Summary Document. Protecting and Saving Lives Made Easy

Summary Document Protecting and Saving Lives Made Easy

Table of Contents Introduction... 2 About Health & Safety Institute (HSI)... 2 Integrating 2015 Science, Treatment Recommendations, and Guidelines... 2 Update Subjects by Brand... 3 American Safety & Health Institute (ASHI)... 4 MEDIC First Aid... 4 Update Subjects by Area and Training Level TABLE 1: Education... 5 TABLE 2: Layperson Adult CPR and AED... 8 TABLE 3: Layperson Pediatric CPR and AED... 15 TABLE 4: First Aid... 17 TABLE 5: Healthcare Provider Adult BLS... 33 TABLE 6: Healthcare Provider Pediatric BLS... 43 HSI Advisory Group... 45 2 P age

Introduction The purpose of the document is to highlight the major changes in science, treatment recommendations, and guidelines. We are hopeful that it and other resources related to the process will provide helpful guidance to both instructors and students during the transition. On October 15, 2015, the International Liaison Committee on Resuscitation, or ILCOR, released the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. On the same day the American Heart Association, Inc. (AHA) released updated treatment guidelines based on the ILCOR Consensus on Science. In addition, the ILCOR First Aid Task Force also released the 2015 International Consensus on First Aid Science With Treatment Recommendations which coincided with the release of the 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. The Consensus on Science process, which spanned a five year period, was designed to identify and review international science and knowledge relevant to cardiopulmonary resuscitation, emergency cardiac care, and first aid treatment. These publications provide updated treatment recommendations for emergency medical care based on the most current scientific evidence and are now being integrated into updated ASHI and MEDIC First Aid training materials. About Health & Safety Institute (HSI) HSI unites the recognition and expertise of the American Safety & Health Institute and MEDIC First Aid to create the largest privately held training organization in the industry. For more than 35 years, and in partnership with thousands of approved training centers and hundreds of thousands of professional emergency care, safety, and health educators, HSI authorized instructors in the U.S. and more than 100 countries throughout the world have certified more than 28 million emergency care providers. HSI representatives for ASHI and MEDIC First Aid were volunteer members of the 2010 and 2015 International First Aid Advisory Board founded by the AHA and ARC, and contributed to the 2010 and 2015 Consensus on First Aid Science With Treatment Recommendations. HSI is an accredited organization of the Continuing Education Board for Emergency Medical Services (CECBEMS), the national accreditation body for Emergency Medical Service Continuing Education programs. CECBEMS is an organization established to standardize the review and approval of EMS continuing education activities. To ensure accepted standards, CECBEMS accreditation requires an evidence- based peer- review process for continuing education programs comparable to all healthcare accreditors. HSI s professional- level resuscitation programs are CECBEMS- approved and meet the requirements of the Joint Commission and the Commission on Accreditation of Medical Transport Systems. HSI s basic- and professional- level programs are nationally approved by the Department of Homeland Security, United States Coast Guard, and are endorsed, accepted, approved, or meet the requirements of more than nearly 4000 state regulatory agencies and occupational licensing boards. HSI is a member of the American National Standards Institute and ASTM International, two of the largest voluntary standards- development and conformity- assessment organizations in the world. Integrating the 2015 Science, Treatment Recommendations, and Guidelines In order to integrate the 2015 science, treatment recommendations, and guidelines, time is required to make systematic and organized changes to our training products. We are currently revising all of our emergency care training materials and will incorporate the updated information into our basic and advanced training program materials throughout 2016. 3 P age

Updated ASHI and MEDIC First Aid training program materials will be based upon these publications: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations i 2015 International Consensus on First Aid Science With Treatment Recommendations ii 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care iii 2015 American Heart Association and American Red Cross Guidelines Update for First Aid iv We will be creating interim training materials that allow instructors to immediately incorporate some of the most significant changes in science and treatment recommendations into current (2010) training materials. The interim materials are only intended to be used until the new training programs are made available. The use of these interim materials is an option and not a requirement. Instructors can also continue to use the current (2010) materials as designed. IMPORTANT: THE NEW SCIENCE AND TREATMENT RECOMMENDATIONS DO NOT IMPLY THAT EMERGENCY CARE OR INSTRUCTION INVOLVING THE USE OF EARLIER SCIENCE AND TREATMENT RECOMMENDATIONS IS UNSAFE. YOU MAY CONTINUE TO PURCHASE AND TEACH USING THE CURRENT (2010) TRAINING MATERIALS UNTIL DECEMBER 31, 2016, OR UNTIL THE CURRENT MATERIALS ARE DEPLETED. Update Subjects by Brand Every instructor needs to understand the guideline changes that affect the program(s) he or she is authorized to teach. On the following pages the most significant guideline changes are organized into tables by area and training level. For each identified change, the guideline tables provide the 2010 guideline for reference, the updated 2015 guideline, and the reason for the change. To assist instructors, the program tables immediately below reference the guideline tables an instructor must review in relation to the current programs he or she is authorized to teach. Instructors for the ASHI Advanced Cardiac Life Support (ACLS) and the Pediatric Advanced Life Support (PALS) training programs can find specific guideline tables for those programs in a separate 2015 HSI Updated Training Guidelines Supplement that will be released in the coming weeks. 4 P age

American Safety & Health Institute Training Programs If you teach: Related changes are in: CPR/AED Tables 1, 2, 3 Basic First Aid Tables 1, 2, 3, 4 Basic Wilderness & Wilderness First Aid Tables 1, 2, 3, 4 Child and Babysitting Safety Tables 1, 2, 3, 4 Emergency Oxygen Administration Tables 1, 2, 3, 4 CPR Pro Tables 1, 5, 6 Emergency Medical Responder Tables 1, 5, 6 Wilderness First Responder Tables 1, 5, 6 Wilderness EMT Upgrade Tables 1, 5, 6 MEDIC First Aid Training Programs If you teach: Related changes are in: BasicPlus CPR, AED, and First Aid for Adults Tables 1, 2, 3, 4 Child/Infant CPR and AED Supplement Tables 1, 2, 3 CarePlus CPR and AED Tables 1, 2, 3 PediatricPlus CPR, AED and First Aid for Children, Infants, and Adults Tables 1, 2, 3, 4 5 P age

TABLE 1: Education Topic Type 2010* 2015** Reason for Change Updated Because even minimal training A combination of self- instruction and in AED use has been shown to instructor- led teaching with hands- on improve performance in training can be considered as an simulated cardiac arrests, alternative to traditional instructor- led training opportunities should courses for lay providers. If instructor- be made available and led training is not available, self- directed promoted for lay rescuers. training may be considered for lay S922 providers learning AED skills (Class IIb, LOE C- EO). S564 Basic Life Support Training Although AEDs are located in public areas and untrained providers are encouraged to use them, even minimal training can improve actual performance. Self- directed training can provide more training opportunities for lay rescuers who typically would not attend a traditional training course. Basic Life Support Training Updated Short video instruction combined with synchronous hands- on practice is an effective alternative to instructor- led BLS courses. S922 CPR self- instruction through video- and/or computer- based modules paired with hands- on practice may be a reasonable alternative to instructor- led courses (Class IIb, LOE C- LD). S564 Video- based, self- directed instruction in CPR with hands- on practice has been found to be as effective as traditional instructor- led courses. Self- directed instruction could help to train more people at a lower cost. Basic Life Support Training Updated The use of a CPR feedback device can be effective for training. S923 Use of feedback devices can be effective in improving CPR performance during training (Class IIa, LOE A). S564 Today's technology allows us to effectively measure high performance CPR recommendations such as compression rate, depth, and recoil using standalone or manikin- integrated feedback devices. The ability to provide that feedback in training allows learners to get a realistic sense of proper skills and the effort it takes to perform them. 6 P age

TABLE 1: Education Topic Type 2010* 2015** Reason for Change Updated The use of a CPR feedback device can be effective for training. S923 Basic Life Support Training If feedback devices are not available, auditory guidance (eg, metronome, music) may be considered to improve adherence to recommendations for chest compression rate only (Class IIb, LOE B- R). S564 If a comprehensive feedback device is not available for training due to cost or logistics, an auditory guidance device such as a metronome can be used to provide some guidance as to compression rate. Many metronome apps are available for no or low cost for mobile devices. Basic Life Support Training Updated Skill performance should be assessed during the 2- year certification with reinforcement provided as needed. S923 Given the rapidity with which BLS skills decay after training, coupled with the observed improvement in skill and confidence among students who train more frequently, it may be reasonable for BLS retraining to be completed more often by individuals who are likely to encounter cardiac arrest (Class IIb, LOE C- LD). S566 A renewal or recertification period of two years has proven for most people to be inadequate for maintaining effective CPR performance. An optimal time for retraining can vary from person to person depending on factors such as the quality of initial training and the frequency in which the skills are used in actual resuscitations. Evidence has shown an improvement in those who train more frequently. Basic Life Support Training Self- directed methods can be considered for healthcare professionals learning AED skills (Class IIb, LOE C- EO). S564 Similar to the recommendation for lay rescuers, self- directed training can provide more frequent training opportunities for healthcare providers. 7 P age

TABLE 1: Education Topic Type 2010* 2015** Reason for Change Communities may consider training bystanders in compression- only CPR for adult out- of- hospital cardiac arrest as an alternative to training in conventional CPR (Class IIb, LOE C- LD). S566 Special Considerations While it is important to still cover both breaths and compressions for trained providers because of the chance of a respiratory- related arrest, sudden cardiac arrests involving adults are still a major overall issue for the public at large. Compression- only CPR by an untrained bystander has shown to be effective as an initial approach to SCA and can be quickly understood via a public service announcement, large group presentation, or by an EMS dispatcher over the phone. Special Considerations Training primary caregivers and/or family members of high- risk patients may be reasonable (Class IIb, LOE C- LD), although further work needs to help define which groups to preferentially target. S566 CPR performed by trained family members or caregivers of individuals who have been identified as high- risk cardiac patients, has shown to improve outcomes compared to situations in which there was no training. *American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122, suppl 3 (2010): S639- S946. **American Heart Association. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 132, suppl 2 (2015): S313- S589. 8 P age

Untrained Lay Rescuer TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Updated Because it is easier for Untrained lay rescuers should provide rescuers receiving telephone compression- only CPR, with or without CPR instructions to perform dispatcher assistance (Class I, LOE C- LD). Hands- Only (compression The rescuer should continue only) CPR than conventional compression- only CPR until the arrival of CPR (compressions plus rescue an AED or rescuers with additional breathing), dispatchers should training (Class I, LOE C- LD). S416 instruct untrained lay rescuers to provide Hands- Only CPR for adults with SCA (Class I, LOE B). S686 Compression- only CPR, provided by a bystander for adult cardiac arrest outside of a hospital, has shown to be as effective as traditional CPR. Due to the simplicity of compression- only CPR, untrained bystanders may be able to provide some early treatment for adult sudden cardiac arrest, a major public health crisis. Information on compression- only CPR can be distributed in messaging to large numbers of people, such as through public service announcements. It can also be easily promoted through a phone conversation with an EMS dispatcher. It has been shown that compression- only CPR initiated through dispatcher instructions has improved survival compared to traditional CPR. It is important to note that the use of compression- only CPR is limited to very specific circumstances and does not take the place of formal training in CPR, which includes training in delivering rescue breaths. 9 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Updated Because rescue breathing is an All lay rescuers should, at a minimum, important component for provide chest compressions for victims successful resuscitation from of cardiac arrest (Class I, LOE C- LD). In pediatric arrests (other than addition, if the trained lay rescuer is able sudden, witnessed collapse of to perform rescue breaths, he or she adolescents), from asphyxial should add rescue breaths in a ratio of cardiac arrests in both adults 30 compressions to 2 breaths.(class I, and children (eg, drowning, LOE C LD).S417 drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) for those specific situations (Class IIa, LOE C). S 691 Layperson Compression- Only CPR Versus Conventional CPR The 2015 evidence evaluation found no overall differences between compression- only and conventional CPR (compressions plus breaths). However, much of the research has been done on persons assumed to have suffered sudden cardiac arrest. When considering the importance of rescue breaths in CPR delivery, the underlying cause matters. Compression- only CPR can be effective early in a sudden cardiac arrest, where the underlying initial cause is the disruption of the heart's own electrical pathway and resulting ventricular fibrillation. Unfortunately, without a quick AED or EMS response, there is a point at which the absence of rescue breaths may reduce survival because of inadequate oxygen and increased carbon dioxide in the blood. Cardiac arrest can also be the progressive end result of the loss of an airway and/or breathing. In these cases, the inclusion of rescue breaths could actually reverse the progression and restore breathing and circulation. While compression- only CPR can quickly be understood without formal training, those who choose to be trained benefit from learning both compressions and rescue breaths. Consequently, if a trained lay rescuer can perform rescue breaths, they should be provided. 10 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change and Updated Cardiac or Respiratory Arrest Associated With Opioid Overdose There are no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.s840 Empiric administration of IM or IN naloxone to all unresponsive opioid associated life- threatening emergency patients may be reasonable as an adjunct to standard first aid and non healthcare provider BLS protocols (Class IIb, LOE C- EO). S505 In high doses, opioids such as morphine, heroin, tramadol, oxycodone, and methadone can cause respiratory depression and death. Opioid overdose is a public health crisis. Naloxone is an antidote to opioid overdose and can completely reverse its effects if administered in time. Naloxone administered by bystanders - particularly by family members and friends of those known to be addicted is a potentially life- saving treatment. Cardiac or Respiratory Arrest Associated With Opioid Overdose Unless the patient refuses further care, victims who respond to naloxone administration should access advanced healthcare services (Class I, LOE C- EO) S506. Responders should not delay access to more- advanced medical services while awaiting the patient s response to naloxone or other interventions (Class I, LOE C- EO). S505 While naloxone administered by bystanders is a potentially life- saving treatment, it should not be seen as a replacement for more advanced medical care. The 2015 evidence evaluation determined that naloxone administration improves spontaneous breathing and consciousness in the majority of persons treated, and complication rates are low. However, activation of EMS and CPR should never be delayed for naloxone administration. 11 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Victims who respond to naloxone administration should access advanced healthcare services (Class I, LOE C- EO). Responders should not delay access to more- advanced medical services while awaiting the patient s response to naloxone or other interventions (Class I, LOE C- EO). S505 Cardiac or Respiratory Arrest Associated With Opioid Overdose Providing naloxone to individuals most likely to witness an opioid overdose (bystanders, friends, family) and training them on its use can substantially reduce the deaths resulting from opioid overdose. Cardiac or Respiratory Arrest Associated With Opioid Overdose It is reasonable to provide opioid overdose response education, either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose (Class IIa, LOE C- LD). It is reasonable to base this training on first aid and non healthcare provider BLS recommendations rather than on more advanced practices intended for healthcare providers (Class IIa, LOE C- EO). S418, S505 Educating those most at risk, along with others who have close contact with those at risk, can improve the speed at which naloxone can be provided. 12 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Updated The adult sternum should be depressed at least 2 inches (5 cm) (Class IIa, LOE B) S690 Chest Compression Depth During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than2.4 inches or 6 cm) (Class I, LOE C- LD). S419 Most CPR compressions are too shallow and it is more effective to compress deeper rather than shallower. Defining an upper limit can help rescuers better understand the allowance for a greater depth. The upper limit also helps rescuers understand that, at some point, compressions become less effective and that there is a small risk of injury. The use of feedback devices during resuscitation may also help rescuers to better achieve the recommended depth range. Chest Compression Rate Updated It is therefore reasonable for lay rescuers and healthcare providers to perform chest compressions for adults at a rate of at least 100 compressions per minute (Class IIa, LOE B). S690 In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/min (Class IIa, LOE C- LD). S419 Defining an upper limit for compression rate, or speed, can help rescuers focus on achieving an optimum approach during CPR. A faster compression rate of more than 100 compressions per minute has shown to be more effective. However, rates above 120 have shown to diminish overall effectiveness, especially in terms of reduced compression depth. Again, feedback devices can help keep compression rates on track. 13 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Chest Wall Recoil Updated Allow the chest to completely recoil after each compression (Class IIa, LOE B). S690 It is reasonable for rescuers to avoid leaning on the chest between compressions to allow full chest wall recoil for adults in cardiac arrest (Class IIa, LOE C- LD). S420 Better describing chest recoil in terms of how a rescuer most likely causes it to happen, may help to reduce its occurrence. Rescuers can concentrate on allowing full expansion of the chest if they do not feel like they are leaning on the chest at the top of each compression. Minimizing Interruptions in Chest Compressions Minimizing Interruptions in Chest Compressions Updated Performing chest compressions while another rescuer retrieves and charges a defibrillator improves the probability of survival. S694 In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60% (Class IIb, LOE C- LD). S420 In adult cardiac arrest, total pre- shock and post- shock pauses in chest compressions should be as short as possible (Class I, LOE C- LD). S420 Research has shown the benefit of minimizing interruptions to chest compressions during CPR. A compression fraction is the percentage of time during overall CPR performance that chest compressions are actually being provided. While there are necessary interruptions such as giving rescue breaths and using an AED, keeping those to the shortest time possible remains a point of emphasis for high quality CPR. Because shorter pauses were associated with greater shock success, return of spontaneous circulation, and higher survival to hospital discharge in some studies, minimizing interruptions in chest compressions remains a point of emphasis for high quality CPR. 14 P age

TABLE 2: Layperson Adult CPR and AED Topic 2010* 2015** Reason for Change Updated Deliver each rescue breath over 1 second (Class IIa, LOE C). S688 Minimizing Interruptions in Chest Compressions For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions for less than 10 seconds to deliver 2 breaths (Class IIa, LOE C- LD). S420 Remembering that avoiding excessive volume on rescue breaths is a goal of high quality CPR, being able to deliver 2 effective rescue breaths as quickly as possible, and under 10 seconds, is recommended. *American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122, suppl 3 (2010): S639- S946. **American Heart Association. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 132, suppl 2 (2015): S313- S589. 15 P age

TABLE 3: Layperson Pediatric CPR and AED Topic Type 2010* 2015** Reason for Change Updated Chest compressions of To maximize simplicity in CPR training, in appropriate rate and depth. the absence of sufficient pediatric Push fast : push at a rate of evidence, it is reasonable to use the at least 100 compressions adult chest compression rate of 100/min per minute. Push hard : to 120/min for infants and children push with sufficient force to (Class IIa, LOE C- EO). S521 depress at least one third the anterior- posterior (AP) diameter of the chest or approximately 1 1 2 inches (4 cm) in infants and 2 inches (5 cm) in children (Class I, LOE C). S864 Components of High- Quality CPR: Chest Compression Rate and Depth There was very little evidence in regard to an ideal compression depth to recommend for a child or infant. To simplify the overall CPR information, the recommendation was to be consistent with the adult recommendation. Components of High- Quality CPR: Chest Compression Rate and Depth Updated Chest compressions of appropriate rate and depth. Push fast : push at a rate of at least 100 compressions per minute. Push hard : push with sufficient force to depress at least one third the anterior- posterior (AP) diameter of the chest or approximately 1 1 2 inches (4 cm) in infants and 2 inches (5 cm) in children (Class I, LOE C). S864 It is reasonable that in pediatric patients (1 month to the onset of puberty) rescuers provide chest compressions that depress the chest at least one third the anterior- posterior diameter of the chest. This equates to approximately 1.5 inches (4 cm) in infants to 2 inches (5 cm) in children (Class IIa, LOE C- LD). S521 There was very little change in the pediatric compression depth recommendation from the previous recommendation in 2010. 16 P age

TABLE 3: Layperson Pediatric CPR and AED Topic Type 2010* 2015** Reason for Change Updated Optimal CPR in infants and children includes both compressions and ventilations, but compressions alone are preferable to no CPR (Class 1 LOE B). S867 Components of High- Quality CPR: Compression- Only CPR Conventional CPR (rescue breathing and chest compressions) should be provided for pediatric cardiac arrests (Class I, LOE B- NR). The asphyxial nature of the majority of pediatric cardiac arrests necessitates ventilation as part of effective CPR. However, because compression- only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression- only CPR for infants and children in cardiac arrest (Class I, LOE B- NR). S522 When considering the importance of rescue breaths in CPR, the underlying cause matters. In adults, most cardiac arrests are sudden and caused by abnormal heart rhythms. Compression- only CPR is focused on these arrests in an attempt to circulate oxygen still available within the blood. Cardiac arrest in infants and children is rarely sudden. Most occur as a result of a severe oxygen shortage in the body, or asphyxia, when breathing is restricted or stops. Causes include respiratory diseases, suffocation, strangulation, submersion, and choking. Giving rescue breaths to a child is extremely important. Rescue breaths improve oxygenation which may prevent brain damage and restore breathing and circulation. Studies show that the use of compression- only CPR on pediatric patients was associated with worse neurologic outcomes when compared with conventional CPR. Thus, rescue breaths remain a critically important component of effective CPR for infants and children in cardiac arrest. *American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122, suppl 3 (2010): S639- S946. **American Heart Association. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 132, suppl 2 (2015): S313- S589. 17 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Burns Updated 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). S937 Cool thermal burns with cool or cold potable water as soon as possible and for at least 10 minutes (Class I, LOE B- NR). S580 Early cooling of a burn has been found to minimize the risk and depth of injury. Both cool and cold water can be effective. The use of ice is not recommended and the time to cool a burn has been more clearly defined. Burns Updated Loosely cover burn blisters with a sterile dressing but leave blisters intact because this improves healing and reduces pain (Class IIa, LOE B). S937 After cooling of a burn, it may be reasonable to loosely cover the burn with a sterile, dry dressing (Class IIb, LOE C- LD). S580 Burns If cool or cold water is not available, a clean cool or cold, but not freezing, compress can be useful as a substitute for cooling thermal burns (Class IIa, LOE B- NR). S580 Burns Care should be taken to monitor for hypothermia when cooling large burns (Class I, LOE C- EO). S580 The use of a dry, sterile dressing on a burn after cooling may be reasonable to help keep the burn clean. Early cooling of a burn has been found to minimize the risk and depth of injury. Clean, cool, or cold (not frozen) dressings can be used as a substitute when running water is not immediately available. For larger and deeper burns, cooling could have a secondary effect of cooling the body overall and causing hypothermia. This is especially true for children. 18 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Burns In general, it may be reasonable to avoid natural remedies, such as honey or potato peel dressings (Class IIb, LOE C- LD). However, in remote or wilderness settings where commercially made topical antibiotics are not available, it may be reasonable to consider applying honey topically as an antimicrobial agent (Class IIb, LOE C- LD). S580 Honey has shown in some studies to actually decrease the risk of infection and healing time for burns. However, the studies were questioned in regard to the quality of the information. At this time, it is generally recommended to avoid natural remedies for burn dressings. Using honey as a topical agent in a remote or wilderness setting when antibiotic ointments are not available may be a reasonable consideration for reducing the risk of infection. Burns Burns associated with or involving (1) blistering or broken skin; (2) difficulty breathing; (3) the face, neck, hands, or genitals; (4) a larger surface area, such as trunk or extremities; or (5) other cause for concern should be evaluated by a healthcare provider (Class I, LOE C- EO). S580 Dental Injury Following dental avulsion, it is essential to seek rapid assistance with reimplantation (Class I, LOE C- EO). S580 Burns most likely to have secondary complications such as infection, restrictions on function, or poor healing due to surface contact or repeated movements, should be evaluated by a healthcare provider. Immediate reimplantation of an avulsed tooth is felt to provide the best chance of survival for the tooth. 19 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Dental Injury Updated Place the tooth in milk, or clean water if milk is not available. S939 In situations that do not allow for immediate reimplantation, it can be beneficial to temporarily store an avulsed tooth in a variety of solutions shown to prolong viability of dental cells (Class IIa, LOE C- LD). If none of these solutions are available, it may be reasonable to store an avulsed tooth in the injured person s saliva (not in the mouth) pending reimplantation (Class IIb, LOE C- LD). S580 When a situation forces a delay in reimplantation, certain solutions have shown to prolong the time period in which successful reimplantation can occur. In order of preference, the solutions are Hank s Balanced Salt Solution (containing calcium, potassium chloride and phosphate, magnesium chloride and sulfate, sodium chloride, sodium bicarbonate, sodium phosphate dibasic and glucose), propolis, egg white, coconut water, Ricetral, or whole milk. If these solutions are not immediately available for the storage of an avulsed tooth, it may be reasonable to store the tooth in the saliva of the affected person. Due to the risk of additional tooth damage or accidentally swallowing the tooth, it is not recommended to store the tooth in the affected person's mouth. First Aid Education Education and training in first aid can be useful to improve morbidity and mortality from injury and illness (Class IIa, LOE C- LD). S575 Studies have shown that education and training in first aid can help to improve the recognition, resolution, and survival of medical emergencies. 20 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated In unusual circumstances, When a person with anaphylaxis does not when advanced medical respond to the initial dose, and arrival of assistance is not available, a advanced care will exceed 5 to 10 minutes, second dose of epinephrine a repeat dose may be considered (Class IIb, may be given if symptoms of LOE C- LD). S577 anaphylaxis persist. S936 Medical Emergencies: Anaphylaxis Greater clarification of the need and timing for a second dose of epinephrine when the symptoms of anaphylaxis do not respond to the first dose and advanced medical care is still not available. Medical Emergencies: Asthma Updated 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. S936 It is reasonable for first aid providers to be familiar with the available inhaled bronchodilator devices and to assist as needed with the administration of prescribed bronchodilators when a person with asthma is having difficulty breathing (Class IIa, LOE B- R). S576 Inhaled bronchodilators have shown to be an effective treatment for asthma and other breathing disorders related to the narrowing of the small breathing passages in the lungs. The risk of adverse reactions from using these medications is low. Being familiar with the use of these devices and being able to assist someone in using one are reasonable training goals for a first aid provider. 21 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change First aid providers caring for individuals with chemical eye injury should contact their local poison control center or, if a poison control center is not available, seek help from a medical provider or 9-1- 1 (Class I, LOE C- EO). S578 Medical Emergencies: Chemical Eye Injury Local poison control centers reached through the Poison Help line (1-800- 222-1222), a medical provider, or EMS can help to quickly identify treatment recommendations for specific chemicals that have injured an eye. Medical Emergencies: Chest Pain Updated While waiting for EMS to arrive, the first aid provider may encourage the victim to chew and swallow 1 adult (non enteric- coated) or 2 low- dose baby aspirins if the patient has no allergy to aspirin or other contraindication to aspirin, such as evidence of a stroke or recent bleeding. S936 Aspirin has been found to significantly decrease mortality due to myocardial infarction in several large studies and is therefore recommended for persons with chest pain due to suspected myocardial infarction (Class I, LOE B- R). While waiting for EMS to arrive, the first aid provider may encourage a person with chest pain to take aspirin if the signs and symptoms suggest that the person is having a heart attack and the person has no allergy or contraindication to aspirin, such as recent bleeding (Class IIa, LOE B- NR). If a person has chest pain that does not suggest that the cause is cardiac in origin, or if the first aid provider is uncertain or uncomfortable with administration of aspirin, then the first aid provider should not encourage the person to take aspirin (Class III: Harm, LOE C- EO). S577 The early administration of aspirin in the first aid setting for chest pain related to myocardial infarction (typically a blood clot blocking an artery responsible for providing oxygen to heart tissue), has shown to be of greater benefit than when given later in the healthcare setting. First aid providers need to be confident in their suspicion of heart- related pain and their ability to rule out any allergies or other reasons, such as recent bleeding If the first aid provider is not confident that the chest pain is related to a cardiac problem, then the provider should not encourage the use of aspirin. 22 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change If a person with diabetes reports low blood sugar or exhibits signs or symptoms of mild hypoglycemia and is able to follow simple commands and swallow, oral glucose should be given to attempt to resolve the hypoglycemia. Glucose tablets, if available, should be used to reverse hypoglycemia in a person who is able to take these orally (Class I, LOE B- R). It is reasonable to use dietary sugars as an alternative to glucose tablets (when not available) for reversal of mild symptomatic hypoglycemia (Class IIa, LOE B- R). For diabetics with symptoms of hypoglycemia, symptoms may not resolve until 10 to 15 minutes after ingesting glucose tablets or dietary sugars. First aid providers should therefore wait at least 10 to 15 minutes before calling EMS and re- treating a diabetic with mild symptomatic hypoglycemia with additional oral sugars (Class I, LOE B- R). If the person s status deteriorates during that time or does not improve, the first aid provider should call EMS (Class I, LOE C- EO). S577- S578 Medical Emergencies: Hypoglycemia If a diabetic person is suspected to have low blood sugar and is able to swallow safely, it is recommended to use oral glucose tablets to reverse early mild symptoms of hypoglycemia. If glucose tablets are not available, specific dietary sugars are recommended for use instead. Because symptoms will diminish gradually, it is recommended that first aid providers wait 10 to 15 minutes before activating EMS and providing additional oral glucose or dietary sugars. If a person's condition deteriorates at any time, it is recommended that EMS be activated immediately. 23 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change The use of a stroke assessment system by first aid providers is recommended (Class I, LOE B- NR). S577 Medical Emergencies: Stroke Hospital- based advanced treatments for strokes are available, but the time to get to them is a big factor in effectiveness and survival. Early use of a stroke assessment by a first aid provider has shown to significantly decrease the time between the onset of the stroke and definitive treatment in a hospital. Medical Emergencies: Toxic Eye Injury Updated Rinse eyes exposed to toxic substances immediately with a copious amount of water (Class I, LOE), unless a specific antidote is available. S940 It can be beneficial to rinse eyes exposed to toxic chemicals immediately and with a copious amount of tap water for at least 15 minutes or until advanced medical care arrives (Class IIa, LOE C- LD). If tap water is not available, normal saline or another commercially available eye irrigation solution may be reasonable (Class IIb, LOE C- LD). S578 The immediate flushing of eyes that have been exposed to toxic substances with copious, or large, volumes of tap water has been found to be the easiest and best approach. Because some toxic substances take longer to become diluted than others, it is recommended to flush for at least 15 minutes or until advanced help arrives. When tap water is not immediately available, normal saline or another commercially available eye irrigating solution can be used. 24 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated Do not move or try to straighten an injured extremity (Class III, LOE C). Expert opinion suggests that splinting may reduce pain 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). S938 Musculoskeletal Trauma In general, first aid providers should not move or try to straighten an injured extremity (Class III: Harm, LOE C- EO). Based on training and circumstance (such as remote distance from EMS or wilderness settings, presence of vascular compromise), some first aid providers may need to move an injured limb or person. In such situations, providers should protect the injured person, including splinting in a way that limits pain, reduces the chance for further injury, and facilitates safe and prompt transport (Class I, LOE C- EO). S580 As a general approach, it is best to not move or straighten an injured extremity that is unnaturally bent or angulated. However, there may be additional training necessary on moving and splinting in specific cases, such as in remote settings or if neurological/vascular compromise is suspected. Training in moving and splinting an injured extremity should emphasize the protection of the affected person, limiting pain, reducing the chance for further injury, and facilitating quick and safe transportation to a healthcare facility. Musculoskeletal Trauma If an injured extremity is blue or extremely pale, activate EMS immediately (Class I, LOE C- EO). S580 When the skin color of an injured extremity indicates a lack of oxygen in the blood (blue) or a lack of blood flow (pale), there is a likely possibility that the vascular system has been compromised by the injury. Early recognition and EMS activation by a first aid provider can help to prevent additional injury. 25 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated There is no evidence for or against the routine use of oxygen as a first aid measure for victims experiencing shortness of breath or chest pain. Oxygen may be beneficial for first aid in divers with a decompression injury. S935- S936 Oxygen Use in First Aid The use of supplementary oxygen by first aid providers with specific training is reasonable for cases of decompression sickness (Class IIa, LOE C- LD). For first aid providers with specific training in the use of oxygen, the administration of supplementary oxygen to persons with known advanced cancer with dyspnea and hypoxemia may be reasonable (Class IIb, LOE B- R). Although no evidence was identified to support the use of oxygen, it might be reasonable to provide oxygen to spontaneously breathing persons who are exposed to carbon monoxide while waiting for advanced medical care (Class IIb, LOE C- EO). S576 Even though supplementary oxygen is used commonly in healthcare environments, there was not much evidence of its beneficial use in the first aid setting. The use of supplementary oxygen in first aid situations is not a standard skill. However, there were a few specific circumstances in which the benefit of supplemental oxygen was shown. In addition, it was felt to be reasonable to provide oxygen, while waiting for advanced medical care, for individuals who had been exposed to carbon monoxide. Specialized training in the use of oxygen delivery systems is required when it is made available. Position for Shock Updated 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. S935 If there is no evidence of trauma or injury (eg, simple fainting, shock from nontraumatic bleeding, sepsis, dehydration), raising the feet about 6 to 12 inches (about 30 to 60 ) from the supine position is an option that may be considered while awaiting arrival of EMS (Class IIb, LOE C- LD). S576 Clarification is provided for the description of non- traumatic situations, including nervous system reactions (fainting), non- traumatic bleeding, sepsis, and dehydration. The recommendation is simply an option to consider based on the limited, or lack of any, benefit shown by the evidence. 26 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated If the victim is facedown 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 HAINES recovery position. S935 Positioning the Ill or Injured Person If a person is unresponsive and breathing normally, it may be reasonable to place him or her in a lateral side- lying recovery position (Class IIb, LOE C- LD). If a person has been injured and the nature of the injury suggests a neck, back, hip, or pelvic injury, the person should not be rolled onto his or her side and instead should be left in the position in which he or she was found, to avoid potential further injury (Class I, LOE C- EO). If leaving the person in the position found is causing the person s airway to be blocked, or if the area is unsafe, move the person only as needed to open the airway and to reach a safe location (Class I, LOE C- EO). S575 When an unresponsive and breathing person is not suspected of being injured, it is reasonable to place them in a lateral side- lying recovery position to improve the airway and the ability to breath. This position uses an extended arm to rest the head on and positioning of the legs to stabilize the body. To avoid additional injury, it is best to leave an injured person, who is unresponsive and breathing, in the position he or she was found. If that position is unsafe or results in a compromised airway, it is appropriate to move the person as needed to create a clear airway or be removed from danger. 27 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Any person with a head injury that has resulted in a change in level of consciousness, has progressive development of signs or symptoms as described above, or is otherwise a cause for concern should be evaluated by a healthcare provider or EMS personnel as soon as possible (Class I, LOE C- EO). S579 Trauma Emergencies: Concussion Available two- stage assessment processes for identifying concussions are not appropriate for use in first aid settings because they require an assessment prior to injury for comparison. An appropriate single stage assessment for first aid is currently not available. The first aid recommendation is to suspect the possibility of a concussion whenever there is a change in the level of consciousness or if there is a progressive development of signs such as feeling stunned or dazed, experiencing headache, nausea, dizziness or difficulty in balance, or showing visual disturbance, confusion, or loss of memory (from either before or after the injury). If a concussion is suspected, it is appropriate for the affected person to be evaluated by EMS or another healthcare provider as soon as possible. Trauma Emergencies: Concussion Using any mechanical machinery, driving, cycling, or continuing to participate in sports after a head injury should be deferred by these individuals until they are assessed by a healthcare provider and cleared to participate in those activities (Class I, LOE C- EO). S579 Because of the progressive nature of concussion, it is best not to allow an affected person to perform actions that could pose a risk for additional injury, until he or she can adequately be assessed by a healthcare provider. 28 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated Bleeding is best controlled by applying pressure until bleeding stops or EMS rescuers arrive (Class I, LOE A). S936 Trauma Emergencies: Control of Bleeding The standard method for first aid providers to control open bleeding is to apply direct pressure to the bleeding site until it stops. Control open bleeding by applying direct pressure to the bleeding site (Class I, LOE B- NR). S578 Further clarification of direct pressure as the standard method of bleeding control for open bleeding. Trauma Emergencies: Control of Bleeding Local cold therapy, such as an instant cold pack, can be useful for these types of injuries to the extremity or scalp (Class IIa, LOE C- LD). Cold therapy should be used with caution in children because of the risk of hypothermia in this population (Class I, LOE C- EO). S578 Although there is limited data on the benefit, local cooling of a closed injury, such as bruising, can be useful when the scalp or an extremity is injured. 29 P age

TABLE 4: First Aid Topic Type 2010* 2015** Reason for Change Updated 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). S937 Trauma Emergencies: Control of Bleeding Because the rate of complications is low and the rate of hemostasis is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control severe external limb bleeding. (Class IIb, LOE C- LD). A tourniquet may be considered for initial care when a first aid provider is unable to use standard first aid hemorrhage control, such as during a mass casualty incident, with a person who has multisystem trauma, in an unsafe environment, or with a wound that cannot be accessed (Class IIb, LOE C- EO). S579 Additional evidence since 2010 indicates a low rate of potential complications and a high rate of success when using a tourniquet for severe bleeding control. For most situations, the guideline remains the same: Begin with direct pressure on a severely bleeding limb wound and use a tourniquet if direct pressure cannot be applied or control the bleeding effectively. However, in certain circumstances, such as a large mass- casualty event, a single person with multiple injuries, a dangerous environment, or a wound that cannot be accessed, the use of a tourniquet as the first bleeding control measure can be considered. Trauma Emergencies: Control of Bleeding It is reasonable for first aid providers to be trained in the proper application of tourniquets, both manufactured and improvised (Class IIa, LOE C- EO). S579 Commercially manufactured tourniquets have shown to be more effective than improvised ones. If a manufactured tourniquet is not immediately available, it is possible to create an improvised tourniquet using nearby materials. 30 P age