AHA Publishes the 2024 AHA & ARC Guidelines for First Aid in Science

1. General care and safety: The first aid provider should provide care within their skill and knowledge set, seeking further medical care as needed, and be mindful of their own safety.
2. First aid for bleeding: When faced with life-threatening bleeding, the first aid provider should apply direct pressure followed by application of a tourniquet or wound packing if the location of the wound is amenable.
3. First aid for chest pain: In adults with acute chest pain, it is recommended that emergency medical services be activated to initiate transport to the closest emergency department. While awaiting the arrival of emergency medical services, first aid providers may encourage alert adults experiencing nontraumatic chest pain to chew and swallow aspirin (162–325 mg) unless the person experiencing pain has a known aspirin allergy or has been advised by a health care professional not to take aspirin.
4. First aid for stroke: The use of a stroke recognition scale such as Face, Arms, Speech, Time is recommended to aid in the recognition of acute stroke in adults and may also be used as an adjunct in pediatrics, although it is not validated in that setting and should not solely be used to identify the broad presentation of stroke in children.
5. First aid for opioid overdose: A first aid provider who encounters a person with suspected opioid overdose who is unresponsive and not breathing normally should activate the emergency response system, provide high-quality cardiopulmonary resuscitation (compressions plus ventilation), and administer naloxone.
6. Assistance with administration of prescribed medications: The first aid provider should help a person self-administer prescribed lifesaving medications as needed, such as inhaled bronchodilators for asthma and intramuscular epinephrine for anaphylaxis.
7. First aid for open chest wounds: In the first aid setting, it is reasonable to leave an open chest wound exposed to ambient air; to place a clean, nonocclusive, dry dressing such as gauze or a clean piece of cloth; or to place a specialized dressing such as a vented chest seal.
8. First aid for tick bites: First aid providers should remove an attached tick as soon as possible by grasping the head of the tick as close to the skin as possible with tweezers or a commercial tick removal device and pulling upward with steady, even pressure.
9. First aid for seizure: First aid providers should activate emergency medical services for first-time seizures; seizures lasting >5 minutes; multiple seizures without return to normal; seizures in water; seizures with injuries, breathing difficulty, or choking; seizures in infants <6 months of age; and seizures in pregnant individuals or if the person does not return to baseline mental status within 5 to 10 minutes after seizure activity stops.
10. Oxygen and pulse oximetry use in first aid: It is reasonable for first aid providers to use pulse oximetry results as part of a complete assessment of an ill or injured person and in consideration of the many limitations of pulse oximeters. First aid providers should be aware of the potential harms of administration of supplemental oxygen in individuals with known chronic obstructive pulmonary disease and should not provide oxygen over an oxygen saturation of 92%.

General Introduction:

Although battlefield first aid training has been documented for centuries, the concept of training members of the lay public is more recent.1 In 1878, 2 British army officers, Surgeon-Major Peter Shepherd and Colonel Francis Duncan, established the concept of teaching first aid skills to civilians by using a comprehensive first aid curriculum.2 In the United States, organized training in first aid started in 1903, when Clara Barton, president of the American Red Cross (Red Cross), formed a committee to establish instruction in first aid among industrial workers.1 In 1911, Red Cross first aid training was expanded to include home nursing and first aid instruction taught by physicians.3 The first Red Cross textbook on first aid for the general public was published in 1913.4

Working in partnership with the International Liaison Committee on Resuscitation (ILCOR), the American Heart Association (AHA) and the Red Cross regularly provide evidence-based treatment recommendations for first aid topics. The last comprehensive review of AHA/ Red Cross first aid recommendations was published in 2010,2 with updates focused on specific topics published in 2015,1 2019,5 and 2020.6 The recommendations in this document are derived from that work, evidence evaluations from the ILCOR First Aid Task Force,7–11 and structured evidence evaluations performed by the writing group.

Scope of the Guidelines:

First aid is defined as “helping behaviors and initial care provided for an acute illness or injury.”1 First aid can be provided by anyone, including the ill or injured person (self-care), nearby individuals, and trained rescuers with a duty to respond (eg, lifeguards). The scope of first aid provided is based on the first aid provider’s level of training, available equipment and resources, overall scenario, and need. First aid competencies include, at any level of training, the following:

• Recognizing, assessing, and prioritizing the need for first aid;
• Providing care by using appropriate knowledge, skills, and behaviors; and
• Recognizing limitations and seeking additional care when needed.1

These guidelines are intended to apply to common residential, workplace, and recreational settings. In general, first aid care begins when the first aid provider begins to assess and assist the ill or injured person and continues until the condition no longer requires urgent intervention, emergency medical services (EMS) professionals arrive, or the person arrives at definitive health care (eg, a hospital, urgent care facility, or doctor’s office).

Organization of the writing Group:

The writing group included a diverse group of experts with backgrounds in critical care nursing, emergency medicine, pediatrics, pediatric emergency medicine, critical care, medical toxicology, pharmacology, critical care, trauma, EMS, wilderness medicine, education, research, and nursing. Group members were appointed by the AHA Emergency Cardiovascular Care Science Subcommittee and the Red Cross Scientific Advisory Council, and evidence reviews and knowledge syntheses were reviewed and approved by the AHA Emergency Cardiovascular Care Science Subcommittee and the Red Cross Scientific Advisory Council.

The AHA and the Red Cross have rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Before appointment, writing group members disclosed all relevant commercial relationships and other potential (including intellectual) conflicts. These procedures are described more fully in “Part 2: Evidence Evaluation and Guidelines Development” in the “2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.”12 The Writing Group Disclosure Table in this document lists the writing group members’ relevant relationships with industry.

Methodology and Evidence Review

The writing group members first created and approved a list of first aid topics, drawing on the scope of prior guidelines and new topics that have gained prominence since the 2015 publication. A population, intervention, comparison, and outcome question was created for each topic. Guided by the chairs and with assistance from a professional medical librarian as needed, the writing group performed a structured evidence evaluation for each topic, which was internally peer reviewed. These searches were executed in Medline and the Excerpta Medica Database (Embase) using the Ovid search interface and the Cochrane Central Register of Controlled Trials. ILCOR evidence reviews published since 2015 were reviewed, and the dates of updated searches were harmonized with these reviews to avoid search overlap. Search results were not limited by language or year as long as an English language abstract was available. Final searches were executed in February through December 2023. Structured searches were supplemented by bibliography review and ad hoc searches when needed. Search results were imported into Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia; https://covidence.org). At least 2 writing group members performed dual screening of the titles and abstracts of all articles identified from each search and identified articles for full-text review. Screening conflicts were resolved between the 2 writing group members and writing group leadership before full-text review. Two writing group members reviewed the full text of all selected articles and applied the information contained to develop treatment recommendations appropriate for each clinical question.

The opioid overdose first aid recommendations are based on guidelines provided by the AHA in 2020,13,14 which were reaffirmed with additional evidence in 2023,15 adapted for the first aid provider and setting.

Each draft recommendation was created by a group of 2 writing group members and then reviewed and refined by all writing group members during regular virtual meetings and 2 in-person meetings. Completed draft recommendations were reviewed by organizational leaders in the AHA and the Red Cross, with recommendations incorporated as draft revisions. Final draft recommendations were then externally peer reviewed.

Class of Recommendation and Level of Evidence

Each recommendation was assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence, alternative treatment options, and impact on patients and society (Table 1(link opens in new window)). Recommendation wording flows in a structured manner based on the COR determination. The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. In determining the COR, the writing group considered the LOE and other factors, including systems issues, economic factors, and ethical factors such as equity, acceptability, feasibility, and risk of harm. These evidence-review methods, including specific criteria used to determine COR and LOE, are described more fully in “Part 2: Evidence Evaluation and Guidelines Development” of the 2020 guidelines.12 The writing group members had final authority over and formally approved these recommendations.

Unfortunately, despite improvements in the design and funding support for emergency care research, the overall certainty of the evidence base for first aid science is low. None of the 179 recommendations in these guidelines are supported by Level A evidence (high-quality evidence from >1 randomized controlled trial [RCT] or ≥1 RCTs corroborated by high-quality registry studies). Thirteen recommendations are supported by Level B randomized evidence (moderate evidence from ≥1 RCTs) and 23 by Level B nonrandomized evidence. The majority of recommendations are based on Level C evidence, including those based on limited data (65 recommendations) and expert opinion (78 recommendations). Accordingly, the strength of recommendations is weaker than optimal: 82 recommendations are Class 1 (strong) recommendations; many of these are about calling for help. Forty-five Class 2a (moderate) recommendations and 31 Class 2b (weak) recommendations are included in these guidelines. In addition, 8 recommendations are designated Class 3: No Benefit, and 13 recommendations are Class 3: Harm. Clinical trials, thoughtfully designed intervention studies with real-world applicability, and well-controlled

Table. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019) This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information). Classes of Recommendation COR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit. Suggested phrases for writing Class 1 recommendations include • Is recommended • Is indicated/useful/effective/beneficial • Should be performed/administered/other Comparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B. Suggested phrases for writing Class 2a recommendations include • Is reasonable • Can be useful/effective/beneficial Comparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to

treatment B, and it is reasonable to choose treatment A over treatment B. For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. Suggested phrases for writing Class 2b recommendations include • May/might be reasonable • May/might be considered • Usefulness/effectiveness is unknown/unclear/uncertain or not well-established Suggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) include • Is not recommended • Is not indicated/useful/effective/beneficial • Should not be performed/administered/other

Suggested phrases for writing Class 3: Harm recommendations include • Potentially harmful • Causes harm • Associated with excess morbidity/mortality • Should not be performed/administered/other Levels of Evidence For LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO. Those categorized as Level A are derived from • High-quality evidence from more than 1 randomized clinical trial, or RCT • Meta-analyses of high-quality RCTs • One or more RCTs corroborated by high-quality registry studies Those categorized as Level B-R (randomized) are derived from • Moderate-quality evidence from 1 or more RCTs • Meta-analyses of moderate-quality RCTs Those categorized as Level B-NR (nonrandomized) are derived from • Moderate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies

Meta-analyses of such studies Those categorized as Level C-LD (limited data) are derived from • Randomized or nonrandomized observational or registry studies with limitations of design or execution • Meta-analyses of such studies • Physiological or mechanistic studies in human subjects Those categorized as Level C-EO (expert opinion) are derived from • Consensus of expert opinion based on clinical experience COR and LOE are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Guidelines Structure

These guidelines are organized into modular knowledge chunks, grouped into discrete modules of information on specific topics or management issues.16 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. A brief introduction is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific supportive text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references facilitate quick access and review.

Document Review and Approval

These guidelines were submitted for blinded peer review to subject-matter experts nominated by the AHA and the Red Cross. Before appointment, all peer reviewers were required to disclose relationships with industry and any other conflicts of interest, and all disclosures were reviewed by AHA journal staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Emergency Cardiovascular Care Science Advisory Committee, the Red Cross Scientific Advisory Council, the AHA Scientific Advisory and Coordinating Committee, and the AHA Executive Committee. Comprehensive disclosure information for peer reviewers is listed in the Reviewer Disclosure Table.

These recommendations supersede the last full set of AHA/Red Cross first aid guidelines, published in 2015, and recommendations in the 2019 and 2020 focused updates.

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