First Aid: Principles and Practice (Updated According to AHA Guidelines 2010)

This is the set of slide that I used during my recent lecture The Principles and Practice of First Aid for First Year Medical/Dental Students in early January 2011.

First aid 2011

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First Aid Recommendations Updates

The American Heart Association (AHA) together with the American Red Cross have published a series of updates in conjunction with the 2010 AHA and Emergency Cardiac Care (ECC) Guidelines on Basic Life Support and Advanced Life Support.

Download the pdf file of this 2010 AHA first aid updates here.

NB: Please note that all the recommendations by AHA and American Red Cross stated below are for first aid setting and not in-hospital setting.

Updates on first aid

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Positioning of Victim
As a general rule a victim should not be moved, especially if you suspect, from the victim's position or the nature of the injury, that the victim may have a spinal injury.

The indications to move the victim include

• If the area is unsafe for the rescuer or the victim,
• If the victim is face down and is unresponsive
• If the victim has difficulty breathing because of copious secretions or vomiting

Place the victim in a modified High Arm IN Endangered Spine (HAINES) recovery position:- Extend one of the victim's arms above the head and roll the body to the side so the victim's head rests on the extended arm. Bend both legs to stabilize the victim

• If the victim shows evidence of shock (e.g. pale, appears apprehensive, sweating profusely, confused. dizzy, etc)

If there is no evidence of trauma or injury, raise the feet about 6 to 12 inches (about 30° to 45°). Do not raise the feet if the movement or the position causes the victim any pain.

The evidence for a benefit to raising the feet is extrapolated from leg raising studies on volume expansion; there are no studies on the effect of leg raising as a first aid maneuver for shock.

Reference:
Teboul JL, Monnet X. Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care. 2008;14:334–339

Medical Emergencies

Chest Discomfort

1. All first aid providers should assume all chest discomfort is cardiac origin until proven otherwise. This is because it is very difficult to differentiate chest discomfort of cardiac origin vs non-cardiac origin.

The most important intervention is to CALL FOR THE EMS or AMBULANCE.

It is recommended to call for EMS to come rather than to drive themselves. This is because professional pre-hospital medical help could be rendered in the ambulance. including the vital utility of defibrillator and cardiopulmonary resuscitation when called for.

2. While waiting for the arrival of EMS to arrive, the first aid provider may encourage victim to chew one tablet of aspirin (crushed aspirin), provided the patient has no allergy to aspirin or contraindication such as bleeding tendencies, recent bleeding, or a stroke.
ISIS-2 study clearly established the beneficial effects of aspirin within the first 24 hours to reduce mortality in patients with acute MI.

Reference:
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction. Lancet. 1988;2:349–360

Zijlstra F, Ernst N, De Boer M-J, Nibbering E, Suryapranata H, Hoorntje JCA, Dambrink J-HE, Van't Hof AWJ, Verheugt FWA. Influence of prehospital administration of aspirin and heparin on initial patency of the infarct-related artery in patients with acute ST elevation myocardial infarction. J Am Coll Cardiol. 2002;39:1733–1737. Click here for pdf download.

It has also been shown that early pre-hospital administration of aspirin reduces mortality in acute MI.

Reference:
Barbash IM, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, Crystal E, Matetzky S, Boyko V, Mandelzweig L, Behar S, Leor J. Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration. Cardiology. 2002;98:141–147.

Knowledge Gap and Research Questions
Does administration of aspirin by first aid providers delay EMS involvement?
Can first aid providers recognize contraindications to aspirin?
What are the clinical results with treatment versus nontreatment with aspirin by first aid providers of patients with subsequently proven coronary events?

Poisoning Emergencies
1. Do not administer anything by mouth for any poison ingestion unless advised to do so by the Poison Center
(Note: In Malaysia, the National Poison Center is located in Universiti Sains Malaysia Penang. You can call in for help at +604-657 2924 from Monday-Friday: 8.10am-5.10pm.)

There is insufficient evidence that dilution of the ingested poison with water or milk is of any benefit as a first aid measure. In fact, possible adverse effect by administering water or milk is vomiting and aspiration.

Knowledge gap and Research Questions: There are no human studies on the effect of treating oral caustic exposure with dilution therapy.
Does early administration of milk or water vs nil by mouth improve outcome in patients with poisoning with caustic substance?

Personal comment:
My personal opinion is that while the guideline says there is insufficient evidence to suggest for or against dilution therapy, it is just too broad to make a recommendation to administer water or any other fluid for that matter to "dilute" the poison.

This is because even though water is inert, and in most cases, would be safe to be mixed with other substances; there are certain chemicals which are exothermic when mix with water. Examples include sodium hydroxide (or caustic soda) and sulfuric acid that can release considerable amount of heat to the point when mix with water although it is often said that household caustic soda as in cleaning solutions, metal polishes, etc are often less concentrated compared to commercial ones. Many literature also suggest that sips of water (not large quantity) may be helpful.

Therefore, my practice would be - sips of water to ease the discomforting taste, yes (the distaste can by itself induce vomiting!); large amount of water to "dilute" poison - no.

2. Do not administer activated charcoal to a victim who has ingested a poisonous substance unless you are advised to. There is insufficient evidence to recommend for or against the administration of activated charcoal in first aid setting although 2 small studies suggest that it may be safe to administer.

References:
Spiller HA, Rodgers GC, Jr. Evaluation of administration of activated charcoal in the home. Pediatrics. 2001;108:E100.

Lamminpaa A, Vilska J, Hoppu K. Medical charcoal for a child's poisoning at home: Availability and success of administration in Finland. Hum Exp Toxicol. 1993;12:29–32

Nevertheless, another study showed that majority of children will not take the recommended dose of activated charcoal.

Reference:
Scharman EJ, Cloonan HA, Durback-Morris LF. Home administration of charcoal: Can mothers administer a therapeutic dose? J Emerg Med. 2001;21:357–361

In fact, extrapolated from other case reports and studies, activated charcoal is not without harm. It can cause harmful effects such as obstructive laryngitis, pulmonary aspiration, etc.

Knowledge gap and Research Question: As there is insufficient evidence to recommend for or against charcoal administration, the research question to answer is:

Does prehospital administration of charcoal by first aid responder improve outcome? On the other hand, does the administration of activated charcoal actually cause harm?

Bleeding Control Control of bleeding is a basic skill of first aid and one of the few actions with which a first aid provider can critically influence outcome.

1. Bleeding is best controlled by applying pressure until bleeding stops The amount of pressure applied and the time the pressure is held are the most important factors affecting successful control of bleeding. Control by applying manual pressure on gauze or other cloth placed over the bleeding source. If bleeding continues, do not remove the gauze; add more gauze on top and apply more pressure.

Unfortunately, there is actually no studies done evaluating the effectiveness of direct pressure as a first aid for bleeding. All our knowledge about direct pressure hemostasis is extrapolated from cardiac catheterization experience and the battlefield

Knowledge Gap and Research Questions:
Because of the lack of studies on the direct pressure as bleeding control in an actual first aid setting, such studies of bleeding control in civilian settings by first aid providers are needed.
Do first aid providers apply sufficient pressure?
Do first aid providers apply pressure for a sufficient amount of time to control bleeding?
How often does properly applied pressure fail to control bleeding, and which alternative method works?

2. The aim of a tourniquet to control bleeding of the extremities is not for first line use; it is indicated only if direct pressure is not effective or possible

Potential dangers of prolonged tourniquet application include temporary or permanent injury to the underlying nerves and muscles, and systemic complications resulting from limb ischemia, including acidemia, hyperkalemia, arrhythmias, shock, and death.

3. Pressure Points and Elevation
Elevation and use of pressure points are no longer recommended to control bleeding.

This new recommendation is made because

1. the hemostatic effect of elevation has not been studied. In other words, there is no evidence for or against elevation of extremity.
2. no effect on distal pulses was found in volunteers when pressure points were used.
3. most important, these unproven procedures may compromise the proven intervention of direct pressure, and so, indirectly, they could be harmful.

Electric Injuries
In managing electric injuries, do not put yourself in danger! Remember in high voltage electrocution, all materials, including wooden materials, can conduct electricity if the voltage is high enough.

Wounds and Abrasions
Superficial wounds and abrasions should be thoroughly washed.
Irrigate with a large volume of warm or room temperature tap water from a reliable source (with or without soap).

Higher irrigation pressures are more effective than lower pressures, that higher volumes are better than lower volumes (within a range of 100 to 1000 mL), and that tap water is as good as (or better than) any other irrigation solution in reducing infection rates.

The wounds actually heal better with less infection if they are covered with an antibiotic ointment or cream and a clean occlusive dressing but in first aid setting, this applies for abrasion or a superficial injury only. Ask to ensure that the victim has no known allergies to the antibiotic - if ever there is a slightest doubt, do not need to apply antibiotics.

Knowledge Gaps
What are the effectiveness and best method of wound irrigation in the home? Is there a benefit to using soap in addition to water in cleaning superficial wounds?

Snake bite
For snake bite, one can also consider applying pressure immobilization. For practical purposes , apply a pressure that is sufficient if the bandage is comfortably tight and snug but allows a finger to be slipped under it.

However, suction device as first aid for snakebites is not recommended in the AHA Guidelines because, although it does remove some venom, but the amount is very small to have no clinical benefit and in fact, it may aggravate the injury as the device may be conducive to a more rapid invasion of the venom (for a description of the suction device, click here.)

Soft tissue Injuries (musculoskeletal injuries - the sprains and strains)

RICE remains the main components of symptomatic treatment.
R= Rest (the affected extremity)
I = Ice (cold) compression
C = Compressive bandage
E = Elevate the extremity

• Cold application is more effective than heat application
• Cold application by mixture of ice and water is more effective than ice alone
• Cold application by mixture of ice and water is more effective than refreezable gel pack.

Cold application decreases hemorrhage, edema, pain, and disability.

To prevent cold injury, limit each application of cold to periods ≤20 minutes.

If that length of time is uncomfortable, limit application to 10 minutes

Jellyfish Stings

First aid for jellyfish stings consists of two important actions: preventing further nematocyst discharge and pain relief.

1. To inactivate venom load and prevent further envenomation, jellyfish stings should be liberally washed with vinegar (4% to 6% acetic acid solution) as soon as possible for at least 30 seconds.

If vinegar is not available, a baking soda slurry may be used instead.

2. For the treatment of pain, after the nematocysts are removed or deactivated, jellyfish stings should be treated with hot-water immersion when possible.

The victim should be instructed to take a hot shower or immerse the affected part in hot water (temperature as hot as tolerated, or 45°C if there is the capability to regulate temperature), as soon as possible, for at least 20 minutes or for as long as pain persists.

If hot water is not available, dry hot packs or, as a second choice, dry cold packs may be helpful in decreasing pain but these are not as effective as hot water.

How does hot water immersion work?

• Marine venoms consist of multiple proteins and enzymes, and there is evidence that these become deactivated when heated to temperatures above 50 °C. Direct heat application leads to inactivation of the venom and deactivation of heat labile proteins.
• Hot water immersion causes modulation of pain receptors in the nervous system leading to a reduction in pain.

Reference: Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J. 2006;23:503–508. [FREE download. Click here]

Do not use fresh water!!!
Fresh water will cause the nematocysts to continue to release their toxin. For the same reason, do not rub the area, apply ice or hot water.



Note:

The Portuguese Man O’ War is actually a cluster of several organisms each highly specialized and cannot sustain themselves individually, dependent for survival on the others to do what the particular “zooid “ cannot do by itself .

The name Portuguese Man O’ War was given to this creature because of its resemblance to the Portuguese Warship known as the Man Of War or Caravela which has triangular sails much like the shape of the Man O’ War’s bubble sail.

Click here to read more.

2010 AHA Guidelines on ECC and CPR

The American Heart Association (AHA) has recently updated the CPR and ECC Guidelines. You can access the full text pdf files of "AHA CPR and ECC Guidelines 2010" articles published in 18 October 2010 issue of Circulation by clicking here.

The most obvious and sensational change would probably be the change from the A-B-C to the C-A-B sequence of basic life support. In a way, I am not at all surprise of this change given the importance of chest compression ever since the last guidelines published in 2005. Numerous studies in recent years have shown the importance of chest compression, particularly for adult, non-traumatic, sudden onset of cardiac arrest, where the most probable etiology in most such cases would be myocardial infarction and its related arrhythmic sequelae of ventricular fibrillation, ventricular tachycardia, etc etc. In fact, over the last few years, we have seen a tremendous emphasis on chest compression so much so that AHA issued a scientific statement on Hands-Only CPR back in April 2008. At the same time, there is a de-emphasis on ventilation. Too much ventilation has the disadvantage of causing too much interruptions and impediment in our attempts in building up a good coronary perfusion pressure during chest compressions. Too much ventilation causes gastric distention as well, and increases risk of aspiration, reducing effectiveness of chest compression by splinting of diaphragm, In fact, too much ventilation is not necessary as the partial pressure of oxygen in the stagnated blood would have been enough to meet the minimal cellular metabolic demand in a cardiac arrest victim, especially during the first few minutes of arrest.



To me, the five major changes in Guidelines 2010 are:

1. The change from A-B-C sequence to C-A-B
- Beside minimizing delay, the C-A-B sequence also has the advantage over A-B-C because in A-B-C sequence, we are starting CPR with the steps which would be considered most repulsive for the public to initiate CPR (steps A and B). Thus, by using C-A-B sequence, we are encouraging public members to participate in CPR, enabling community empowerment and participation in this vital partnership of resuscitation.

Although no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than 2 ventilations leads to improved outcome, chest compressions provide vital blood flow to the heart and brain, and studies of out-of-hospital adult cardiac arrest showed that survival was higher when bystanders made some attempt rather than no attempt to provide CPR.

2. Look, listen, feel is no longer recommended.
- “Look, listen, and feel for breathing” has been removed from the sequence for assessment of breathing after opening the airway. The healthcare provider briefly checks for breathing when checking responsiveness to detect signs of cardiac arrest. After delivery of 30 compressions, the lone rescuer opens the victim’s airway and delivers 2 breaths.

3. Atropine in cardiac arrest is out
Atropine is not recommended for routine use in the management of PEA/asystole and has been removed from the ACLS Cardiac Arrest Algorithm

4. Adenosine is in.
Adenosine is recommended in the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic WCT

Note: adenosine should not be used for irregular WCTs because it may cause degeneration of the rhythm to VF.

5. Capnograph is in.
Capnography waveform can be used to check whether endotracheal intubation is successful or not, and secondly, it is used to monitor effectiveness of chest compression including achieving ROSC.

Other changes include:
Cricoid pressure
Cricoid pressure applied routinely is out.
Although it can prevent gastric aspiration, cricoid pressure may impede ventilation and interfere with placement of a supraglottic airway or intubation.

If cricoid pressure is used in special circumstances during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or advanced airway placement.

De-emphasis on pulse check
This guidelines minimizes the importance of pulse checks by healthcare providers. This is because detection of a pulse can be difficult, and even highly trained healthcare providers often incorrectly assess the presence or absence of a pulse when blood pressure is abnormally low or absent. Anyhow, chest compressions delivered to patients subsequently found not to be in cardiac arrest rarely lead to significant injury