AHA 2010 Part 17 First Aid

AHA 2010 Part 17 First Aid
Part 17: First Aid: 2010 American Heart Association and American Red Cross
Guidelines for First Aid
David Markenson, Jeffrey D. Ferguson, Leon Chameides, Pascal Cassan, Kin-Lai
Chung, Jonathan Epstein, Louis Gonzales, Rita Ann Herrington, Jeffrey L. Pellegrino,
Norda Ratcliff and Adam Singer
Circulation 2010;122;S934-S946
DOI: 10.1161/CIRCULATIONAHA.110.971150
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
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Part 17: First Aid
2010 American Heart Association and American Red Cross Guidelines for
First Aid
David Markenson, Co-Chair*; Jeffrey D. Ferguson, Co-Chair*; Leon Chameides; Pascal Cassan;
Kin-Lai Chung; Jonathan Epstein; Louis Gonzales; Rita Ann Herrington; Jeffrey L. Pellegrino;
Norda Ratcliff; Adam Singer
he American Heart Association (AHA) and the American
Red Cross (Red Cross) cofounded the National First Aid
Science Advisory Board to review and evaluate the scientific literature on first aid in preparation for the 2005
American Heart Association (AHA) and American Red
Cross Guidelines for First Aid.1 In preparation for the 2010
evidence evaluation process, the National First Aid Advisory Board was expanded to become the International First
Aid Science Advisory Board with the addition of representatives from a number of international first aid organizations (see Table). The goal of the board is to reduce
morbidity and mortality due to emergency events by
making treatment recommendations based on an analysis
of the scientific evidence that answers the following
In which emergency conditions can morbidity or mortality
be reduced by the intervention of a first aid provider?
How strong is the scientific evidence that interventions
performed by a first aid provider are safe, effective, and
A critical review of the scientific literature by members of
the International First Aid Science Advisory Board is summarized in the 2010 International Consensus on First Aid
Science With Treatment Recommendations (ILCOR 2010
CPR Consensus), from which these guidelines are derived.2
That critical review evaluates the literature and identifies
knowledge gaps that might be filled through future scientific
The history of first aid can be traced to the dawn of organized
human societies. For example, Native American Sioux medicine men of the Bear Society were noted for treating battle
injuries, fixing fractures, controlling bleeding, removing arrows, and using a sharp flint to cut around wounds and
Modern, organized first aid evolved from military experiences when surgeons taught soldiers how to splint and
bandage battlefield wounds. Two British officers, Peter Shepherd and Francis Duncan, are said to have been the first to
expand the concept to civilians and to develop the first
curriculum in first aid.4 Organized training in civilian first aid
began in the United States in 1903 when Clara Barton,
president of the Red Cross, formed a committee to establish
instruction in first aid among the nation’s industrial workers,
where, under dangerous conditions, accidents and deaths
were all too frequent.
The Evidence Evaluation Process
The International First Aid Science Advisory Board first
identified 38 questions in first aid practice that either were not
raised in previous evidence evaluations or were in need of
updating. Two or more board members volunteered to review
the scientific literature independently and develop an
evidence-based review worksheet summarizing the literature
relevant to each question (see Part 2: “Evidence Evaluation
and Management of Potential or Perceived Conflicts of
Interest”). After each worksheet was presented to, and reviewed by, the full board, a summary draft of the scientific
evidence and a treatment recommendation were crafted. The
evidence-based review for each question was presented and
discussed a second time at a subsequent board meeting. All
first aid worksheets, co-copyrighted by the American Heart
Association and the American Red Cross, can be viewed
through hyperlinks in the 2010 American Heart Association
and American Red Cross International Consensus on First
Aid Science with Treatment Recommendations.2 Each question, evidence-based review, draft summary of science, and
draft treatment recommendation was presented, discussed,
and debated on 2 separate occasions until a consensus was
reached. These guidelines are based on the scientific consensus findings reported in the 2010 International Consensus on
First Aid Science with Treatment Recommendations.2
The American Heart Association and the American Red Cross request that this document be cited as follows: Markenson D, Ferguson JD, Chameides
L, Cassan P, Chung K-L, Epstein J, Gonzales L, Herrington RA, Pellegrino JL, Ratcliff N, Singer A. Part 17: first aid: 2010 American Heart Association
and American Red Cross Guidelines for First Aid. Circulation. 2010;122(suppl 3):S934 –S946.
*Co-chairs and equal first co-authors.
(Circulation. 2010;122[suppl 3]:S934 –S946.)
© 2010 American Heart Association, Inc., and American Red Cross.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.110.971150
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by on December 4, 2010
Markenson et al
Table. International First Aid Science Advisory Board
Member Organizations
American Academy of Pediatrics
American Burn Association
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Surgeons
American Heart Association
American Pediatric Surgical Association
American Red Cross
American Red Cross Advisory Council on First Aid, Aquatics, Safety and
Preparedness (ACFASP)
Part 17: First Aid
sound and based on scientific evidence or, in the absence
of such evidence, on expert consensus. Administration of
first aid must not delay activation of the emergency
medical services (EMS) system or other medical assistance
when required. We strongly believe that education in first
aid should be universal: everyone can learn first aid and
everyone should.
The scope of first aid is not purely scientific; it is
influenced by both training and regulatory issues. The definition of scope is therefore variable, and should be defined
according to circumstances, need, and regulatory
American Safety & Health Institute (ASHI)
Calling for Help
Austrian Red Cross
Canadian Red Cross
Divers Alert Network
European Reference Center on First Aid Education
Egyptian Red Crescent
French Red Cross
A first aid provider must be able to recognize when help is
needed and how to get it. First aid providers should learn
how and when to access the EMS system, how to activate
the on-site emergency response plan (ERP), and how to
contact the Poison Control Center (see “Poison Emergencies” below).
Grenada Red Cross
Positioning the Victim
Hong Kong Red Cross
Hungarian Red Cross
International Federation of Red Cross and Red Crescent Societies
Medic First Aid International
National Association of EMS Educators
National Association of EMS Physicians
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 (see “Spine
Stabilization” below). There are times, however, when the
victim should be moved:
National Athletic Trainers’ Association
National Safety Council
Norwegian Red Cross
Occupational Safety and Health Administration
Red Cross Society of China
Resuscitation Council of Asia
St. John Ambulance, UK
Previous reports5– 8 have noted the paucity of scientific
evidence supporting many interventions in prehospital emergency care. In reviewing the medical literature, members of
the International First Aid Science Advisory Board once
again found a paucity of evidence to guide first aid interventions. Very little research is being conducted in first aid, and
many of the following recommendations are extrapolated
from the experience of healthcare professionals. It is important to recognize the limitations of the evidence that supports
many of these guidelines so that research can be undertaken
and future guidelines can be based on a larger body of
scientific evidence.
Definition of First Aid
We define first aid as the assessments and interventions
that can be performed by a bystander (or by the victim)
with minimal or no medical equipment. A first aid provider
is defined as someone with formal training in first aid,
emergency care, or medicine who provides first aid. First
aid assessments and interventions should be medically
If the area is unsafe for the rescuer or the victim, move the
victim to a safe location if it is safe to do so.
If the victim is face down and is unresponsive, turn the
victim face up.
If the victim has difficulty breathing because of copious
secretions or vomiting, or if you are alone and have to leave
an unresponsive victim to get help, place the victim in a
modified High Arm IN Endangered Spine (HAINES)
recovery position:9,10 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 (Class IIb, LOE C).
If a victim shows evidence of shock, have the victim lie
supine. If there is no evidence of trauma or injury, raise the
feet about 6 to 12 inches (about 30° to 45°) (Class IIb, LOE
C). 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. The results of the volume expansion studies are
contradictory with some showing an increase in cardiac
output,11–13 while others show no change in cardiac output or
mean arterial pressure14 –18 with leg raising.
There is insufficient evidence to recommend routine use of
supplementary oxygen by a first aid provider for victims
complaining of chest discomfort19,20 or shortness of breath21
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(Class IIb, LOE C). Supplementary oxygen administration
may be beneficial as part of first aid for divers with a
decompression injury (Class IIb, LOE C22).
epinephrine may be given if symptoms of anaphylaxis
persist (Class IIb, LOE C).
Medical Emergencies
Breathing Difficulties
The incidence of acute asthma is increasing, especially in
urban populations.23 Many victims with asthma take a prescribed bronchodilator medication and can self-administer
it.24 –26 First aid providers are not expected to make a
diagnosis of asthma, but they may assist the victim in using
the victim’s prescribed bronchodilator medication (Class IIa,
LOE B) under the following conditions:
The victim states that he or she is having an asthma attack
or symptoms associated with a previously diagnosed
breathing disorder, and the victim has the prescribed
medications or inhaler in his or her possession.
The victim identifies the medication and is unable to
administer it without assistance.24
First aid providers should become familiar with inhalers so
that they can assist a victim with an acute asthma attack in
using the inhaler.
Allergies are relatively common, but only a small proportion
of people with allergies develop anaphylactic reactions. An
anaphylactic reaction is a progressive series of signs and
symptoms characterized by swelling, breathing difficulty,
an itching rash, and eventually shock, which, if left
untreated, may lead to death. Some of these signs and
symptoms can also be present in other conditions, and first
aid rescuers should not be expected to make a diagnosis of
Older patients who suffer from anaphylactic reactions
know their signs and symptoms and many carry a lifesaving
epinephrine auto-injector. With proper training, parents can
be taught to correctly use an auto-injector to administer
epinephrine to their allergic children.31 All too often, however, neither the victim nor family members know how to
correctly use an auto-injector.32–34 First aid providers should
be familiar with the epinephrine auto-injector so that they can
help a victim with an anaphylactic reaction to self-administer
it. First aid providers should also know how to administer the
auto-injector if the victim is unable to do so, provided that the
medication has been prescribed by a physician and state law
permits it (Class IIb, LOE B).
In retrospective studies35–37 18% to 35% of patients
having signs of anaphylaxis required a second dose of
epinephrine if symptoms persisted or progressed after the
first dose. Because of the difficulty in making a diagnosis
of anaphylaxis27–30,38,39 and the potential harm from epinephrine if the diagnosis is incorrect,40 – 43 first aid providers are advised to seek medical assistance if symptoms
persist, rather than routinely administering a second dose
of epinephrine. In unusual circumstances, when advanced
medical assistance is not available, a second dose of
The general principles of first aid management of seizures
are to
Ensure an open airway.
Prevent injury.
Do not restrain the victim during a seizure. Do not try to
open the victim’s mouth or try to place any object between
the victim’s teeth or in the mouth. Restraining the victim
may cause musculoskeletal or soft-tissue injury. Placing an
object in the victim’s mouth may cause dental damage or
aspiration (Class IIa, LOE C). It is not unusual for the
victim to be unresponsive or confused for a short time after
a seizure.
Chest Discomfort
Because it is very difficult, even for the healthcare professional, to differentiate chest discomfort of cardiac origin from
other chest discomfort, the first aid provider should assume
that chest discomfort is cardiac until proven otherwise.
Cardiac chest discomfort is often described as “crushing” or
“pressing” and is often accompanied by shortness of breath or
perspiration. But cardiac chest discomfort may not have these
classical characteristics, especially in women. Call EMS
immediately for anyone with chest discomfort. Do not delay
and do not try to transport the patient to a healthcare facility
While waiting for EMS to arrive, the first aid provider may
encourage the victim to chew 1 adult (not enteric coated) or
2 low-dose “baby” aspirin if the patient has no allergy to
aspirin or other contraindication to aspirin, such as evidence
of a stroke or recent bleeding (Class IIa, LOE A).44 – 46
Injury Emergencies
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.
Direct Pressure
Bleeding is best controlled by applying pressure until bleeding stops47–53 or EMS rescuers arrive (Class I, LOE A). The
amount of pressure applied and the time the pressure is held
are the most important factors affecting successful control of
bleeding. The pressure must be firm, and it must be maintained for a long time. Methods of applying pressure include
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.
If it is not possible to provide continuous manual pressure,
wrap an elastic bandage firmly over gauze to hold it in
place with pressure.54 –57
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Markenson et al
Although tourniquets have been shown to control bleeding
effectively on the battlefield58 – 60 and during surgery and have
been used by paramedics in a civilian setting without complications,61 there are no studies on controlling bleeding with
first aid provider use of a tourniquet. Potential dangers of
prolonged tourniquet application include temporary62 or permanent63 injury to the underlying nerves and muscles,64 and
systemic complications resulting from limb ischemia,65 including acidemia, hyperkalemia, arrhythmias, shock, and
death. Complications are related to tourniquet pressure66 and
duration of occlusion,67 but there is insufficient evidence to
determine a minimal critical time beyond which irreversible
complications may occur. Because of the potential adverse
effects of tourniquets and difficulty in their proper application, use of a tourniquet to control bleeding of the extremities
is indicated only if direct pressure is not effective or possible
(Class IIb, LOE B). Specifically designed tourniquets appear
to be better than ones that are improvised,60,68 –71 but tourniquets should only be used with proper training (Class IIa,
LOE B). If a tourniquet is used, make sure that you note the
time it was applied and communicate that time to EMS
Pressure Points and Elevation
Elevation and use of pressure points are not recommended to
control bleeding (Class III, LOE C). This new recommendation is made because there is evidence that other ways of
controlling bleeding are more effective. The hemostatic effect
of elevation has not been studied. No effect on distal pulses
was found in volunteers when pressure points were used.72
Most important, these unproven procedures may compromise
the proven intervention of direct pressure, so they could be
Hemostatic Agents
Among the large number of commercially available hemostatic agents, some have been shown to be effective.73–76
However, their routine use in first aid cannot be recommended at this time because of significant variation in
effectiveness by different agents and their potential for
adverse effects, including tissue destruction with induction of
a proembolic state and potential thermal injury (Class IIb,
Wounds and Abrasions
Superficial wounds and abrasions should be thoroughly
irrigated with a large volume of warm or room temperature
potable water with or without soap77– 82 until there is no
foreign matter in the wound (Class I, LOE A). Cold water
appears to be as effective as warm water, but it is not as
comfortable. If running water is unavailable, use any source
of clean water. Wounds heal better with less infection if they
are covered with an antibiotic ointment or cream and a clean
occlusive dressing (Class IIa, LOE A).83– 85 Apply antibiotic
ointment or cream only if the wound is an abrasion or a
superficial injury and only if the victim has no known
allergies to the antibiotic.
Part 17: First Aid
Thermal Burns
Cool thermal burns with cold (15° to 25°C) tap water as soon
as possible and continue cooling at least until pain is relieved
(Class I, LOE B).86 –93 Cooling reduces pain, edema, and
depth of injury. It speeds healing and may reduce the need for
excision and grafting of deep burns. Don’t apply ice directly
to a burn; it can produce tissue ischemia (Class III, LOE B).
Prolonged cold exposure to small burns, and even brief
exposure if the burn is large, can cause further local tissue
injury93–95 and hypothermia.
Burn Blisters
Loosely cover burn blisters with a sterile dressing but leave
blisters intact because this improves healing and reduces pain
(Class IIa, LOE B).96 –99
Electric Injuries
The severity of electric injuries can vary widely, from an
unpleasant tingling sensation caused by low-intensity current to thermal burns, cardiopulmonary arrest, and death.
Thermal burns may result from burning clothing that is in
contact with the skin or from electric current traversing a
portion of the body. When current traverses the body,
thermal burns may be present at the entry and exit points
and along its internal pathway. Cardiopulmonary arrest is
the primary cause of immediate death from electrocution.100 Cardiac arrhythmias, including ventricular fibrillation, ventricular asystole, and ventricular tachycardia that
progresses to ventricular fibrillation, may result from
exposure to low- or high-voltage current.101 Respiratory
arrest may result from electric injury to the respiratory
center in the brain or from tetanic contractions or paralysis
of respiratory muscles.
Do not place yourself in danger by touching an electrocuted victim while the power is on (Class III, LOE C).
Turn off the power at its source; at home the switch is
usually near the fuse box. In case of high-voltage electrocutions caused by fallen power lines, immediately notify
the appropriate authorities (eg, 911 or fire department). All
materials conduct electricity if the voltage is high enough,
so do not enter the area around the victim or try to remove
wires or other materials with any object, including a
wooden one, until the power has been turned off by
knowledgeable personnel.
Once the power is off, assess the victim, who may need
CPR, defibrillation, and treatment for shock and thermal
burns. All victims of electric shock require medical assessment because the extent of injury may not be apparent.
Spine Stabilization
There is approximately a 2% risk of injury to the cervical
spine after blunt trauma that is serious enough to require
spinal imaging in an emergency department,102,103 and this
risk is tripled in patients with craniofacial injury.104 Most
victims with spinal injuries are males between the ages of
10 and 30 years. Motor vehicles cause approximately half
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of all spinal injuries; many of the remainder are caused by
falls (especially from a height or diving), sports, and
If the cervical spine is injured, the spinal cord may be
unprotected, and further injury (secondary spinal cord
injury) could result from stresses to the cord that occur
when the victim is manipulated or moved. This could
result in permanent neurological damage including quadriplegia.106,107 Only one controlled but underpowered study
with some methodological problems108 has examined this
question. In the study, the group of injured victims with
spinal immobilization by emergency medical technicians
using equipment failed to show any neurological benefit
compared with a group of injured victims without spinal
Because of the dire consequences if secondary injury
does occur, maintain spinal motion restriction by manually
stabilizing the head so that the motion of head, neck, and
spine is minimized (Class IIb, LOE C). First aid providers
should not use immobilization devices because their benefit in first aid has not been proven and they may be
harmful (Class III, LOE C). Immobilization devices may
be needed in special circumstances when immediate extrication (eg, rescue of drowning victim) is required, but first
aid providers should not use these devices unless they have
been properly trained in their use.
First aid rescuers cannot conclusively identify a victim
with a spinal injury, but they should suspect spinal injury
if an injured victim has any of the following risk factors
(these have been modified slightly from the 2005 American Heart Association and American Red Cross First Aid
Guidelines103,109 –114):
Age ⱖ65 years
Driver, passenger, or pedestrian, in a motor vehicle, motorized cycle, or bicycle crash
Fall from a greater than standing height
Tingling in the extremities
Pain or tenderness in the neck or back
Sensory deficit or muscle weakness involving the torso or
upper extremities
Not fully alert or is intoxicated
Other painful injuries, especially of the head and neck
Children 2 years of age or older with evidence of head or
neck trauma
Musculoskeletal Trauma
Sprains and Strains
Soft-tissue injuries include joint sprains and muscle contusions. Cold application decreases hemorrhage, edema, pain,
and disability,115–120 and it is reasonable to apply cold to a
soft-tissue injury. Cooling is best accomplished with a plastic
bag or damp cloth filled with a mixture of ice and water; the
mixture is better than ice alone.121–123 Refreezable gel packs
do not cool as effectively as an ice-water mixture.124,125 To
prevent cold injury, limit each application of cold to periods
ⱕ20 minutes.126 –128 If that length of time is uncomfortable,
limit application to 10 minutes.129 Place a barrier, such as a
thin towel, between the cold container and the skin (Class IIb,
LOE C126,128).
It is not clear whether a compression bandage is helpful for
a joint injury. Heat application to a contusion or injured joint
is not as good a first aid measure as cold application.115
Assume that any injury to an extremity includes a bone
fracture. Cover open wounds with a dressing. Do not move
or try to straighten an injured extremity (Class III, LOE C).
There is no evidence that straightening an angulated
suspected long bone fracture shortens healing time or
reduces pain prior to permanent fixation. Expert opinion
suggests that splinting may reduce pain130 and prevent
further injury. So, if you are far from definitive health care,
stabilize the extremity with a splint in the position found
(Class IIa, LOE C). If a splint is used, it should be padded
to cushion the injury. If an injured extremity is blue or
extremely pale, activate EMS immediately because this
could be a medical emergency. A victim with an injured
lower extremity should not bear weight until advised to do
so by a medical professional.
Human and Animal Bites
Irrigate human and animal bites with copious amounts of
water (Class I, LOE B). This irrigation has been shown to
prevent rabies from animal bites 131,132 and bacterial
Do not apply suction as first aid for snakebites (Class III,
LOE C). Suction does remove some venom, but the amount
is very small.134 Suction has no clinical benefit135 and it may
aggravate the injury.136 –138
Applying a pressure immobilization bandage with a pressure between 40 and 70 mm Hg in the upper extremity and
between 55 and 70 mm Hg in the lower extremity around the
entire length of the bitten extremity is an effective and safe
way to slow the dissemination of venom by slowing lymph
flow (Class IIa, LOE C139,140). For practical purposes pressure
is sufficient if the bandage is comfortably tight and snug but
allows a finger to be slipped under it. Initially it was theorized
that slowing lymphatic flow by external pressure would only
benefit victims bitten by snakes producing neurotoxic venom,
but the effectiveness of pressure immobilization has also been
demonstrated for bites by non-neurotoxic American
snakes.140,141 The challenge is to find a way to teach the
application of the correct snugness of the bandage because
inadequate pressure is ineffective and too much pressure may
cause local tissue damage. It has also been demonstrated that,
once learned, retention of the skill of proper pressure and
immobilization application is poor.142,143
Jellyfish Stings
This section is new to the First Aid Guidelines. First aid
for jellyfish stings consists of two important actions:
preventing further nematocyst discharge and pain relief.
To inactivate venom load and prevent further envenomation, jellyfish stings should be liberally washed with
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Part 17: First Aid
containers of warm, but not hot, water in contact with the
vinegar (4% to 6% acetic acid solution) as soon as possible
for at least 30 seconds (Class IIa, LOE B). The inactivation
of venom has been demonstrated for Olindias sambaquiensis144 and for Physalia physalis (Portuguese man-ofwar).145 If vinegar is not available, a baking soda slurry
may be used instead.145
For the treatment of pain, after the nematocysts are
removed or deactivated, jellyfish stings should be treated with
hot-water immersion when possible (Class IIa, LOE B). 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.146 –149 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
(Class IIb, LOE B146,150,151). Topical application of aluminum
sulfate or meat tenderizer, commercially available aerosol
products, fresh water wash, and papain, an enzyme derived
from papaya used as a local medicine, are even less effective
in relieving pain (Class IIb, LOE B147,152).
Pressure immobilization bandages are not recommended
for the treatment of jellyfish stings because animal studies153,154 show that pressure with an immobilization bandage
causes further release of venom, even from already fired
nematocysts (Class III, LOE C).
Frostbite usually affects an exposed part of the body such as
the extremities and nose. In case of frostbite, remove wet
clothing and dry and cover the victim to prevent hypothermia.
Transport the victim to an advanced medical facility as
rapidly as possible. Do not try to rewarm the frostbite if there
is any chance that it might refreeze161,162 or if you are close to
a medical facility (Class III, LOE C).
Minor or superficial frostbite (frostnip) can be treated with
simple, rapid rewarming using skin-to-skin contact such as a
warm hand.
Severe or deep frostbite should be rewarmed within 24
hours of injury and this is best accomplished by immersing
the frostbitten part in warm (37° to 40°C or approximately
body temperature) water for 20 to 30 minutes (Class IIb, LOE
C161–170). Chemical warmers should not be placed directly on
frostbitten tissue because they can reach temperatures that
can cause burns (Class III, LOE C171). Following rewarming,
efforts should be made to protect frostbitten parts from
refreezing and to quickly evacuate the patient for further care.
The effectiveness of ibuprofen or other nonsteroidal antiinflammatory drugs (NSAIDs) in frostbite has not been well
established in human studies.170,172–175
Dental Injuries
Heat Emergencies
Traumatic dental injuries are common. The first aid for an
avulsed tooth is as follows:
Clean bleeding wound(s) with saline solution or tap water.
Stop bleeding by applying pressure with gauze or cotton.
Handle the tooth by the crown, not the root (ie, do not
handle the part that was beneath the gum).
Place the tooth in milk, or clean water if milk is not
Contact the patient’s dentist or take the tooth and victim to
an emergency care center as quickly as possible (Class IIa,
LOE C).155–158
Environmental Emergencies
Cold Emergencies
Hypothermia is caused by exposure to cold. The urgency of
treatment depends on the length of exposure and the victim’s
body temperature. Begin rewarming a victim of hypothermia
immediately by moving the victim to a warm environment,
removing wet clothing, and wrapping all exposed body
surfaces with anything at hand, such as blankets, clothing,
and newspapers. If the hypothermia victim is far from
definitive health care, begin active rewarming (Class IIa,
LOE B159,160) although the effectiveness of active rewarming
has not been evaluated. Active rewarming should not delay
definitive care. Potential methods of active rewarming include placing the victim near a heat source and placing
Heat-induced symptoms, often precipitated by vigorous exercise, may include heat cramps, heat exhaustion, and heat
Heat cramps are painful involuntary muscle spasms that
most often affect the calves, arms, abdominal muscles, and
back. First aid includes rest, cooling off, and drinking an
electrolyte-carbohydrate mixture, such as juice, milk, or a
commercial electrolyte-carbohydrate drink.176 –185 Stretching,
icing, and massaging the painful muscles may be helpful.
Exercise should not be resumed until all symptoms have
Heat exhaustion is caused by a combination of exerciseinduced heat and fluid and electrolyte loss as sweat. Signs and
symptoms may start suddenly and include: nausea, dizziness,
muscle cramps, feeling faint, headache, fatigue, and heavy
sweating. Heat exhaustion is a serious condition because it
can rapidly advance to the next stage, heat stroke, which can
be fatal. Heat exhaustion must be vigorously treated by
having the victim lie down in a cool place, taking off as many
clothes as possible, cooling the victim with a cool water
spray, and encouraging the victim to drink cool fluids,
preferably containing carbohydrates and electrolytes.
Heat stroke includes all the symptoms of heat exhaustion
plus signs of central nervous system involvement, including
dizziness, syncope, confusion, or seizures. The most important action by a first aid provider for a victim of heat stroke
is to begin immediate cooling, preferably by immersing the
victim up to the chin in cold water.186 –189 It is also important
to activate the EMS system. Heat stroke requires emergency
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treatment with intravenous fluids. Do not try to force the
victim to drink liquids.
Drowning is a major cause of unintentional death. Methods of
preventing drowning include isolation fencing around swimming pools (gates should be self-closing and self-latching),190
wearing personal flotation devices (life jackets) while in,
around, or on water, never swimming alone, and avoiding
swimming or operating motorized watercraft while intoxicated. Outcome following drowning depends on the duration
of the submersion, the water temperature, and how promptly
CPR is started.191,192 Occasional case reports have documented intact neurological survival in children following
prolonged submersion in icy waters.193,194
Remove the victim rapidly and safely from the water, but
do not place yourself in danger. If you have special training,
you can start rescue breathing while the victim is still in the
water195 providing that it does not delay removing the victim
from the water. There is no evidence that water acts as an
obstructive foreign body, so do not waste time trying to
remove it with abdominal or chest thrusts. Start CPR and, if
you are alone, continue with about 5 cycles (about 2 minutes)
of chest compressions and ventilations before activating
EMS. If 2 rescuers are present, send 1 rescuer to activate
EMS immediately.
Poison Emergencies
If the patient exhibits any signs or symptoms of a lifethreatening condition, (eg, sleepiness, seizures, difficulty
breathing, vomiting) after exposure to a poison, activate the
EMS immediately.
Poison Control Centers
There are many poisonous substances in the home and
worksite. It is important to understand the toxic nature of the
chemical substances in the environment and the proper
protective equipment and emergency procedures in case of
toxic exposure. The Poison Help hotline of the American
Association of Poison Control Centers (800-222-1222) is an
excellent resource in the United States for information about
treating ingestion of, or exposure to, a potential poison.
Further information is available at www.aapcc.org. Similar
resources may be available internationally, and their contact
information (eg, 112 in Europe) should be standard in
international first aid training. When phoning a poison control
center or other emergency medical services, know the nature
and time of exposure and the name of the product or toxic
Chemical Burns
Brush powdered chemicals off the skin with a gloved hand or
piece of cloth. Remove all contaminated clothing from the
victim, making sure you do not contaminate yourself in the
process. In case of exposure to an acid or alkali on the skin196 –202
or eye,203–208 immediately irrigate the affected area with copious
amounts of water (Class I, LOE B).
Toxic Eye Injury
Rinse eyes exposed to toxic substances immediately with a
copious amount of water (Class I, LOE C203,209,210), unless a
specific antidote is available.203,210,211
Ingested Poisons
Treatment With Milk or Water
Do not administer anything by mouth for any poison
ingestion unless advised to do so by a poison control center
or emergency medical personnel because it may be harmful
(Class III, LOE C). There is insufficient evidence that
dilution of the ingested poison with water or milk is of any
benefit as a first aid measure. Animal studies212–216 have
shown that dilution or neutralization of a caustic agent
with water or milk reduces tissue injury, but no human
studies have shown a clinical benefit. Possible adverse
effects of water or milk administration include emesis and
Activated Charcoal
Do not administer activated charcoal to a victim who has
ingested a poisonous substance unless you are advised to do
so by poison control center or emergency medical personnel
(Class IIb, LOE C). There is no evidence that activated
charcoal is effective as a component of first aid. It may be
safe to administer,217,218 but it has not been shown to be
beneficial, and there are reports of it causing harm.219 –221 In
addition the majority of children will not take the recommended dose.222
Do not administer syrup of ipecac for ingestions of toxins
(Class III, LOE B). Several studies223–225 found that there is
no clinically relevant advantage to administering syrup of
ipecac; its administration is not associated with decreased
healthcare utilization.226 Untoward effects of ipecac administration include intractable emesis and delayed care in an
advanced medical facility.227,228
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Markenson et al
Part 17: First Aid
Guidelines Part 17: First Aid: Writing Group Disclosures
Writing Group
NYMC–Interim Chair; EMA–Chief
Pediatric ED
Jeffrey D.
Brody School of Medicine, East
Carolina University–Assistant
*Serving as an expert
witness in two ongoing
lawsuits involving EMS
related cases. Billing for
this service has not yet
occurred and will likely
represent less than
$10,000 per 12 months.
This payment is expected
to come directly to me
Emeritus Director Pediatric
Cardiology, Connecticut Children’s
Medical Center, Clinical Professor,
University of Connecticut
French Red Cross, National Medical
Advisor and Coordinator of the
European Reference Centre for first
aid education Coordinator of the
Scientific Commission of First Aid
for the French Interior Ministry
Hong Kong Hospital Authority
Hospital Chief Executive
NorthEast Emergency Medical
Services, Inc.– Regional EMS
Council: Provide EMS System
Oversight. Also provide education
(First aid and CPR/AED) as an AHA
Training Center. Executive Director;
Isis Maternity: Pre-Natal and Post
Partum edu.- Provide CPR and First
Aid Training via AHA Curriculum.
For-Profit Company—Instructor
*Volunteer: American Red
Cross Advisory Council
on First Aid, Aquatics,
Safety and Preparedness
(ACFASP) Vice-Chair
City of Austin - Office of the
Medical Director: EMS System
Medical Director Staff–Performance
Management & Research
*Beginning July 1, 2009, I will
serve as a paid consultant to the
AHA ECC Product Development
Group as a Senior Science Editor.
This assignment will include
providing Science review of AHA
First Aid Products
Rita Ann
Minute Clinic–Family Nurse
Kent State University–Assistant Dir
Faculty Professional Dev. Center
†Wilderness First Aid
consultant for StayWell
Norda Ratcliff
Bloomington Hospital Prompt
Care–Nurse Practitioner
Adam Singer
Stony Brook University-Physician
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person
receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share
of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the
preceding definition.
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November 2, 2010
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KEY WORDS: emergency
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In the article by Markenson et al, “Part 17: First Aid: 2010 American Heart Association and
American Red Cross Guidelines for First Aid,” which published online October 18, 2010, and
appeared with the November 2, 2010, issue of the journal (Circulation. 2010;122(suppl 3):S934 –
S946), several corrections were needed.
On page S935, in the Table, the American Safety & Health Institute (ASHI) and Medic First
Aid International should be listed as members of the International First Aid Science Advisory
Board Member Organizations. The word “(Observer)” has been deleted from both entries.
The American Heart Association and the American Red Cross regret listing these organizations
as observers.
These corrections have been made to the current online version of the article, which is available
at http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S934.
DOI: 10.1161/CIR.0b013e318205da55
(Circulation. 2010;122:2228.)
© 2010 American Heart Association, Inc., and American Red Cross.
Circulation is available at http://circ.ahajournals.org
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