‘Early versus late administration of aspirin for non-
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64 traumatic chest pain’ (Djarv 2020 e6862), ‘Cooling techniques for heat stroke and
65 exertional hyperthermia’ (Douma 2020 173), ‘Compression Wrapping for Acute
66 Closed Extremity Joint Injuries’ (Borra 2020 submitted) and ‘Dental avulsion’ (Niels
67 De Brier 2020 submitted).
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69 The European Resuscitation Council First Aid writing group has used the published
70 systematic reviews and scoping reviews together with the ILCOR First Aid Task
71 Force consensus on science and treatment recommendations (ILCOR/CoSTR) as
72 evidence for these first aid guidelines. The writing group also carefully considered
73 the evidence to decision tables, narrative reviews and task force discussions when
74 writing these guidelines. In addition, the Writing Group considered five additional
75 topics, not included in the 2020 ILCOR process, that had been previously included in
76 the 2015 ILCOR process, for short evidence reviews. The Writing Group have added
77 these additional clinical recommendations as expert consensual opinion and labelled
78 them as Good Practice Points to differentiate them from guidelines derived directly
79 from scientific review.
80 In total these guidelines include 19 PICO topics, subdivided into eleven medical and
81 eight trauma emergencies.
82 Medical emergencies:
83 Recovery position
84 Optimal position for shock victim
85 Bronchodilator administration for asthma
86 Recognition of stroke
87 Early aspirin for chest pain
88 Anaphylaxis
89 Second dose of adrenaline (epinephrine) in anaphylaxis
90 Recognition of anaphylaxis by first aid providers
91 Hypoglycaemia treatment
92 Exertion-related dehydration and rehydration
93 Heat stroke by cooling
94 Supplemental oxygen in acute stroke
95 Presyncope
96 Trauma emergencies
97 Control of life-threatening bleeding
98 Open chest wounds
99 Cervical spine motion restriction and stabilisation
100 Recognition of concussion
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101 Thermal burns:
102 Cooling of thermal burns
103 Thermal burn dressings
104 Dental avulsion
105 Compression wrap for closed extremity joint injuries
106 Eye injury from chemical exposure
107
108 Definition of First Aid
109 First aid is the initial care provided for an acute illness or injury. The goals of first aid include
110 preserving life, alleviating suffering, preventing further illness or injury and promoting
111 recovery. First aid can be initiated by anyone in any situation, including self-care. General
112 characteristics of the provision of first aid, at any level of training include:
113 • Recognizing, assessing and prioritizing the need for first aid.
114 • Providing care using appropriate competencies and recognizing limitations.
115 • Seeking additional care when needed, such as activating the emergency medical
116 services (EMS) system or other medical assistance.
117 Key principles include:
118 • First aid should be medically sound and based on the best available scientific
119 evidence.
120 • First aid education should be universal: everyone should learn first aid.
121 • Helping behaviours should be promoted; everyone should act.
122 • The scope of first aid and helping behaviours varies and may be influenced by
123 environmental, resource, training and regulatory factors.
124
125 Concise guideline for clinical practice
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127 Recovery Position
128 For adults and children with a decreased level of consciousness which is due to medical
129 illness or non-physical trauma that do not meet criteria for the initiation of rescue breathing
130 or chest compressions (CPR), the ERC recommends the following sequence of actions:
131
132 • kneel beside the victim and make sure that both legs are straight,
133 • place the arm nearest to you out at right angles to the body, elbow bent with the hand palm
134 uppermost;
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135 • bring the far arm across the chest, and hold the back of the hand against the victim’s cheek
136 nearest to you;
137 • with your other hand, grasp the far leg just above the knee and pull it up, keeping the foot
138 on the ground;
139 • keeping the hand pressed against the cheek, pull on the far leg to roll the victim towards
140 you onto their side;
141 • adjust the upper leg so that both hip and knee are bent at right angles;
142 • tilt the head back to make sure the airway remains open;
143 • adjust the hand under the cheek if necessary, to keep the head tilted and facing
144 downwards to allow liquid material to drain from the mouth;
145 • check breathing regularly;
146 • only leave the victim unattended if absolutely necessary, for example to attend to other
147 victims.
148 It is important to stress the importance of maintaining a close check on all unconscious
149 victims until the EMS arrives to ensure that their breathing remains normal. In certain
150 situations, such as resuscitation-related agonal respirations or trauma, it may not be
151 appropriate to move the individual into a recovery position.
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153 Optimal position for shock victim
154 • Place individuals with shock into the supine (lying-on-back) position.
155 • Where there is no evidence of trauma first aid providers might consider the use of
156 passive leg raising as a temporizing measure while awaiting more advanced
157 emergency medical care.
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160 Bronchodilator administration for asthma
161 • Assist individuals with asthma who are experiencing difficulty in breathing with their
162 bronchodilator administration.
163 • First aid providers must be trained in the various methods of administering a
164 bronchodilator.
165 Recognition of stroke
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166 • Use a stroke assessment scale to decrease the time to recognition and definitive
167 treatment for individual suspected of acute stroke
168 • The following stroke assessment scales are available
169 o Face Arm Speech Time to call (FAST)
170 o Melbourne Ambulance Stroke Scale (MASS)
171 o Cincinnati Prehospital Stroke Scale (CPSS)
172 o Los Angeles Stroke Scale (LAPSS) are the most common.
173 • The MASS and LAPSS scales can be augmented by blood glucose measurement.
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175 Aspirin for chest pain
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177 For conscious adults with non-traumatic chest pain due to suspected myocardial infarction:
178 • Reassure the casualty
179 • Sit or lie the casualty in a comfortable position
180 • Call for help
181 • Administer 150–300 mg chewable aspirin as soon as possible after the onset of non-
182 traumatic chest pain.
183 • First aid providers should encourage and assist the self- administration of aspirin.
184 • Do not administer aspirin to adults with chest pain of unclear or traumatic aetiology.
185 • There is a relatively low risk of complications, particularly anaphylaxis and serious
186 bleeding. Do not administer aspirin to adults with a known allergy to aspirin or
187 contraindications such as severe asthma or known gastrointestinal bleeding.
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189 Anaphylaxis
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191 The management of anaphylaxis has been described in Special Circumstances
192 • If the symptoms of anaphylaxis do not resolve after ten to fifteen minutes of the first
193 injection or, if the symptoms begin to return after the first dose, administer a second
194 dose of adrenaline by intramuscular injection using an autoinjector.
195 • Call for help
196 • Train first aid providers regularly in the recognition and first aid management of
197 anaphylaxis
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199 First aid in case of hypoglycaemia
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200
201 • The signs of hypoglycaemia are sudden impaired consciousness: ranging from
202 dizziness, fainting, sometimes nervousness and deviant behaviour (mood swings,
203 aggression, confusion, loss of concentration, signs that look like drunkenness) to
204 loss of consciousness.
205 • If hypoglycaemia is suspected in someone who feels faint but is conscious and able
206 to swallow:
207 o Give glucose or dextrose tablets (15-20 gram), by mouth.
208 o If glucose or dextrose tablets are not available give other dietary sugars such
209 as Skittles, Mentos, sugar cubes, jelly-beans, or a can of orange juice.
210 o Repeat the administration of sugar if the symptoms are still present and not
211 improving after 15 minutes.
212 o If oral glucose is not available a glucose gel (partially held in the cheek, and
213 partially swallowed) can be given.
214 o Following recovery from the symptoms after taking the sugar, encourage
215 taking a light snack such as a sandwich or a waffle.
216 • For children who may be uncooperative with swallowing oral glucose:
217 o Administer half a teaspoon of table sugar (2.5 gram) under the child’s tongue.
218 • If possible, measure and record the blood sugar levels before and after treatment.
219 • Call the emergency services if:
220 o the casualty is or becomes unconscious,
221 o the casualty’s condition does not improve after first aid.
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224 Oral rehydration solutions for treating exertion-related dehydration
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226 • If a person has been sweating excessively during a sports performance and exhibits
227 signs of dehydration such as feeling thirsty, dizzy or light-headed and/or having dry
228 mouth or dark yellow and strong-smelling urine, give him/her 3-8% carbohydrate-
229 electrolyte (CE) drinks or skimmed milk.
230 • If 3-8% CE drinks or milk are not available or not well tolerated, alternative
231 beverages for rehydration include 0-3% CE drinks, 8-12% CE drinks or water.
232 • Clean water is an acceptable alternative, although it may require longer times to
233 rehydrate.
234 • Avoid the use of alcoholic beverages.
235 • Call the emergency services on 112 if:
236 o The person is or becomes unconscious.
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237 o The person shows signs of a heat stroke.
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240 Management of heat stroke by cooling
241 Recognise the symptoms and signs of heat stroke (in the presence of a high ambient
242 temperature):
243 • Elevated temperature
244 • Confusion
245 • Agitation
246 • Disorientation
247 • Coma
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249 When a diagnosis of suspected exertional or classical heat stroke is made:
250 • Immediately remove casualty from the heat source and commence passive cooling
251 • Commence immediate cooling using any technique immediately available.
252 • Where possible measure the casualty’s core temperature (rectal temperature
253 measurement) – will require special training.
254 • If the core temperature is above 40°C commence whole body (neck down) cold water
255 (1-26°C) immersion until the core temperature falls below 39°C.
256 • Casualties with exertional hyperthermia or non-exertional heatstroke will require
257 advanced medical care and advance assistance should be sought
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259 It is recognised that the diagnosis and management of heat stroke requires special training
260 (rectal temperature measurement, cold water immersion techniques). However, the
261 recognition of the signs and symptoms of a raised core temperature and the use of active
262 cooling techniques is critical in avoiding morbidity and mortality.
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264 Alternative, but less effective, cooling techniques include evaporative cooling (mist and fan),
265 ice sheets, commercial ice packs, fan alone, cold shower, hand cooling devices, cooling
266 vests and jackets.
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268 Concise guideline for clinical practice - Use of supplemental oxygen in acute
269 stroke
270 • Do not routinely administer supplemental oxygen in acute stroke in the pre-hospital
271 first aid environment.
272 • Oxygen should be administered if the individual is showing signs of hypoxia.
273 • Training is required for first aid providers in the provision of supplementary oxygen
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274
275 Management of Presyncope
276
277 • Presyncope is characterised by light-headedness, nausea, sweating, black spots in
278 front of the eyes and an impending sense of loss of consciousness.
279 • Ensure the casualty is safe and will not fall or injure themselves if they lose
280 consciousness.
281 • Use simple physical counterpressure manoeuvres to abort presyncope of vasovagal
282 or orthostatic origin.
283 • Lower body physical counterpressure manoeuvres are more effective than upper
284 body manoeuvres.
285 o Lower body – Squatting with or without leg crossing
286 o Upper body – Hand clenching, neck flexion
287 • First aid providers will need to be trained in coaching casualties in how to perform
288 physical counterpressure manoeuvres
289
290 Control of bleeding
291
292 Direct pressure, haemostatic dressings, pressure points and cryotherapy for life-
293 threatening bleeding
294 • Apply direct manual pressure for the initial control of severe, life-threatening external
295 bleeding from wounds that are not amenable to a tourniquet (i.e., trunk, scalp, neck,
296 groin, axilla or small limbs of infants or toddlers) or when a tourniquet is not
297 immediately available.
298 • Consider the use of a haemostatic dressing when applying direct manual pressure
299 for severe, life-threatening bleeding. Apply the haemostatic dressing directly to the
300 bleeding injury and then apply direct manual pressure to the dressing.
301 • A pressure dressing may be useful once bleeding is controlled to maintain
302 hemostasis, but should not be used in lieu of direct manual pressure for uncontrolled
303 bleeding.
304 • Use of pressure points or cold therapy is not recommended for the control of life-
305 threatening bleeding.
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307 Tourniquets for life-threatening bleeding from a limb
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308 • For life-threatening bleeding from wounds on limbs in a location amenable to use of a
309 tourniquet (i.e., arm or leg wounds, traumatic amputations).
310 o Consider the application of a manufactured tourniquet as soon as possible
311 § Place the tourniquet around the traumatised limb.
312 § Tighten the tourniquet until the bleeding slows and stops. This may
313 be extremely painful for the casualty.
314 § Maintain the tourniquet pressure.
315 § Note the time the tourniquet was applied.
316 § Do not release the tourniquet – the tourniquet must only be released
317 by a healthcare professional.
318 § Take the casualty to hospital immediately for further medical care.
319 § In some cases it may require the application of two tourniquets to slow
320 or stop the bleeding.
321 o If a manufactured tourniquet is not immediately available, or if bleeding is
322 uncontrolled with use of manufactured tourniquet, apply direct manual
323 pressure, with a haemostatic dressing if available.
324 o Consider use of an improvised tourniquet only if a manufactured tourniquet is
325 not available, direct manual pressure with or without a haemostatic dressing
326 fails to control life-threatening bleeding, AND the first aid provider is trained in
327 use of improvised tourniquets.
328
329 Management of Open Chest Wound
330
331 • Leave an open chest wound exposed to freely communicate with the external
332 environment.
333 • Do not apply a dressing or cover the wound dressing.
334 • If necessary
335 o Control localised bleeding with direct pressure.
336 o Apply a specialised non-occlusive or vented dressing ensuring a free
337 outflow of gas during expiration (training required).
338
339 Cervical Spine Motion Restriction and Stabilisation
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341 • The routine application of a cervical collar by a first aid provider is not recommended.
342 • In a suspected cervical spine injury:
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343 o If the casualty is awake and alert, encourage them to hold their neck in a
344 stable position.
345 o If the casualty is unconscious or uncooperative consider immobilising the
346 neck using manual stabilisation techniques.
347 § Head Squeeze
348 • With the casualty lying supine hold the casualty’s head
349 between your hands.
350 • Position your hands so that the thumbs are above the
351 casualty’s ears and the other fingers are below the ear
352 • Do not cover the ears so that the casualty can hear.
353 § Trapezium Squeeze
354 • With the casualty lying supine hold the casualty’s trapezius
355 muscles on either side of the head with your hands (thumbs
356 anterior to the trapezius muscle). In simple terms – hold the
357 casualty’s shoulders with the hands thumbs up.
358 • Firmly squeezes the head between the forearms with the
359 forearms placed approximately at the level of the ears.
360
361 [h2] Recognition of concussion
362 • Although a simple single-stage concussion scoring system would greatly
363 assist first aid providers’ recognition and referral of victims of suspected head
364 injury there is currently no such validated system in current practice.
365 • An individual with a suspected concussion must be evaluated by a healthcare
366 professional.
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372 Thermal Burns
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375 Following a thermal burn injury:
376 • Immediately commence cooling the burn in cool or cold (not freezing) water.
377 • Continue cooling the burn for at least 20 minutes.
378 • Cover the wound with a loose sterile dressing or use cling wrap. Do not
379 circumferentially wrap the wound.
380 • Seek immediate medical care.
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381 Care must be taken when cooling large thermal burns or burns in infants and small children
382 so as not to induce hypothermia.
383
384 First aid in case of avulsed teeth
385 • If the casualty is bleeding from the avulsed tooth socket
386 o Put on disposable gloves prior to assisting the victim.
387 o Rinse out the casualty’s mouth with cold, clean water.
388 o Control bleeding by:
389 § Pressing a damp compress against the open tooth socket.
390 § Tell the casualty to bite on the damp compress.
391 § Do not do this if there is a high chance that the injured person will
392 swallow the compress (for example, a small child, an agitated person
393 or a person with impaired consciousness).
394 • If it is not possible to immediately replant the avulsed tooth at the place of accident,
395 o Seek help from a specialist
396 § Take the casualty and the avulsed tooth seek expert help.
397 o Only touch an avulsed tooth at the crown. Do not touch the root.
398 o Rinse a visibly contaminated avulsed tooth for a maximum of 10 seconds under
399 running tap water prior to transportation.
400 o To transport the tooth:
401 § Wrap the tooth in cling film or store the tooth temporarily in a small
402 container with Hank’s Balanced Salt solution (HBSS), propolis or Oral
403 Rehydration Salt (ORS) solution.
404 § If none of the above are available, store the tooth in cow’s milk (any
405 form or fat percentage).
406 § Avoid the use of tap water, buttermilk or saline (sodium chloride).
407
408 Compression wrap for closed extremity joint injuries
409 • If the casualty is experiencing pain in the joint and finds it difficult to move the affected
410 joint, ask him/her not to move the limb. It is possible there is swelling or bruising on
411 the injured joint.
412 • There is no evidence to support or not support the application of a compression wrap
413 to any joint injury.
414 • Training will be required to correctly and effectively apply a compression wrap to a joint
415 injury.
416
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417 Eye injury from chemical exposure
418 For an eye injury due to exposure to a chemical substance:
419 • Immediately irrigate the contaminated eye using continuous, large volumes of clean
420 water or normal saline for 10 to 20 minutes.
421 • Take care not to contaminate the unaffected eye.
422 • Refer the casualty for emergency health care professional review.
423 • It is advisable to wear gloves when treating eye injuries with unknown chemical
424 substances and to carefully discard them when treatment has been completed.
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428 Evidence informing the guidelines
429 Recovery Position
430 The 2015 ILCOR CoSTR suggested that first aid providers position individuals who are
431 unresponsive and breathing normally into a lateral, side-lying recovery (lateral recumbent)
432 position as opposed to leaving them supine (weak recommendation, very-low-quality
433 evidence). There is little evidence to suggest the optimal recovery position. (Zideman 2015,
434 e225; Singletary 2015, S269). Since this review there have been a series of publications
435 evidencing delays in commencing resuscitation when the casualty is turned into the recovery
436 position (Freire-Tellado 2016 e1; Freire-Tellado 2017 173; Navarro-Paton 2019 104). In
437 2016 ILCOR revised its review population to ‘Adults and children with decreased level of
438 consciousness, due to medical illness or nonphysical trauma, that do not meet criteria for the
439 initiation of rescue breathing or chest compressions (CPR)’ and undertook a scoping review.
440 The result of this scoping review for this modified question was no change from the 2015
441 treatment recommendation or guideline.
442 The subsequent 2020 scoping review (ILCOR First Aid CoSTR) with this modified population
443 identified over 4000 citations from which 34 were selected for review. All studies were
444 considered to be of low or very low certainty of evidence with most being undertaken on
445 conscious healthy volunteers and focussing on comfort and non-occlusion of the dependent
446 arm vascular supply. Seven studies did report on patients with a decreased level of
447 consciousness due to medical aetiology or intervention (Julliand 2016 531; Arai 2004 1638;
448 Arai 2005 949, Litman 2005 484; Svatikova 2011 262; Turkington 2002 2037). The
449 remainder were studies of healthy volunteers with normal level of consciousness, patients
450 with obstructive sleep apnea or sleep disordered breathing or cadavers with surgically
451 induced cervical spine injuries.
David Zideman-GDP first edit Page 13 19/10/2020DRAFT 452 There were reported beneficial outcomes, such as maintenance of a clear airway, supporting 453 the lateral recumbent position for medical conditions resulting in a decreased level of 454 consciousness. However, the semi-recumbent position was favoured over the lateral 455 position in opioid overdosage (Adnet 1999, 745) 456 The First Aid Task Force discussions reflected the lack of direct evidence in favour of any 457 one particular recovery position and recommended that the 2015 treatment recommendation 458 be upheld but with the addition of the question modification of ‘in adults and children with 459 decreased level of consciousness, due to medical illness or nonphysical trauma, that do not 460 meet criteria for the initiation of rescue breathing or chest compressions (CPR)’. 461 Optimal position for shock victim 462 Shock is a condition in which there is failure of the peripheral circulation. It may be caused 463 by sudden loss of body fluids (such as in bleeding), serious injury, myocardial infarction 464 (heart attack), pulmonary embolism, and other similar conditions. 465 This subject was reviewed in the 2015 ILCOR CoSTR (Zideman 2015, e225; Singletary 466 2015, S269) and in the 2015 ERC guidelines (Zideman 2015, 278). It was not formally 467 reviewed in 2020 but was subject to an evidence update. 468 While the primary treatment is usually directed at the cause of shock, support of the 469 circulation is important. Although the evidence is of low certainty, there is potential clinical 470 benefit of improved vital signs and cardiac function by placing individuals with shock into the 471 supine (lying-on-back) position, rather than by moving them into an alternative position. 472 The use of passive leg raising (PLR) may provide a transient (
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486 This CoSTR was not re-examined by ILCOR in 2020. In the 2015 CoSTR it was
487 recommended that when an individual with asthma is experiencing difficulty in breathing, we
488 suggest that trained first aid providers assist the individual with administration of a
489 bronchodilator (weak recommendation, very-low-quality evidence). (Singletary 2015 S269;
490 Zideman 2015 e225). This recommendation was made on the evidence provided by 8
491 double-blind randomised controlled trials (RCTs) (Bentur 1992, 133; van der Woude 2004,
492 816; Littner 1983, 309; Karpel 1997, 348; Berger 2006, 1217; Politiek 1999, 988; Hermansen
493 2006, 1203; Amirav 2007, 1), 2 observational studies (Emerman 1990, 512; Weiss 1994,
494 813) and 1 meta-analysis (Osmond 1995, 651). None of these studies examined the
495 administration of bronchodilators by first aid providers. Two RCTs demonstrated a faster
496 return to baseline levels following the administration of fast acting beta-2 agonist (Bentur
497 1992, 133; van der Woude 2004) with only three studies reporting complications (Bentur
498 1992, 133; Littner 1983, 309; Karpel 1997, 348). The remaining studies reported an
499 improvement in the specific therapeutic endpoints of Forced Expiratory Volume in 1 second
500 (FEV1) (Littner 1983, 309; Karpel 1997, 348; Berger 2006, 1217; Politiek 1999, 988;
501 Hermansen 2006, 1203; Amirav 2007, 1) and Peak Expiratory Flow Rate (PEFR) (Emerman
502 1990, 512; Weiss 1994, 813).
503
504 The 2015 first aid guideline remains unchanged.
505
506 Recognition of stroke
507 Stroke is one of the leading causes of death and disability worldwide (Mortality 2016, 1459).
508 Over the last 20 years, new treatments such as rapid thrombolytic delivery or endovascular
509 reperfusion techniques for ischemic stroke and medical or surgical treatment for
510 hemorrhagic stroke have been shown to significantly improve outcomes (Bracard 2016,
511 1138; Emberson 2014,1929; Saver 2016, 1279) Earlier detection of stroke in prehospital
512 setting will reduce time to treatment delays and prenotification of the hospital is key to
513 improve successful treatment (Lin 2012, 514; Medoro 2017, 476; Schlemm 2017,2184)
514 In recent years, stroke recognition campaigns for laypeople and first aid providers or
515 paramedics in training are based on use of stroke scales to facilitate stroke recognition.
516 Several stroke scales have been proposed. They present some specificity as a low number
517 of criteria, identifying easily the clinical signs and simple to implement. The aim of their use
518 is to screen patients suspected of stroke with the best scale sensitivity. An ideal stroke
519 assessment system for first aid use must be easily understood, learned and remembered,
520 must have high sensitivity and must take a minimal time to be completed.
521 The systematic review of the 2015 ILCOR First Aid task Force (Singletary 2015, S269;
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522 Zideman 2015, e225) was rerun in late 2019. Four included studies published following the
523 2015 First Aid CoSTR showed that achieving a rapid stroke recognition score during the first
524 aid assessment decrease the key outcome time from onset to treatment (Chenkin 2009,
525 153; Iguchi 2011, 51; O’Brien 2012, 241; Wojner-Alexandrov 2005, 1512). Use of the
526 stroke recognition scale in prehospital setting increased the number of patients with
527 confirmed stroke diagnosis promptly admitted to hospital and the rate of administering
528 urgent treatment (Chenkin 2009, 153; O’Brien 2012, 241; Wojner-Alexandrov 2005, 1512;
529 Harbison 2003, 71). First aid providers should use stroke scale assessment protocols that
530 provide the highest sensitivity and the lowest number of false negatives. FAST, CPSS,
531 LAPSS and MASS are commonly used in prehospital setting. (strong recommendation, very
532 low quality of evidence).
533 In many of the prehospital setting studies, the stroke assessments were performed by
534 paramedics or nurses (ILCOR First Aid CoSTR; Zhelev 2019, 11427) so this guideline has
535 been based on extrapolation of potential benefit when these tools are used by lay people or
536 first aid providers. The lack of data demonstrating benefit of these tools when used by first
537 aid providers is a substantial weakness of the evidence base.
538 The specificity of stroke recognition can be improved by using a stroke assessment tool that
539 includes blood glucose measurement such as the LAPSS Zhelev 2019, 11427; Asimos
540 2014, 519; Bergs 2010, 2; Bray 2005, 28; Chen 2013, e70742; Kidwell 2000,71) or MASS
541 (Bergs 2010, 2; Bray 2005, 28; Bray 2010, 1363). (weak recommendation, low certainty
542 evidence). However, it is recognised that not all first aid providers have access to or the
543 skills or the authority to use a calibrated glucose measurement device. For first aid
544 providers, assessment stroke recognition scale including blood glucose measurement will
545 require additional training and the acquisition of measurement devices that can be costly.
546
547 Aspirin for chest pain
548
549 The pathogenesis of acute coronary syndromes (ACS) including acute myocardial infarction
550 (AMI) is most frequently a ruptured plaque in a coronary artery. As the plaque contents leak
551 into the artery, platelets clump around them and coronary thrombosis occurs completely or
552 partially occluding the lumen of the artery, leading to myocardial ischemia and possible
553 infarction. Symptoms of an AMI is chest pain often described as a pressure with/without
554 radiation of pain to the neck, lower jaw, or left arm, however some patients present with less
555 typical symptoms such as dyspnoea, nausea/vomiting, fatigue or palpitations.
556
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557 The 2015 CoSTR recommended the administration aspirin to adults with chest pain due to
558 suspected myocardial infarction (strong recommendation, high quality evidence) (Singletary
559 2015 S269; Zideman 2015 e225). This recommendation was based on the evidence from
560 four studies ( Elwood 1979, 413. Frilling 2001,200, ISIS-2 1988, 349. Verheugt 1990,267) .
561 A second 2015 CoSTR recommended the aspirin administration early rather than late. This
562 was a weak recommendation from very low certainty evidence as no evidence was found to
563 support this recommendation ((Singletary 2015 S269; Zideman 2015 e225).
564
565 In 2020 the First Aid Task Force re-evaluated the question of early versus late administration
566 of aspirin for non-traumatic chest pain. Two further observational studies were identified
567 (Freimark 2002 381; Barbash 2002 141) comparing the early and late administration of
568 aspirin in the pre-hospital environment. Both studies reported an improvement in survival at
569 7 days and at 30 days, although the dose of aspirin did vary between studies. One study
570 reported an improved survival at one year associated with the early administration of aspirin
571 (Freimark 2002 381). Both studies did not report any increase in complications from early
572 administration. Interestingly, one study (Barbash 2002 141) reported a lower incidence in
573 the occurrence of asystole and the need for resuscitation with early administration whereas
574 the second study (Freimark 2002 381) reported a higher incidence of ventricular fibrillation
575 and ventricular tachycardia associated with early administration.
576
577 The use of aspirin as an antithrombotic agent to potentially reduce mortality and morbidity in
578 ACS/AMI is considered beneficial even when compared with the low risk of complications,
579 particularly anaphylaxis and serious bleeding. (Quan 2004, 362, ISIS-2 1988,249,
580 Simonsson 2019, Verheugt 1999,267).
581
582 Anaphylaxis
583
584 In the 2015 ILCOR CoSTR the Task Force suggested that a second dose of epinephrine be
585 administered by autoinjector to individuals with severe anaphylaxis whose symptoms are not
586 relieved by an initial dose (weak recommendation, very-low-quality evidence) (Singletary
587 2015 S269; Zideman 2015 e225). Nine observational studies provided very low quality
588 evidence to support this recommendation (Inoue 2013,106; Jarvinen 2008,133; Noimark
589 2012, 284; Korenblat 1999,383; Oren 2007, 429; Banerji 2010,308; Rudders 2010, e711;
590 Tsuang 2013 AB; Rudders 2010, 85) and a further study. This CoSTR was not re-examined
591 in 2020.
592
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593 However, a question arose in the knowledge gaps of the 2015 CoSTR as to the ability of
594 first aid providers to be able to recognize the symptoms of anaphylaxis. In 2019 the Task
595 Force undertook a scoping review to examine this question. 1081 records were identified
596 but only two studies were relevant (Brockow 2015 227; Litarowsky 2004 279). Both studies
597 reported an improvement in the knowledge, recognition and management of anaphylaxis
598 with education and training, but neither were tested in clinical scenarios.
599
600 First aid in case of hypoglycaemia
601 Hypoglycaemia commonly occurs in individuals with diabetes but can also occur in other
602 individuals due to an imbalance in blood sugar regulation. Someone experiencing
603 hypoglycaemia will exhibit sudden impaired consciousness: ranging from dizziness, fainting,
604 sometimes nervousness and deviant behaviour (mood swings, aggression, confusion, loss
605 of concentration, signs that look like drunkenness) to loss of consciousness (Ostenson 2014
606 92; Sako 2017 e7271). First aid for this condition consists of providing glucose tablets or
607 other dietary forms of sugar such as juice, candies or dried fruit strips, to quickly increase
608 the blood sugar level. These sugars can be self-administered but are also often provided by
609 family or friends (Ostenson 2014 92; Rostykus 2016 524). Glucose or sugar can be given
610 orally, followed by swallowing the substance. However, other forms of administration are
611 also possible, where the substance is not swallowed and does not pass the gastrointestinal
612 tract, leading to faster absorption than the oral route. These other administration forms
613 include ‘buccal administration’, placing the glucose inside the cheek against the buccal
614 mucosa or ‘sublingual administration’, taking it under the tongue.This 2020 guideline is
615 based on two systematic reviews conducted by the ILCOR First Aid Task Force.
616
617 The first systematic review investigated the effect of oral glucose (i.e. tablets) or other
618 dietary sugars (search date June 2016). The review identified 3 randomised controlled trials
619 and one observational study comparing dietary sugars, including sucrose, fructose, orange
620 juice, jelly beans, Mentos, cornstarch hydrolysate, Skittles and milk to glucose tablets
621 (Carlson 2017 100). It was shown in a meta-analysis that dietary sugars resulted in a lower
622 resolution of symptoms 15 minutes following treatment than glucose tablets. The evidence
623 has a low to very low certainty and led to a strong recommendation concerning the use of
624 glucose tablets, and a weak recommendation concerning the use of other dietary sugars
625 when glucose tablets are not available (Singletary 2015 S269; Zideman 2015 e225). This
626 systematic review has been updated within the purpose of this guideline (search date June
627 2019), but no new evidence could be identified.
628
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629 The second systematic review aimed to assess the effects of different enteral routes for
630 glucose administration as first aid treatment for hypoglycaemia (search date January 2018)
631 (De Buck 2018 1). The review identified two randomised controlled trials, including
632 individuals with hypoglycaemia, and two non-randomised controlled trials, including healthy
633 volunteers. It was shown that sublingual glucose administration, by giving table sugar under
634 the tongue to children with hypoglycaemia and symptoms of concomitant malaria or
635 respiratory tract infection, had better results in terms of glucose concentration after 20
636 minutes, than oral glucose administration. When comparing buccal administration to oral
637 administration, the buccal route was shown to be worse, with a lower plasma glucose
638 concentration after 20 minutes. When glucose was administered in the form of a dextrose
639 gel (resulting in a combined oral and buccal mucosal route), no benefit could be shown
640 compared to oral glucose administration. The certainty of the evidence is moderate to very
641 low certainty and led to a strong recommendation concerning the use of oral glucose
642 (swallowed) and a weak recommendation in favour of using a combined oral + buccal
643 glucose (e.g. glucose gel) administration if oral glucose (e.g. tablet) is not immediately
644 available, both in case of individuals with suspected hypoglycemia who are conscious and
645 able to swallow. In addition, a weak recommendation against buccal glucose administration
646 compared with oral glucose administration and a weak recommendation concerning the use
647 of sublingual glucose administration for suspected hypoglycaemia for children who may be
648 uncooperative with the oral (swallowed) glucose administration route is formulated (draft
649 CoSTR: https://costr.ilcor.org/document/methods-of-glucose-administration-in-first-aid-for-
650 hypoglycemia).
651
652 Oral rehydration solutions for treating exertion-related dehydration
653
654 Human body water accounts for 50-70% of the total body mass but, despite this abundance,
655 it is regulated within narrow ranges. During prolonged exercise, sweat losses generally
656 exceed fluid intake and even low levels of dehydration (about 2% of the body mass) already
657 impair thermoregulation (Kenefick 2007 378) and cardiovascular strain (Crandall 2010 407,
658 Adams 2014 344). When these dysfunctions are allowed to progress, they can lead to
659 impaired physical and cognitive performance (Masento 2014 1841; Savoie 2015 1207),
660 syncope due to hypotension and, finally, heat illness that can be fatal (Carter 2006 1744,
661 Carter 2008 S20). In such situations, it is of utmost importance to promote post-exercise
662 drinking to restore fluid balance. For rapid and complete rehydration, the drink volume and
663 composition are key (Osterberg 2010 245; James 2015 2621). Although the American
664 College of Sports Medicine Guidelines on Nutrition and Athletic Performance recommend
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665 drinking 1.25–1.5 L fluid per kg body mass lost (Thomas 2016 543), there is no clear
666 endorsement regarding the specific type of rehydrating fluid.
667
668 This topic was previously reviewed in 2015 (Singletary 2015 S269; Zideman 2015 e225)
669 and is now updated by the ILCOR First Aid Task Force. An additional 15 studies were
670 identified (search date July, 2019), leading to inclusion of a total of 23 randomized controlled
671 trials (RCTs) and 4 non-randomized studies, comparing different concentrations of
672 carbohydrate-electrolyte solutions (CES), beer of different alcohol percentages, milk,
673 coconut water or high alkaline water, yoghurt drink or tea with regular water. The best
674 available evidence was of low to very-low certainty due to limitations in study design,
675 imprecise results and strongly suspected conflict of interest.
676
677 Evidence for carbohydrate-electrolyte solutions (CES) compared with water
678 8-12% CES compared with water
679 Very-low-certainty evidence from 2 RCTs (Volterman 2014 1275; Niksefat 2019 43) could
680 not demonstrate benefit from 8-12% CES for cumulative urine output when compared with
681 water. Furthermore, very-low-certainty evidence from 2 RCTs (Volterman 2014 1275;
682 Osterberg 2010 245) showed benefit from 8-12% CES for fluid retention after 1 and 2 h and
683 on dehydration after 1 and 2 h when compared with water. Low-certainty evidence from 1
684 RCT could not show benefit for the development of hyponatremia (Niksefat 2019 43).
685
686 3-8% CES compared with water
687 Very-low-certainty evidence from 3 RCTs (Chang 2010 3220; Ismail 2007 769; Perez-
688 Idarraga 2014 1167) and 3 non-RCTs (Gonzalez-Alonso 1992 399; Seifert 2006 420; Wong
689 2011 300) showed benefit from 3-8% CES for cumulative urine output when compared with
690 water. In addition, benefit for cumulative urine output could not be demonstrated in 3 RCTs
691 (Seery 2016 1013; Shirrefs 2007 173; Wijnen 2016 45). Very-low-certainty evidence from 6
692 RCTs (Chang 2010 3220; Ismail 2007 769; Saat 2002 93; Seery 2016 1013; Perez-Idarraga
693 2014 1167; Wijnen 2016 45) and 2 non-RCTs (Seifert 2006 420; Wong 2011 300) showed
694 benefit from 3-8% CES for fluid retention when compared with water. In addition, a beneficial
695 effect for fluid retention or rehydration could not be demonstrated in 4 RCTs (Kalman 2012
696 1; Osterberg 2010 245; Shirrefs 2007 173; Wong 2000 375).
697
698 0-3% CES compared with water
699 Low-certainty evidence from 2 RCTs (Evans 2017 945; Lau 2019 e000478) showed benefit
700 from 0-3% CES for cumulative urine output, fluid retention and serum sodium concentration
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701 when compared with water. A benefit for serum potassium concentration could not be
702 demonstrated.
703
704 Evidence for milk compared with water
705 Very-low-certainty evidence from 3 RCTs (Shirrefs 2007 173; Seery 2016 1013; Volterman
706 2014 1257) showed benefit from skim milk for cumulative urine output, fluid retention and
707 dehydration when compared with water.
708 Additionally, very-low-certainty evidence from 1 RCT (Shirrefs 2007 173) showed benefit
709 from skim milk with 20 mmol/L sodium chloride for cumulative urine output and fluid
710 retention.
711
712 Evidence for regular beer compared with water
713 Very-low-certainty evidence from 1 RCT (Flores-Salamanca 2014 1175) showed harm from
714 regular beer (4.5 – 5 % alcohol) for cumulative urine output and fluid retention when
715 compared with water. Additionally, in 2 other RCTs (Jimenez-Pavon 2015 26; Wijnen 2016
716 45), benefit for cumulative urine output, fluid retention and serum sodium and serum
717 potassium concentration could not be demonstrated.
718
719 Other rehydration solutions compared with water
720 For the following rehydration solutions, insufficient evidence is available to recommend their
721 use: coconut water (Pérez-Idárraga 2014 1167, Kalman 2012 1), maple water (Matias 2019
722 5), yoghurt drink (Niksefat 2019 43), rooibos tea (Utter 2010 85), Chinese tea plus caffeine
723 (Chang 2010 3220), high alkaline water (Weidman 2016 45), deep ocean (Harris 2019 15;
724 Keen 2016 17) or commercial bottled water (Valiente 2009 2210), 3% glycerol (McKenna
725 2017 2965), low- or non-alcoholic beer (Flores-Salamanca 2014 1175; Wijnen 2016 45) or
726 whey protein isolate solution (James 2014 1217).
727
728 Management of heat stroke by cooling
729
730 Heat stroke occurs when the core body temperature exceeds 40°C. It is a medical
731 emergency and can lead to severe organ damage and death if not dealt with promptly.
732 (Bouchama 2002 1978). Non-exertional heat stroke is typically seen after prolonged
733 exposure to the sun and is often seen during heat waves (Yaqub 1986 526; Sahni 2013 89;
734 How 2000 474). However, it may be seen during hot weather in individuals with impaired
735 heat regulation such as in the elderly or children. Exertional heat stroke is associated with
736 physical exertion in a hot or warm environment.
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737 In 2020 the ILCOR First Aid Task Force published a systematic review of cooling methods
738 for heat stroke (Douma 2020 173. 3289 records were identified with 63 studies included in
739 the quantitative GRADE analysis. A detailed analysis of the science supporting various
740 cooling techniques was made and summarized by the ILCOR First Aid Task Force.(ILCOR
741 First Aid CoSTR) In the systematic review most of the evidence was from studies from
742 healthy adult volunteers with induced exertional heat stroke, although cohort studies and
743 case series from exertional heat stroke casualties were also used by the task force to inform
744 their recommendations.
745
746 A Task Force consensus opinion was that core temperature (rectal or oesophageal) should
747 be measured if possible when evaluating or managing heat stroke. For adults with
748 exertional hyperthermia or exertional heat stroke actively cool the casualty using whole body
749 (neck down) water immersion at 1-26°C until a core body temperature below 39°C has been
750 reached (weak recommendation, very low certainty evidence). If cold water immersion is not
751 available use any other cooling technique immediately available (weak recommendation,
752 very low certainty evidence) that will provide the most rapid rate of cooling (weak
753 recommendation, very low certainty evidence). No recommendation was made for classic
754 heat stroke (no recommendation, very low certainty evidence) as only scientific evidence
755 was found for exertional heat stroke. No recommendation was made for cooling children
756 with exertional or classic heat stroke (no recommendation, very low certainty evidence) as
757 all the science referred to adult subjects.
758
759 Figure 2 shows cooling techniques reviewed in the systematic review, in decreasing order of
760 effectiveness, included ice water immersion (1-5°C), temperate water immersion (20-25°C),
761 cold water immersion (14-17°C), colder water immersion (8-12°C), commercial ice packs,
762 showers (20°C), ice sheets and towels (3°C), hand and feet cold water immersion (16-17°C),
763 cooling vests and jackets, cold intravenous fluids, fanning, passive cooling, hand cooling
764 devices and evaporative cooling (Douma 2020 173).
765
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766
767
768 Use of supplemental oxygen in acute stroke
769
770 The use of supplemental oxygen in acute stroke is controversial. The ILCOR First Aid Task
771 Force undertook a systematic review and published a CoSTR (Chang 2020; ILCOR First
772 Aid CoSTR). The treatment recommendation suggested against the routine use of
773 supplementary oxygen in the first aid setting compared with no use of supplementary
774 oxygen (weak recommendation, low to moderate certainty of evidence).
775
776 Direct evidence was provided by one prehospital observational study (Dylla 2019 30742)
777 supported by 8 in-hospital randomised controlled trials (Ali 2013 e59274; Mazdeh 2015 676;
778 Padma 2010 284; Roffe 2011 e19113; Roffe 2017 1125; Ronning 1999 2013, Singhal 2005
779 797; Wu 2012 5) comparing supplementary oxygen, at different flow rates and delivery
780 methods, to no supplementary oxygen. The overall majority of these studies failed to show
781 any improvement in survival, quality of life or neurologic outcome, including NIHSS score.
782 One retrospective observational study did report that when comparing three acute stroke
783 groups (oxygen provided for hypoxia, routine provision of oxygen, no oxygen) there was no
784 increase in respiratory complications or neurologic complications at hospital discharge
785 suggesting that early supplementary oxygen may be safe.
786
787 The Task Force also considered that the provision of supplemental oxygen may not be
788 considered as routine first aid. Oxygen administration does require the provision and use of
789 equipment and an understanding of the mechanisms and risks of oxygen administration. It
790 was recognised that this may not be available or applicable to all first aid providers and that
791 further specific training would be required for providers.
792
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793 Management of Presyncope
794
795 Syncope (fainting) is a temporary loss of consciousness. In many cases it is preceded by a
796 prodromal phase, presyncope, which is characterised by light-headedness, nausea,
797 sweating, black spots in front of the eyes and an impending sense of loss of consciousness.
798 The estimated worldwide incidence is between 15 and 39%, 50% of females and 25% of
799 males having a syncopal event in their lifetime (Tomaino 2014; Serletis 2006 1965; Lipsitz
800 1985 45). Injuries from syncope related falls include fractures, intracranial haemorrhage,
801 internal organ injury and neurologic injury and account for approximately 30%of patients
802 admitted to emergency rooms (Bartoletti 2008 618). Syncope may be of vasovagal (50%) or
803 orthostatic (7%) or cardiac (7%) origin (Bennett 2015 1591) and there has been laboratory
804 evidence to suggest that physical counterpressure manoeuvres may abort syncope if
805 applied in the presyncopal phase (Wieling 1996 601; Ten Harkel 1994 553; Groothuis 2007
806 193; van Dijk 2006 1652). Physical counterpressure manœuvres include muscle contraction
807 of the large muscles of arms, legs and abdomen - leg-pumping, tensing, crossing, squatting,
808 hand-grip, and abdominal compression.
809
810 In 2020 the ILCOR First Aid Task Force published a systematic review of immediate
811 interventions for presyncope of vasovagal or orthostatic origin (Jensen 2020 64) and a CoSTR
812 statement (ILCOR First Aid CoSTR). 5160 citations were initially identified; this reduced to 81
813 studies to be examined for full text examination with only eight studies progressing to full
814 GRADE analysis (two randomized controlled studies (Alizadeh 2016 5348; Bouvette 1996
815 847) and six prospective cohort studies (Brignole 2002 2053; Croci 2004; Clarke 2010 1019;
816 Kye 2005 1084; Krediet 2002 1684, Krediet 2008 179 ). All studies investigated the effects
817 of physical counterpressure manoeuvres with six of the eight studies examining presyncope
818 of vaso-vagal origin (Alizadeh 2016 5348; Brignole 2002 2053; Croci 2004;; Kye 2005 1084;
819 Krediet 2002 1684, Krediet 2008 179) whilst the other studies examined presyncope of
820 orthostatic origin (Bouvette 1996; Clarke 2010 1019). All eight studies showed mostly
821 beneficial results for key outcomes for both the combined vasovagal and orthostatic
822 presyncope group, as well as for those with presyncope of vasovagal origin alone. Pooled
823 observational studies of various types of PCM did not show a benefit for aborting syncope, but
824 several studies comparing use of one method of PCM compared with an alternate method or
825 compared to control showed benefit for aborting syncope. Low certainty evidence suggesting
826 a modest benefit with use of PCM for aborting syncope, and low certainty evidence showing
827 a strong association with symptom reduction. (Alizadeh 2016 5348; Bouvette 1996 847;
828 Brignole 2002 2053; Croci 2004; Clarke 2010 1019; Kye 2005 1084; Krediet 2002 1684,
829 Krediet 2008 179). No adverse events were reported by studies, suggesting that the use of
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830 PCM may be a safe and effective first aid intervention in the specific population of individuals
831 with suspected or recurrent vasovagal or orthostatic presyncope origin (Brignole 2002 2053;
832 Croci 2004).
833 Two further studies that did not fully comply with the search criteria for the systematic review
834 and were not included in the review have also supported the use of physical counterpressure
835 manouevres (Tomaino 2014; van Dijk 2006 1652).
836 The ILCOR First Aid Task Force recommended the use of any type of physical counter-
837 pressure manoevre by individuals with acute symptoms of presyncope due to vasovagal or
838 othostatic origin (strong recommendation, low and very low-certainty evidence). Lower body
839 physical counter-pressure manoevres (squatting, sqautting with leg crossing, marching
840 action) were recommended in preference to upper body manoevres (hand gripping, neck
841 flexion, core tensioning) (weak recommendation, very low certainty evidence) (Jensen
842 2019). The Task Force were aware that many of these studies were laboratory studies in
843 individuals with pre-existing vaso-vagal or orthostatic syncope. They were also aware that
844 to promulgate this recommendation first aid providers would need to be trained in coaching
845 techniques so that the provider could instruct the sufferer in how to perform the physical
846 counter-pressure manoevre.
847
848 Control of Bleeding
849
850 Trauma is the leading cause of injury-related morbidity and mortality across the globe.
851 Uncontrolled bleeding is the primary cause of death in up to 35% of victims of trauma
852 {Jacobs 2014 67; Kauvar 2006 S3}. Exsanguination can occur in as little as 5 minutes,
853 making the immediate control of life-threatening bleeding a critical skill for first aid. Life-
854 threatening bleeding can be recognized by rapidly flowing or spurting blood from a wound,
855 pooling of blood on the ground, or bleeding that cannot be controlled by direct manual
856 pressure alone. Although direct manual pressure has been the gold standard for the initial
857 control of bleeding, alternative techniques such as use of tourniquets and haemostatic
858 dressings are being applied more commonly for life-threatening bleeding in the prehospital
859 military and civilian settings.
860
861 A recent systematic review by the International Liaison Committee on Resuscitation (ILCOR)
862 evaluated multiple methods for the control of life-threatening external bleeding.{Singletary
863 2020 in press} Evidence included for this review was identified from the prehospital civilian
864 setting, supplemented by studies from the military prehospital setting, the in-hospital setting,
865 and some simulation studies. Although evidence was identified to support recommendations
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866 for the use of direct pressure, tourniquets, and hemostatic dressings, the sequence of
867 application has yet to be studied. In addition, no comparative evidence was identified for use
868 of pressure points, ice (cryotherapy) or elevation for control of life-threatening bleeding.
869 There was inadequate evidence to support the use of junctional tourniquets or wound
870 clamping devices by lay providers.
871
872
873 Direct pressure, pressure dressings, hemostatic dressings, pressure points and
874 cryotherapy for life-threatening bleeding
875
876 Despite being considered the traditional ‘gold standard’ for bleeding control, the evidence
877 supporting the use of direct manual pressure is limited and indirect, with 3 in-hospital
878 randomized controlled trials of endovascular procedures in 918 patients showing a longer
879 time to hemostasis with use of mechanical pressure devices compared with direct manual
880 pressure. {Chlan 2005 391; Lehmann 1999 1118; Walker 2001 366}
881
882 The use of pressure dressings for maintaining hemostasis following control of life-
883 threatening bleeding is also supported by limited, low certainty evidence. A cohort study of
884 64 patients with arteriovenious fistula puncture reported bleeding cessation in 45.5% with
885 use of direct manual pressure compared with 82% with use of a commercial elastic
886 compression bandage, while a case series of 62 victims of penetrating wounds in the
887 prehospital civilian setting reported control of bleeding with use of a commercial pressure
888 dressing in 87% and reduced bleeding in the remaining 11%. {Boulanger 2014 102; Naimer
889 2006 644}
890
891 Hemostatic dressings vary in design or mechanism of action, but typically are specially
892 treated gauze sponges containing an agent that promotes blood clotting. These dressings
893 are applied to or packed inside a wound and work when combined with direct manual
894 pressure. First aid providers have demonstrated the ability to use hemostatic dressings in
895 addition to direct manual pressure for the treatment of life-threatening bleeding {Kotwal 2011
896 1350} Although primarily indirect, evidence supports the use of hemostatic dressings, with
897 direct manual pressure, for control of life-threatening bleeding.
898 One low-certainty randomized controlled trial of 160 patients with stab wounds to the limbs
899 demonstrated cessation of bleeding in less than 5 minutes in 51.2% of those who had a
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