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.
BRONCHODILATORS FOR ASTHMA WITH SHORTNESS OF BREATH (FA-534)
Recommendation Author: Bradley M. Chapman, MD
Dr. Chapman is a member of the emergency medicine residency training class of 2018 at the Wake Forest School of Medicine.
Question: Among adults and children in the prehospital setting who suffer from asthma and are experiencing difficulty in breathing (P), does bronchodilator administration (I) compared with no bronchodilator administration (C) change time to resolution of symptoms, time to resumption of usual activity, complications, harm to patient, therapeutic endpoints, and need for advanced medical care (O)?
Results: Eight double-blind randomized controlled trials (RCTs), two observational studies, and one meta-analysis were identified that addressed the PICO but were all deemed very-low-quality evidence.
Outcomes: Regarding the critical outcome of time to resolution of symptoms, two RCTs showed benefit in reduction of time to subjective improvement in dyspnea in participants treated with fast-acting bronchodilators. Regarding complications, two RCTs and one observational study demonstrated little or no difference between participants treated with bronchodilators and those treated with placebo. Regarding the therapeutic endpoints of oxygenation and ventilation, two RCTs showed benefit in an improvement in forced expiratory volume over one second when comparing inhalers to placebo.
Discussion: This review found evidence that use of a bronchodilator in asthmatics with acute difficulty breathing is effective for reducing wheezing, dyspnea, and respiratory rate while improving measures of effectiveness with few reported side effects.
Recommendation: When an individual with asthma is experiencing difficulty breathing, trained first-aid providers should assist the individual with administration of a bronchodilator.
Note from Dr. Stopyra: Inhaled bronchodilators are beneficial to patients and have very low risk of complication. If they are available outside of the hospital, they should be used.
CONCUSSION (FA799)
Recommendation Author: Heather Rybasack-Smith, MD
Dr. Rybasack-Smith is a member of the emergency medicine residency training class of 2017 the Warren Alpert Medical School of Brown University.
Question: Among adults and children with concussion defined as suspected head injury (P), does use of a scoring system (I) compared to standard first-aid assessment (C) change outcomes (O)?
Results: One retrospective observational study was identified that addressed the PICO and was deemed appropriate for first-aid providers. The study rescored prehospital Glasgow coma score (GCS) from trauma registry data with a simple motor score. Scores were compared to four outcomes. This study was deemed low-quality evidence.
Outcomes: For differentiation between minor and severe concussion and need for advanced care, no significant difference was observed between the motor score versus the GCS. For change in time to recognize clinical deterioration, time to transport, risk of poor neurologic outcome, and 30-day survival, no evidence was identified.
Discussion: Recognition of concussion by first-aid providers is difficult. Signs and symptoms of concussion are complex and may be subtle and progressive. Failure to recognize a concussion and refer for further evaluation, or failure to remove from sports activities, can result in significant morbidity and mortality. The use of a simple validated tool to identify concussions is valuable but would need robust evidence to support its use by first-aid providers. The task force identified several tools that used before-and-after assessments, but these were felt to be impractical for standard first-aid use. The task force found no evidence to support or refute the use of any simplified tool to identify significant concussion.
Recommendation: No recommendation.
Note from Dr. Smith: Individuals with head injury and any evidence of alteration of consciousness require evaluation by advanced health care providers or evaluation in an emergency department.
DENTAL AVULSION (FA 794)
Recommendation Author: Andrew Escamilla, MD
Dr. Escamilla is a member of the emergency medicine residency training class of 2017 at the Mayo Clinic School of Graduate Medical Education/Mayo Clinic.
Question: Among adults and children with an avulsed permanent tooth (P), does storage of the tooth in any solution prior to replantation (I) compared with storage in whole milk or the patient’s saliva (C) change success of replantation, tooth survival or viability, infection rate, pain, malfunction (eg, eating, speech), or color of the tooth (O)?
Results: Eight studies were identified comparing the success of replantation and survival in Hank’s balanced salt solution (4), propolis (2), egg white (2), coconut water (1), Ricetral (1), saline (2), or phosphate-buffered saline (1) compared with whole milk. Based upon the available data, early immersion in Hank’s balanced salt solution, propolis, egg white, coconut water, Ricetral, whole milk, saline, or phosphate-buffered saline is beneficial (in order of preference). There is insufficient evidence for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. There was no evidence to address the important outcomes of infection rate, pain, malfunction, and cosmetic outcome.
Discussion: An avulsed tooth constitutes a dental emergency and can result in permanent loss of the tooth. Tooth survival is dependent on early replantation. Previous recommendations state that the tooth should be placed in a variety of storage media in situations that do not allow for immediate replantation. Based upon current data, rapid assistance with replantation should be sought. The use of a particular storage medium should depend upon availability and should not delay efforts at replantation.
Recommendation: If a tooth cannot be immediately replanted, the preferred storage medium is Hank’s balanced storage solution (weak recommendation, very-low-quality evidence). Whole milk is preferred to saline solution as a temporary storage solution (weak recommendation, very-low-quality evidence).
Note from Dr. Sztajnkrycer: The dental guidelines assume an ideal world in which Hank’s balanced salt solution is available to first-aid providers, especially in a remote setting in which immediate replantation is not a viable option. While there was insufficient evidence supporting the use of saliva as a temporary medium, there was also insufficient evidence against this. Whole milk is also an option.
“Nine studies showed benefit from repeat administration of epinephrine, while a single study demonstrated no difference in resolution of symptoms when comparing one dose versus two doses. None of these studies specifically addressed adverse effects or complications from multiple epinephrine doses.”
ANAPHYLAXIS (FA 500)
Recommendation Author: Eric C. Funk, MD
Dr. Funk is a member of the emergency medicine residency training class of 2017 at the Mayo Clinic School of Graduate Medical Education/Mayo Clinic.
Question: In patients with anaphylaxis who do not experience resolution of symptoms after receiving the first dose of epinephrine (P), does administering a second dose of epinephrine (I) compared to not administering a second dose of epinephrine (C) change outcomes (O)?
Results: Ten observational studies were identified, all of which were categorized as very low quality due to risk of bias and confounding variables.
Outcomes: Nine studies showed benefit from repeat administration of epinephrine, while a single study demonstrated no difference in resolution of symptoms when comparing one dose versus two doses. None of these studies specifically addressed adverse effects or complications from multiple epinephrine doses.
Discussion: Despite limited data, the benefit of resolution of life-threatening symptoms, including compromised airway, difficulty breathing, and hemodynamic collapse, appears to outweigh the potential risks. While a time frame for administration of a second dose was not addressed by the current literature review, previous studies suggest 10 to 15 minutes between the two doses. There are reports in the literature of adverse effects following incorrect doses or routes of administration. Auto-injectors may reduce the occurrence of these adverse events.
Recommendation: A second dose of epinephrine should be administered to patients who are experiencing severe anaphylaxis and who have not had a resolution of symptoms after the initial dose (weak recommendation, very-low-quality evidence).
Note from Dr. Mell: While the data only weakly support the practice in the prehospital environment, this is the standard practice in emergency medicine. There’s no reason to withhold a second epinephrine dose (if needed) outside of the hospital.
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