Editor’s Note: This is part three of a four-part series.

The International Liaison Committee on Resuscitation (ILCOR) appointed a task force in 2013 to prepare recommendations regarding first-aid care by trained or untrained rescuers. The recommendations were released with the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The goal was to provide an evidence base for the initial care provided by laypersons, EMS, and physicians outside of the office or hospital setting.

ACEP Now has partnered with three emergency medicine residency training programs (Wake Forest School of Medicine, Winston-Salem, North Carolina; Mayo School of Graduate Medical Education/Mayo Clinic, Rochester, Minnesota; and Warren Alpert Medical School of Brown University, Providence, Rhode Island) to review 15 of these recommendations following the PICO (Population, Intervention, Comparator, and Outcomes) analytic format utilized by the recommendation authors.

Panel Commentators

• Howard Mell, MD, MPH, CPE, FACEP, assistant professor, Wake Forest Baptist Medical Center, Department of Emergency Medicine
• Jessica L. Smith, MD, FACEP, associate professor (clinical), Warren Alpert Medical School of Brown University, and program director, Emergency Medicine Residency
• Jason Stopyra, MD, FACEP, assistant professor, Wake Forest Baptist Medical Center, Department of Emergency Medicine
• Matthew Sztajnkrycer, MD, PHD, FACEP, associate professor, Mayo Clinic, Department of Emergency Medicine

Reference: Singletary EM, Charlton NP, Epstein JL, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation. 2015;132(suppl 2):S574–S589.

Open Chest Wound (FA 525)

Recommendation Author: Anuradha Ganapathy, MD

Dr. Ganapathy is a member of the emergency medicine residency training class of 2018 at the Warren Alpert Medical School of Brown University.

Question: Among adults and children with open chest wounds outside of the hospital (P), does use of occlusive dressing (I) compared to non-occlusive dressing (C) change outcomes (O)?

Results: One animal study (deemed very-low-quality evidence) addressed the PICO question of use of occlusive versus non-occlusive dressings in open chest wounds for respiratory arrest and to improve oxygen saturation. Vented and unvented chest seals were placed serially on open chest wounds in eight pigs, and onset of tension pneumothorax and deterioration of respiratory parameters were measured upon serial air injections into the pleural cavity.

Outcomes: There was benefit from use of non-occlusive devices for the outcomes of respiratory arrest, oxygen saturation, tidal volumes, and respiratory rate. There was no significant benefit in terms of mean arterial pressure, survival, or cardiac arrest.

Discussion: Tension pneumothorax is a life-threatening complication in open chest wounds. The task force recognized the limited evidence addressing this but noted that both evidence and the medical practice of treating a tension pneumothorax by creating an open wound to allow communication between it and the ambient air justified the benefit of non-occlusive dressings in open chest wounds. Further research into non-occlusive dressings is required due to the concern that they may inadvertently occlude open chest wounds, causing life-threatening complications.

Recommendation: First-aid providers should not apply occlusive dressings or devices in patients with open chest wounds.

Note from Dr. Smith: In the first-aid setting, occlusive dressings should not be placed on open chest wounds due to the possibility of doing harm by creating a tension pneumothorax.

Hypoglycemia (FA 795)

Recommendation Author: Derick D. Jones, MD

Dr. Jones is a member of the emergency medicine residency training class of 2018 at the Mayo School of Graduate Medical Education/Mayo Clinic.

Question: Among adults and children with symptomatic hypoglycemia (P), does administration of dietary forms of sugar (I) compared with standard dose (15–20 g) of glucose tablets (C) change time to resolution of symptoms, risk of complications (eg, aspiration), blood glucose, hypoglycemia, or hospital length of stay (O)?

Results: Three randomized control studies and one observational study that addressed the PICO were identified. All four studies were downgraded for risk of bias and imprecision. The three randomized studies were deemed low-quality evidence, while the observational study was deemed very low quality.

Outcomes: No study showed that any form of dietary sugar or glucose tablets improved the blood glucose before 10 minutes. The observational study showed fewer diabetic patients demonstrating a 20 mg/dL increase in blood glucose level 20 minutes after treatment when treated with dietary sugars compared to glucose tablets. Pooled data from the three randomized trials showed a slower resolution of symptoms 15 minutes after diabetic patients were treated with dietary sugars compared with glucose tablets. No studies assessed the risk of complications or assessed hospital length of stay.

Discussion: The current analysis evaluated glucose supplementation from glucose tablets compared with dietary sugars at equivalent doses of 15–20 g. Alternative dietary sugars and glucose gels/pastes may be effective. This study does not look at adverse effects of administering more sugar than needed.

Recommendation: In conscious individuals with symptomatic hypoglycemia, glucose tablets should be administered (strong recommendation, low-quality evidence). If glucose tablets are not available, dietary sugars can be used (weak recommendation, very-low-quality evidence).

Note from Dr. Sztajnkrycer: Although 15–20 g dietary-equivalent glucose tablets were identified as the best first-aid option based on four studies, lack of availability should not deter the use of other sugars, despite the weak recommendation, in a symptomatic hypoglycemic patient who is conscious, able to follow commands, and able to swallow.

Positioning (FA 517)

Recommendation Author: Sean O’Rouke, MD

Dr. O’Rouke is a member of the residency training class of 2018 at Wake Forest School of Medicine.

Question: Among adults who are breathing and unresponsive outside of a hospital (P), does positioning in a lateral, side-lying recovery position (I) compared with supine position (C) change overall mortality, need for airway management, stridor, the incidence of aspiration, the likelihood of cervical spinal injury, complications, or incidence of cardiac arrest (O)?

Results: Eight observational studies that addressed the PICO were identified but were all deemed very-low-quality evidence.

Outcomes: There is limited evidence to suggest the lateral decubitus position improves morbidity or mortality, with very-low-quality evidence to suggest a lower incidence of aspiration, increased total lung volume, or decreased stridor. Several studies have identified different positioning methods with very-low-quality evidence of benefit from these alternative positions.

Discussion: On arrival to a scene with injured or ill persons, first responders must protect these individuals from continued harm. Actions to safely position patients are guided by several variables. In a person who is unresponsive and breathing normally without evidence of serious injuries, consider placing the person in the lateral decubitus position. If a person is unresponsive and not breathing normally, resuscitation efforts should begin immediately. Furthermore, if there is concern for neck, back, hip, or pelvic injury, the person should be left in the position in which they were found to avoid further injury.

Recommendation: Although there is little evidence to suggest the optimal recovery position, consider placing the unconscious person who is breathing normally in a lateral decubitus position.

Note from Dr. Stopyra: This is one of those common-sense recommendations. If uninjured, place the patient in a position that makes it easy to clear their airway should they vomit. A different recommendation debunks the “feet-elevated” position for shock (FA 520).

Oxygen Use in First Aid (FA 519)

Recommendation Author: Shannon Mumma, MD

Dr. Mumma is a member of the residency training class of 2018 at Wake Forest School of Medicine.

Question: Among adults and children who exhibit symptoms of shortness of breath, difficulty breathing, or hypoxia outside the hospital (P), does administration of oxygen (I) compared with no administration of oxygen (C) change survival with favorable outcomes, shortness of breath, time to resolution of symptoms, or therapeutic endpoints (O)?

Results: One retrospective study presents very-low-quality evidence that there is no benefit of supplemental oxygen administration for reducing death, the need for assisted ventilation, and respiratory failure for patients with acute exacerbation of chronic obstructive pulmonary disease. One randomized controlled trial presents low-quality evidence showing the benefit of supplementary oxygen administration for treatment of shortness of breath in cancer patients with dyspnea and hypoxemia. A meta-analysis and four randomized controlled trials present low-quality evidence of no benefit for advanced cancer patients with dyspnea without hypoxemia for shortness of breath. Oxygen administration was found to have a positive effect on oxygen saturation.

Outcomes: No evidence was found for or against routine administration of supplemental oxygen by first-aid providers. Supplemental oxygen administration has been found to be of some benefit in specific circumstances, including advanced cancer patients with dyspnea and hypoxia as well as individuals with decompression injuries. Oxygen provided to patients with hypoxemia helped them reach normal oxygen levels.

Discussion: There is no recommendation for the use of supplemental oxygen as the evidence is conflicting and too low quality to recommend a change to current practice. The use of supplemental oxygen should be limited to individuals with specific training in oxygen administration.

Recommendation: No recommendation.

Note from Dr. Mell: Providing supplemental oxygen does not appear to improve outcomes for patients with dyspnea. Emergency physicians do not need to routinely carry oxygen as part of first-aid kits.