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.

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).

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.

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.

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 observational studies in first aid science are clearly needed.

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.

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.

First aid scenarios vary widely, from minor illness and injuries to immediately life-threatening conditions such as heart attack, stroke, major trauma, or overdose. People may require first aid care for a few minutes or many hours, and not all scenes are safe. First aid providers vary in age, physical ability, level of acquired and retained skill, and willingness and ability to act. No single set of guidelines can encompass all scenarios. The philosophical principles of beneficence, non-maleficence, and autonomy are applicable: The first aid provider should assist the ill or injured person as much as possible, avoid causing harm, and respect the right of a person who is alert and capable of decision-making to accept or refuse care.¹

First aid recommendations do not include actions that legally can be performed only by a health care professional or those actions that require specialized training or equipment. In some cases, a first aid provider may have specialized training and a duty to respond; common examples include lifeguards and members of industrial emergency response teams. Local and institutional protocols and the tenets of advanced training supersede general first aid recommendations.

These guidelines assume that a first aid provider has access to common household items and nonprescription medications but does not have access to specialized medical equipment or monitoring tools. In addition, they are assumed to apply to settings where access to EMS and higher levels of medical care are readily available. Recommendations may need to be altered or amended in rural, wilderness, and other low-resource settings.

The first aid provider can improve and empower their response through training and preparation, including maintaining a first aid kit and preparing for setting and activity-related responses such as in the home, at the beach, or while backcountry skiing. The Red Cross’ recommended first aid kit content list is detailed in Tables 2(link opens in new window) and 3(link opens in new window). The first step in the first aid response is to assess the scene for hazards and threats and to take actions to protect oneself, such as using personal protective equipment (PPE). There can be ambiguity in emergencies, and it can be difficult to determine whether help is needed. Deciding to act is the most important first step in the provision of first aid.

The person who may be ill or injured should be assessed with the standard systematic approach taught in a first aid course. First aid providers should assess the ill or injured person by checking for responsiveness, breathing, and potential injuries. Any abnormalities in responsiveness or breathing and any major injuries should be viewed as an emergency and should prompt activation of EMS.

Signs of a first aid emergency requiring professional assistance include (but are not limited to) the following:

• Unresponsiveness or new confusion
• Breathing that is absent, abnormal sounding, too fast, or too slow
• Severe or life-threatening bleeding
• Persistent vomiting or diarrhea
• Pallor, weakness, lethargy, diaphoresis, weak or absent peripheral pulses
• Evidence of allergic reaction such as hives, facial swelling, difficulty breathing, or vomiting
• Loss of vision, hearing, speech, movement, or balance
• Severe pain, including chest and abdominal pain
• Unusual behavior, especially actions that may cause harm (eg, walking into traffic)
• Bites and stings from venomous snakes, scorpions, spiders, and certain insects
• Exposure to toxins and poisons
• Broken and dislocated limbs and joints

Whenever possible, first aid providers should approach from the direction that the person who needs help is facing, so as not to surprise or startle them and cause unnecessary movement. First aid providers should always begin by introducing themselves and their intention and obtaining the consent of the person or their parent or guardian. If the person is unresponsive or the parent or guardian of a minor is not present, consent to treatment is implied. A calm voice and approach can reduce the person’s fear and anxiety. This also allows the first aid provider to determine whether the person is awake and responsive to voice and verbal commands. If the ill or injured person can talk or cry normally, it may be assumed that their airway is open and their breathing is adequate. The first aid provider should communicate with the ill or injured person, explaining what they are doing to help and acting with respect and empathy. Many people with underlying health conditions will wear medical alert jewelry (typically a bracelet or pendant). The first aid provider should quickly look for this to help guide initial evaluation and treatment.

In many cases, an ill or injured person with a normal alertness and responsiveness may be left in the position in which they are most comfortable (usually the position in which they are found) unless there is a need to move them to a different location or position for safety reasons or to facilitate treatment. First aid providers may assess an ill or injured person by asking them questions to determine their mental status or medical history or by more closely examining part of their body (after obtaining consent). The first aid provider should activate EMS as soon as they determine that help is needed. Emergency telecommunicators (911 dispatchers or 911 call takers) can be a valuable source of help in directing first aid actions. If first aid provider is using a mobile phone, they should provide care to the ill or injured person while talking to the emergency dispatcher by activating the phone’s speaker function.

Not having first aid equipment is not a barrier to providing first aid. First aid providers may use whatever resources are available to them, and improvised equipment such as dressings and splints may be found among common items. Moreover, the simple act of attending to a frightened person is a compassionate act of first aid in and of itself.

A crucial early step of first aid intervention is to recognize when help is needed and how to get it. First aid providers should know how to activate an on-site emergency response plan, how and when to access the EMS system, and how to contact the regional poison center (Table 4(link opens in new window)).

Providing care for someone who is ill or injured should not delay calling for more advanced care if it is needed. However, if the first aid provider is alone with an injured or ill person and there are imminent threats to life involving the ABCs (airway, breathing, circulation), it may be necessary to perform lifesaving emergency interventions such as opening the airway or controlling life-threatening hemorrhage before leaving the person to activate the emergency response system.

Proper hand hygiene prevents the spread of infections to the first aid provider and the ill or injured person. Hands should be cleaned with soap and water before and after first aid is provided and after contact with bodily fluids and surfaces around the person and handling medical equipment. An alcohol-based hand sanitizer may be used if soap and water are unavailable and the hands are not visibly soiled. If using soap and water, the first aid provider should wash hands for at least 20 seconds, scrubbing all surfaces of the fingers, hands, and wrists. Alcohol-based sanitizers should contain at least 60% ethanol or isopropyl alcohol and should be rubbed over all surfaces of the fingers, hands, and wrists until the sanitizer has dried, ≈ 30 seconds.

First aid should not be delayed or deferred because of concerns about disease transmission. However, the use of PPE may help protect the first aid provider, the ill or injured person, and any bystanders. PPE minimizes exposure to hazards that cause injuries or illnesses and includes items such as gloves, masks, eye shields, gowns, and aprons. Education on and demonstration of how to perform hand hygiene and to safely put on, take off, and dispose of PPE are integral parts of risk reduction and should be included in all first aid education programs.

Providing first aid requires special consideration of the unique cultures, experiences, and characteristics of people and communities. Special consideration may be beneficial for the following groups.

Various Age Groups

Neonates (<30 days of age) and infants (between 30 days and 1 year of age): Care must be gentle and specialized, with attention to the fragility of their small size. Techniques such as infant cardiopulmonary resuscitation (CPR) require specific knowledge and handling.

Children (1 year of age–beginning of puberty): Communication might be challenging; attempt to calm them and possibly engage their caregiver. Age-appropriate techniques and equipment are essential. Beginning of puberty is defined by appearance of breast buds in girls and axillary hair in boys.

Adolescents: Consider their privacy and emotional concerns, and be sensitive to their potential fear or embarrassment.

Adults: Approach with standard procedures, adjusting for any preexisting conditions or other special needs.

Older people: Be aware of possible preexisting medical conditions, medications, or frailty. Ensure comfort, and take extra time if needed to communicate effectively.

Gender Identity

Respectful language: Use the person’s preferred pronouns and name if known.

Consider privacy and sensitivities: Recognize and respect potential sensitivities related to the person’s gender identity, especially if their clothing needs to be removed for treatment.

Different Cultures, Religions, and Languages

Cultural sensitivity: Recognize that cultural beliefs and practices may influence how a person reacts to illness or injury.

Religious considerations: Respect religious restrictions or requirements such as modesty, and seek guidance from family or community members if needed.

Language considerations: With appropriate privacy considerations, use translation assistance from bystanders or technology as appropriate.

People Experiencing Homelessness and People Who Use Drugs

Nonjudgmental approach: Approach with compassion and without judgment, focusing on the immediate medical needs.

Cognitively Diverse People

Respect for personal space: Maintain a respectful distance whenever possible because some individuals may have sensory sensitivities. Work with caregivers if possible.

Clear communication: Use simple, clear language and be patient, allowing extra time for responses.

Engage caregivers: If present, caregivers or family members may help with communication or care.

People Who Have Physical Disabilities

Understanding the differences and limitations: Be aware of the specific disability if possible, and adjust your approach accordingly.

Communication aids: Use aids or assistance from caregivers if needed for effective communication.

Victims of Physical or Sexual Violence

Injury and treatment may cause or exacerbate psychological trauma. A sensitive approach using the principles of trauma-informed care may be helpful.^2–4

First Aid Education

The primary goal of first aid education is to enhance layperson response to emergencies, aiming to increase both the quantity and quality of engagement in treating ill or injured people. This increase in layperson intervention is essential for reducing morbidity and saving lives.⁵ Universal access to first aid education is strongly recommended, and its integration into everyday activities is advocated to achieve this goal.⁵

Teaching Methodology

Although there is a lack of extensive RCTs, the combination of health science educational best practices and observational and quasi-experimental studies in first aid education provides a solid foundation for these recommendations. The teaching methodology of first aid is crucial. The “Learn, See, Practice, Prove, Do, Maintain” framework proposed by Sawyer et al⁶ incorporates various educational concepts from procedural learning,⁶ simulation,⁷ and resuscitation science.⁸ This model begins with learning, ideally through multimedia resources, followed by real-life demonstrations (seeing). These steps represent a “flipped classroom” model, enhancing advanced learning tasks in the presence of a teacher and peers.⁹ Deliberate practice combines appropriate training frequency,¹⁰ low-risk practice environments,¹¹ and direct observation for feedback.^12,13 Proving involves using valid and reliable assessments to ensure effective learning outcomes.¹⁴ For instance, a first aid provider certificate should indicate a learner’s ability to positively affect patient outcomes.¹⁵ Maintaining the ability to perform first aid skill sets independently requires intermittent skill refreshers, also called spaced learning.^{16, 17, 18} No educational effort perfectly integrates all aspects of the Learn, See, Practice, Prove, Do, Maintain framework, but it serves as a comprehensive guide for educators planning first aid training, covering content, teaching methods, and evaluation strategies.^19,1020

Local Context

A crucial aspect of education delivery is understanding local needs before implementing an intervention.²⁰ Community engagement helps tailor the content such as prioritizing anaphylaxis education in schools that have a history of related emergencies or focusing on naloxone administration training for people who are most likely to witness an opioid emergency.^21–25 Programs like Stop the Bleed have gained traction partly because of their relevance to societal issues like mass shootings in America.²⁶ First aid educators should also focus on communities with historically poor medical outcomes attributable to lack of prior efforts for dedicated first aid education.⁵

After the appropriate first aid topics are selected, decisions on the target audience, educators, additional teaching strategies, and evaluation methods are made.²⁰ Schools and other community institutions are key venues for universal first aid education. Even young children in schools should be included because they are capable of performing essential first aid tasks.²⁷ A collaborative approach in which first aid experts and community leaders work together in a train-the-trainer model is ideal.²⁸ This approach not only facilitates initial learning but also supports ongoing training refreshers.¹⁷ Various methods, including discussions, simulations, and technological innovations such as CPR feedback devices²⁹ and potential future use of virtual/augmented reality platforms,³⁰ enhance the learning experience.

Evaluation

Evaluating the impact of first aid education involves aligning learning objectives with appropriate evaluation techniques, considering the constraints of time and resources.^20,31 Educational evaluations should focus on the effects of a course on first aid providers’ willingness and ability to provide appropriate first aid rather than just on course enjoyment.¹⁹ Integrating educational efforts with implementation science, quality improvement science, and human factors principles can further enhance education and lead to better patient and provider outcomes.³²

The positioning of the ill or injured person is an important first aid intervention that may affect their safety, airway patency, and sustained injuries. The recovery position, also described as semiprone, lateral recumbent, side lying, and three-quarters prone (Figure 1), has long been recommended for individuals with decreased level of consciousness. Although the recovery position has been the subject of little formal study, its anticipated benefits are to maintain an open airway, prevent aspiration, and provide stability and comfort.¹ However, the recovery position may not be ideal if there are injuries to the spine, hip, or pelvis; if breathing is abnormal; or if CPR is needed.

This topic was the subject of a 2022 ILCOR systematic review.¹ An updated literature search was performed by the writing group in 2023.

1. The AHA and the Red Cross provide basic life support algorithms for lay rescuers and health care professionals to perform the initial steps of resuscitation for adults and children, with single rescuer and multiple rescuer procedures.^2,3 These algorithms include checking for responsiveness, shouting for nearby help, activating the emergency response system, assessing respirations, applying an automatic external defibrillator, and initiating CPR or rescue breathing as appropriate. Chest compressions and rescue breathing are performed with the person being assisted in the supine position.
2. Activation of the emergency response system leads to the arrival of rescuers who are trained and equipped to manage medical emergencies, facilitates rapid transport to a health care facility, and may shorten time to definitive treatment.^4–7
3. Remaining with an ill or injured person enables the first aid provider to assist the person, provide reassurance, and monitor for changes in the person’s condition.¹ In some cases, it may be necessary to leave the person briefly to summon help, including activating the emergency response system.
4. To provide effective first aid care, a provider needs to recognize whether the setting is safe to assess or deliver medical assistance.³
5. Although studies about moving an injured person in the first aid setting could not be identified, prior first aid guidelines have recommended that a person with suspected injuries to the neck, back, hip, or pelvis remain in their original position to avoid worsening the injury (eg, worsening hemorrhage or neurological injury).^8,9
6. It is presumed that a person who is alert will choose a position that optimizes their ability to breathe and avoids airway obstruction. No studies were identified that directly address this. A systematic review evaluated the effect of lateral position compared with other body positions on mortality, morbidity, and clinical adverse events in critically ill adults. The review authors could not identify one best position because of the lack of evidence in the included studies.¹⁰ Encouraging individuals with difficulty breathing to assume a position of comfort is widely recommended.^11–15 Studies of adults with heart failure or chronic obstructive pulmonary disease found improved respiratory mechanics when patients were allowed to assume a sitting-up position.^16,17 A systematic review on the influence of body position on lung function in healthy individuals and specific patient groups found that in healthy individuals and patients with lung, heart, or neuromuscular diseases or obesity, lung function parameters such as forced expiratory volume and vital capacity were generally higher in more erect positions.¹⁸
7. There is a well-documented association between both hyperthermia and hypothermia and adverse outcomes in patients who are ill or injured. In environments that are warm or hot, it is crucial to implement measures to prevent overheating. This can be achieved through the use of shade and promoting evaporative and convective heat loss. Conversely, in cold settings, it is essential to prevent the loss of body heat to the environment and the ground. This can be accomplished by using insulating materials such as blankets and foam pads to maintain the patient’s normal body temperature.^19–23
8. The recovery position may reduce the risk for airway obstruction, facilitate drainage of airway secretions, and reduce the risk of aspiration in a person with a decreased level of responsiveness, particularly if the airway cannot be closely monitored by a first aid provider. In addition, a side-lying position may be preferred for comfort over the supine position by individuals in certain circumstances such as pregnant individuals, those with respiratory difficulties, or those with a greater or smaller body habitus.¹ A left-side lying position improves blood circulation for people in the later stages of pregnancy.^24,25 However, the recovery position is associated with delayed recognition of respiratory arrest and delayed initiation of chest compressions.²⁶

A person presenting with shock, including cardiogenic, hypovolemic, or hemorrhagic shock, may experience dizziness, difficulty breathing, chest pain, or skin mottling. While waiting for EMS, the first aid provider can position the person in a way to optimize circulation to vital organs such as the brain and to avoid decompensation. Various studies have evaluated how body positioning such as standing, being supine, or elevating the legs potentially affects vital signs and cardiac function.

This topic was the subject of a 2022 ILCOR systematic review.¹ An updated literature search was performed by the writing group in 2023.

1. An observational study found that in individuals undergoing phlebotomy, a supine position resulted in greater cardiac index and lower heart rate compared with a standing position.²
2. The recovery position may reduce the risk for airway obstruction, facilitate drainage of airway secretions, and reduce the risk of aspiration in individuals with a decreased level of responsiveness, particularly if the airway cannot be closely monitored by a first aid provider. In addition, a side-lying position may be preferred for comfort over the supine position by individuals in certain circumstances such pregnant individuals, people with respiratory difficulties, or those with a greater or smaller body habitus.¹
3. The beneficial evidence for feet elevation is extrapolated from an RCT and observational studies performed in non–first aid settings, demonstrating an effect of the passive leg raise on vital signs and indicators of cardiac output. Observed improvements with passive leg raise compared with the supine position in hypotensive subjects were temporary, and not all studies show this effect.^3–7
4. Complications such as arrhythmias and hypoxia have developed in hemodynamically unstable patients who have been moved into the elevated-feet position. Although these were detected with the use of in-hospital monitors, the development of new symptoms may indicate condition decompensation. ⁸

The administration of oxygen for injured or ill individuals in the prehospital setting has been a mainstay of EMS care for nearly 50 years. Historical indications have included breathing problems, chest pain, traumatic injury, and stroke. Oxygen therapy plays a vital role in stabilizing patients experiencing inadequate tissue oxygenation, thereby averting or mitigating hypoxia-induced cellular damage. Although oxygen is generally safe and straightforward to administer, its use is not without controversy. Recent studies have demonstrated worse outcomes for some conditions when oxygen is administered. Moreover, the availability and suitability for lay first aid providers of oxygen therapy have been questioned.

ILCOR completed a scoping review on the use of oxygen for first aid in 2022¹ and a systematic review on the use of oxygen for acute stroke in 2020.² An updated literature search was performed by the writing group in 2023.

1. A 2022 ILCOR scoping review did not identify any studies on the effectiveness of oxygen therapy in the first aid setting.¹ The ILCOR First Aid Task Force concluded that there is no direct evidence to support or not support the use of oxygen by first aid providers in the first aid setting. No evidence was found about whether people with specific conditions such as drowning, carbon monoxide poisoning, decompression illness, or pneumonia would benefit from oxygen administration in the first aid setting. Although there are specific conditions for which oxygen administration by health care professionals or specially trained rescuers has been proven beneficial, particularly when guided by reliable pulse oximetry, the overarching message is that a role for oxygen administration in general first aid has not been established.
2. An ILCOR 2020 systematic review on oxygen for acute stroke did not identify a benefit of oxygen over room air for survival or neurological outcome.² A single observational study in the prehospital setting³ provided direct evidence from the prehospital setting, supported by 8 RCTs from the in-hospital setting. These studies compare the use of supplementary oxygen with varying flow rates and delivery methods with no use of supplementary oxygen (ie, room air) in individuals with acute stroke. These studies failed to find a benefit for critical outcomes such as survival, favorable neurological outcomes, and quality of life.
3. One study and a Cochrane systematic review identified by the task force enrolled 214 adults with chronic obstructive pulmonary disease receiving treatment by paramedics en route to the hospital. The study observed a reduction in mortality in favor of the group in whom oxygen was titrated to maintain pulse oximetry of 92% compared with the group receiving high-flow oxygen (2 deaths in the titrated oxygen group compared with 11 deaths in the high-flow control arm; risk ratio, 0.22 [95% CI, 0.05–0.97]; 214 participants).⁴,⁵

Pulse oximetry is a simple, noninvasive test for assessing health conditions in both health care facilities and out-of-hospital settings. Recently, this technology has also found its way into home first aid kits and wearable devices such as watches and fitness bands. By using these devices, first aid providers may be able to measure the level of oxygen bound to hemoglobin in the blood. This information is valuable for evaluating both respiratory and circulatory health, particularly in urgent situations. During the COVID-19 pandemic, pulse oximetry was used by infected individuals at home as a tool to detect silent hypoxia and to determine whether they needed to present for care in a clinic or emergency department (ED).¹,²

Patients and health care professionals highly value the use of pulse oximeters for home management of different conditions.³ Of concern, however, are the numerous limitations pulse oximeters, including their systematic overestimation of oxygen saturation in individuals with darker skin pigmentation^4–6 (Table 5(link opens in new window)). Moreover, pulse oximeters sold over the counter may not be approved or cleared by the US Food and Drug Administration or other regulatory agencies.⁷

This topic was the subject of a 2022 ILCOR scoping review.⁸ An updated literature search was performed by the writing group in 2023.

1. The primary survey, physical examination, and SAMPLE history (signs/symptoms, allergies, medications, past medical history, last oral intake, events leading up to present illness/injury) are essential components of the first aid assessment, which is structured to rapidly detect life-threatening conditions. Skipping these essential assessment components may result in delays in the detection and resolution of life-threatening conditions. Assessment of respiratory status includes observing for bluish discoloration of the face, lips, or nails; abnormal respiratory rate and effort; cough; a sensation of dyspnea; restlessness and discomfort; chest pain or tightness; and increased heart rate. Interpretation of any numerical value provided by a pulse oximeter must include considering these and other potential assessment findings.
2. Pulse oximeters have numerous limitations. Pulse oximeter accuracy can be affected by many patient, device, and environmental factors. In 2 large hospital-based cohort studies that compared oxygen saturation measured by pulse oximetry with the gold standard of arterial blood gas analysis, Black patients had almost 3 times the frequency of hypoxemia that was missed by pulse oximetry compared with White patients.⁴ A systematic review and meta-analysis concluded that pulse oximetry may overestimate oxygen saturation in people with high levels of skin pigmentation and people whose ethnicity is reported as Black/African American compared with oxygen saturation measured from a blood sample.⁵ Many environmental factors, including ambient lighting, temperature, and movement, can also interfere with pulse oximeter accuracy.⁷ Devices that have not been approved by the US Food and Drug Administration may be even less accurate.

There are many causes of shortness of breath. First aid providers may encounter a person with a previous diagnosis of asthma who has acute difficulty breathing or is wheezing. Many will carry prescribed inhaled medication with them to use when they are experiencing an asthma exacerbation. Some people, because of severity of illness or other factors, may require assistance to self-administer bronchodilator medication.

The ILCOR performed a scoping review on potential harms from bronchodilator administration in 2022.¹ An updated literature search was performed by the writing group in 2023.

1. Inhaled bronchodilators are effective in patients with asthma and acute shortness of breath.^2–12 Evidence from included studies was extrapolated from the EMS and ED settings to the first aid setting. No new studies specifically examining the first aid setting have been published since the prior guidelines in 2015.¹³ Bronchodilator administration is safe; treatment with albuterol/salbutamol causes no clinically significant change in heart rate,^5–7,12 blood pressure,⁵ serum potassium, tremor, headache, nervousness, weakness, palpitation, or dry mouth.¹²
2. When used with a metered dose inhaler, spacer devices improve the delivery of bronchodilator medications to the lungs.¹⁴ Inhalers with spacer devices provide clinical effectiveness equal to that of nebulizer machines, including in community settings.¹⁵
3. Improvised spacers made with a 500-mL (≈16 oz) plastic cold drink bottle^16–19 or a 150-mL (≈5 oz) disposable paper cup²⁰ appear to provide drug delivery similar to that achieved with commercial spacer devices (Figure 2).

Stroke is a leading cause of death and disability worldwide. Each year, nearly 800 000 people in the United States experience a new or recurrent stroke.¹ Projections show that between 2012 and 2030, ≈3.4 million US adults, representing 3.9% of the adult population, will have had a stroke.^1,2

Various stroke recognition instruments have been developed for both in-hospital and prehospital use. Compared with stroke scales intended for in-hospital use, stroke scales designed for the first aid setting have fewer diagnostic criteria, easily identified clinical signs, and simple implementation.

The ILCOR published a systematic review on stroke recognition in 2020.^3,4 An updated literature search was performed by the writing group in 2023.

1. Stroke is a serious and time-sensitive medical emergency. Emergency interventions are most effective when delivered promptly. Use of EMS by patients with stroke has been associated with earlier ED arrival, quicker ED evaluation, more rapid treatment, and more eligible patients receiving intervention.^5,6 For the best outcomes possible, recognition and activation of the stroke care system should occur as quickly as possible.
2. A 2020 ILCOR systematic review³ evaluated 9 different screening tools reported in 19 observational studies. The FAST,⁷ which is essentially identical to the Cincinnati Prehospital Stroke Scale, was the only tool intended for administration by laypeople (Figure 3). The FAST and the Cincinnati Prehospital Stroke Scale have the same 3 physical examination items (face, arms, and speech), which the review authors identified as appropriate for use by first aid providers. Although data specific to first aid providers are lacking, the use of stroke scales coached by EMS dispatchers and by EMS personnel improves early recognition of stroke.^9,10
3. If a first aid provider has the necessary knowledge and equipment to perform capillary blood glucose measurement, the measurement of blood glucose may aid in ruling out hypoglycemia, a common stroke mimic.

Approximately 40 000 children worldwide experience stroke each year.¹ Pediatric stroke incidence peaks at 3 time points: in the perinatal period, before 5 years of age, and in adolescence. Whereas perinatal strokes typically occur when the neonate is in the hospital, strokes affecting older children and adolescents may first be noted by a first aid provider. Although pediatric stroke can present in similar ways to adult stroke, it can also present in nonspecific ways and mimic other childhood diseases. Table 6(link opens in new window) lists the most common signs and symptoms of pediatric stroke.

The ILCOR published a systematic review on stroke recognition in 2020.^2,3 An updated literature search was performed by the writing group in 2023.

1. Early identification of stroke in children is important because a shorter time to definitive therapy decreases the risk of death and permanent disability from stroke.^4–8 Shortening the time from presentation in the first aid setting to an ED, preferably with pediatric neurology and stroke expertise, is an important component of this timeline.
2. Stroke in children can present in nonspecific ways and mimic other childhood diseases. Symptoms can present suddenly or come on more gradually, making identification difficult.⁹ Symptoms can be nonspecific such as sudden or severe headache, altered mental status, and sudden onset vomiting, or they can be more localized such as focal numbness or weakness, ataxia, and speech and visual disturbances.^5,7–9 Although headache and vomiting can be symptoms of other common childhood diseases, their presence in association with other neurological symptoms should raise concern for stroke. Some strokes can also present as either generalized or focal seizures, which is especially common in children <1 year of age.^5,9,10
3. Stroke scales and recognition tools used in adult patients such as the FAST have not been validated for use in children. Pediatric stroke scales such as the Pediatric National Institutes of Health Stroke Scale are complex and have been validated only for administration by health care professionals.⁸ We were unable to identify a pediatric stroke recognition rubric that is validated in the first aid setting.

More than 7.8 million people are evaluated in US EDs each year for chest pain. Chest pain is a common health problem with multiple causes, ranging from minor chest wall strains to pneumonia or myocardial infarction (heart attack). It can be difficult to differentiate chest pain of cardiac origin such as a heart attack from chest pain of other origins.¹ The prevalence of myocardial infarction in patients presenting to the ED with nontraumatic chest pain varies by age, ranging from ≈ 1% in patients 18 to 44 years of age to 4% in patients ≥ 80 years of age.² Individuals with chest pain often delay seeking care, leading to poor outcomes.^3,4 Common signs and symptoms associated with a heart attack include chest pain or pressure, shortness of breath, nausea, sweating, or pain in the jaw, arm(s), or back.

The most important action for a person experiencing chest pain or other symptoms that might indicate a myocardial infarction is to activate EMS. Aspirin in the dose of 162 to 324 mg improves survival in patients with myocardial infarction.^5,6 A 2020 systematic review found that early or first aid administration of aspirin to adults with nontraumatic chest pain was associated with reduced mortality.⁷ The rate of major complications associated with administration of a single dose of aspirin to an individual experiencing chest pain appears to be low, but certain individuals may have an allergy to aspirin or a bleeding risk, or they may have been advised by a health care professional not to take aspirin.⁸

The AHA does not recommend administration of oxygen in health care settings for people with acute coronary syndromes who are not hypoxic.^9,10

In 2020, the ILCOR performed a systematic review on administration of aspirin for people with chest pain.¹¹ An updated literature search was performed by the writing group in 2023.

1. Although chest pain is a common sign of a heart attack, some people such as women, people who have diabetes, and older people may experience other symptoms, including dyspnea; pain or discomfort in the back, neck, jaw, or stomach; sweating; nausea; or lightheadedness.^1,12–14 The use of EMS transportation is associated with a substantial reduction in ischemic time and treatment delays compared with transportation by personal vehicle.¹⁵ In 1 study, ≈ 1 in 300 patients with chest pain transported to the ED by private vehicle had a cardiac arrest en route.¹⁶
2. Two observational studies with a total of 2122 patients with acute myocardial infarction demonstrated higher survival with early administration (median, 1.6 hours from pain onset) of aspirin by health care professionals compared with late administration (median, 3.5 hours from pain onset).^4,7,17 One of the observational studies with 1200 patients demonstrated higher survival at 1 year with early compared with late administration (same medians as reported previously).⁴ These same studies found no significant difference in the risk of complications from early as opposed to late aspirin administration.
3. Although harm from aspirin in individuals with nontraumatic chest pain is uncommon, no study has evaluated the risks of aspirin administration in the first aid setting.⁸ Therefore, if there are potential contraindications to the use of aspirin by the lay first aid provider, it is reasonable not to encourage aspirin use while awaiting the arrival of EMS.

Anaphylaxis is a life-threatening, systemic allergic reaction that can be triggered by many exposures, including foods, drugs, and insect venom. Signs and symptoms of anaphylaxis include lip and facial swelling, a sensation of the throat closing, difficulty breathing, rash, vomiting or diarrhea, and symptoms of low blood pressure such as changes in level of consciousness, pallor, and dizziness. The mainstay of immediate treatment for anaphylaxis is intramuscular epinephrine, typically administered in the first aid setting with an epinephrine autoinjector. Epinephrine autoinjectors are often prescribed to people with a history of anaphylaxis to self-administer at the first sign of an anaphylactic reaction. First aid providers are sometimes called on to assist people experiencing anaphylaxis as they self-administer this medication. In many cases, this will significantly improve or resolve the person’s symptoms, but sometimes additional epinephrine is required.

ILCOR performed scoping reviews related to anaphylaxis in 2019 and 2022.^1,2 An updated literature search was performed by the writing group in 2023.

1. Strong international consensus, based primarily on observational data, endorses early administration of intramuscular epinephrine given in the lateral thigh as the primary treatment of anaphylaxis regardless of the triggering agent.^3–11
2. A person experiencing anaphylaxis may be unable to access or manipulate their autoinjector because of respiratory distress, hypotension, or altered mental status. First aid providers may assist the ill person. Epinephrine is typically injected into the muscle of the lateral thigh.^3–12
3. Approximately 500 to 1000 people die in the United States of anaphylaxis each year.¹³ In addition to intramuscular epinephrine, patients with anaphylaxis may require endotracheal intubation, intravenous fluids, vasopressors, and other advanced treatments to survive.
4. It is estimated that between 7% and 18% of people with anaphylaxis require >1 dose of epinephrine.^14,15 Most patients who required a second dose of epinephrine for anaphylaxis improved after administration.² One study found that patients who received a second dose of epinephrine were more likely to be admitted to the hospital than those receiving 1 dose, although this appeared to be due to severity of illness rather than an adverse effect of epinephrine.¹⁶

Seizures are uncontrolled electrical discharges of the neurons in the brain. Seizures can occur as a result of infections, trauma, poisonings, lack of oxygen, metabolic abnormalities (hypoglycemia), fevers (in children), and underlying neurological conditions such as epilepsy. Febrile seizures occur in 2% to 4% of children, most commonly between 6 months and 2 years of age. Generalized tonic-clonic seizures affect large areas or both sides of the brain and manifest as full-body rhythmic jerking with alterations in consciousness. Focal seizures affect only 1 area of the brain and can present as jerking of only 1 extremity or 1 side of the body, abnormal facial movements, small repetitive movements, or staring spells (focal impaired awareness), with or without changes in consciousness. Some focal seizures will progress to generalized seizures. Urinary incontinence may also occur during a seizure. Seizure duration can be seconds to hours. Most seizures are followed by a postictal period in which the person appears tired and confused for several minutes. Seizures lasting >5 minutes and multiple seizures occurring one after the other represent a critical medical emergency, status epilepticus.¹

A literature search was performed by the writing group in 2023.

1. Seizures are usually self-limited and resolve spontaneously within 1 to 2 minutes. However, seizures lasting >5 minutes may not stop spontaneously and may need emergency medical intervention such as anticonvulsant medications.¹ For prolonged seizures, respiratory distress, seizures with associated traumatic injuries, seizures occurring in the water, and seizures associated with choking events, EMS should be activated to provide more definitive care² (Table 7(link opens in new window)).

2–3. Seizure movements often involve erratic movements of the head, body, and extremities that can result in significant traumatic injury during a fall or from the seizure movements.^2–4 The first aid provider can prevent the person who is experiencing a seizure from unintentional injury. The recovery position is intended to reduce the risk of aspiration if the person vomits during the seizure or the postictal period.

4.Febrile seizures are a common benign condition in childhood, affecting ≈2% to 4% of children.⁵ Febrile seizures may be diagnosed by a health care professional after an appropriate evaluation. Two meta-analyses published in 2021 examined the effectiveness of antipyretics at preventing recurrent febrile seizures in children in both the same febrile episode and subsequent febrile illnesses. They demonstrated no benefit of seizure prevention to antipyretics in the same illness or a subsequent illness.^6,7 Fever treatment can help children feel better but will not prevent subsequent seizures.

5.Restraining a person experiencing a seizure will not abort the seizure and may lead to injury of the person or the first aid provider.^2–4

6. People experiencing seizures will often clench their jaw, which may lead to traumatic injury within the mouth. Although swallowing the tongue will not occur, people can aspirate blood, saliva, food, or other items during a seizure and the postictal period. Attempting to place something in the mouth risks injury to the person’s teeth or the rescuer’s finger and is generally ineffective.^3,8 Most seizures are followed by a postictal period in which the individual is somnolent, incoherent, and unable to swallow normally and therefore is at risk of aspiration of food, liquids, or medications placed in the mouth.^2,4

Blood glucose levels are tightly regulated by several hormones, mainly insulin and glucagon. Normal blood glucose range is 70 to 120 mg/dL (3.9–6.6 mmol/L). Hypoglycemia (blood glucose <70 or <2.8 mmol/L) can result from starvation, underlying metabolic disorders, deficiencies of hormones, and medications (eg, antidiabetic medications). Symptoms typically develop when blood glucose falls below 50 to 60 mg/dL (2.8–3.3 mmol/L) and include dizziness, fatigue, feeling shaky or jittery, tachycardia (fast heart rate), confusion, slurred speech, and diaphoresis (sweating). Significant hypoglycemia can lead to a state of unconsciousness and seizures. In the first aid setting, correction of hypoglycemia is performed through the enteral route.

The ILCOR performed a systematic review of glucose administration for hypoglycemia in 2020.¹ An updated literature search was performed by the writing group in 2023.

1. Administration of ≥20 g oral glucose or the equivalent in glucose-containing foods can rapidly restore blood glucose levels.² Oral glucose is available in different forms and can be given through different routes in the first aid setting. Glucose products that are swallowed (eg, tablets or gels) result in higher blood glucose levels than buccally applied glucose (spray or gel).³

2. Untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death. For people with hypoglycemia who are unable to swallow, intravenous dextrose can be lifesaving.

3-4. Oral glucose tablets demonstrated better resolution of symptoms 15 minutes after treatment compared with dietary sugars such as sucrose, fructose, orange juice, jellybeans, candy tablets, and milk.⁴ Although data on this topic are limited, 1 study suggests that glucose tablets are superior to gel in terms of hypoglycemia correction.⁵ Dietary sources of simple sugar (Table 8(link opens in new window)) have been shown to be effective in the treatment of hypoglycemia.^6,7

5. In children who are responsive but unwilling to swallow oral glucose, applying a slurry of granulated sugar (≈1 teaspoon) and water under the tongue resolves hypoglycemia faster than oral granulated sugar.^3,8

6. Attempting to treat severe hypoglycemia with oral glucose in a person who is not fully alert or who is unable to swallow can lead to choking and aspiration.

Syncope, a transient loss of consciousness, results from global cerebral hypo perfusion and has an estimated lifetime prevalence of ≈35%.^1,2 Syncope leads to a loss of postural tone that may result in physical injury, which is present in 30% of patients treated in an ED after syncope.³ Fractures, intracranial hemorrhage, or other organ damage may occur if the individual is upright at the time of the syncopal episode. Syncope causes a considerable medical and socioeconomic burden on the adult population, resulting in 2% to 6% of hospital admissions internationally and accounting for at least $2.4 billion in annual hospital costs in the United States.^3–5

There are many causes of syncope. Vasovagal syncope and orthostatic syncope result in 21.2% and 9.4% of syncopal episodes, respectively.⁶ However, syncope also may have more dangerous causes such as cardiac dysrhythmia. Vasovagal syncope is preceded by prodromal symptoms in about two-thirds of cases.⁷ Presyncope is the prodrome of syncope that may last for a few seconds and may include lightheadedness or dizziness, blurry or tunnel vision, nausea, a sensation of warmth, and signs such as diaphoresis and pallor. This prodrome represents a short time in which a first aid intervention may be used to prevent syncope. Physical counterpressure maneuvers (PCMs) are a first aid intervention demonstrated to help prevent syncope.^8,9 PCMs include the contraction of muscles of the body such as those in the legs, arms, abdomen, or neck, causing a rise in blood pressure and alleviating symptoms of near syncope originating from vasovagal or orthostatic causes^8,9 (Table 9(link opens in new window)).

The ILCOR performed a systematic review of first aid interventions for presyncope in 2020,¹¹ with an evidence update in 2022.¹² An updated literature search was performed by the writing group in 2023.

1. Physical injuries are frequent complications of syncope, occurring in ≈30% of patients admitted to EDs, of whom ≈5% experience severe trauma.³ Therefore, the initial goal of presyncope treatment should be to assume a safe position to decrease the risk of trauma.
2. A meta-analysis of 11 clinical trials demonstrated an ≈50% reduction in the risk of syncope when PCMs were used compared with no intervention.⁹ Although no studies directly assessed the ability of first aid providers to instruct a person with presyncope on PCMs in real time, in several studies, researchers were able to effectively instruct research participants on the use of PCMs before an intervention (eg, tilt table test) or for the treatment of presyncope in the real-world setting.^13–17
3. An observational study enrolling 27 participants with recurrent vasovagal syncope demonstrated better improvements in heart rate and a lower likelihood of syncope with the use of lower-body PCM (squatting with leg crossing) compared with upper-body PCM (handgrip).^8,18
4. In studies involving tilt-table testing, PCMs were able to improve cardiovascular parameters, reduce or eliminate symptoms of presyncope, and prevent syncope within seconds of implementing the PCM.^14,15,19 In a tilt table study of people with vasovagal syncope, continuously applied PCMs were beneficial for at least 2 minutes.¹⁵
5. Dangerous medical conditions such as myocardial infarction or stroke may cause presyncope. Although a systematic review found no reported adverse events or injuries from PCM use, the study populations included only people with known recurrent orthostatic or vasovagal syncope.⁸ PCMs have not been advocated for cardiac causes of syncope and may delay definitive medical care.²⁰

Stings from bees, wasps, and hornets commonly result in small local reactions consisting of pain, swelling, and itching. Larger local reactions and anaphylaxis may occur. Stinging bees, wasps, and hornets result in ≈ 60 deaths per year in the United States.¹ Most deaths are due to anaphylaxis, a severe reaction that may include rapid development of difficulty breathing, tongue or throat swelling, lightheadedness (a possible symptom of low blood pressure), vomiting, and disseminated hives. Death can also occur from massive envenomation, generally from at least 20 stings by large hornets or hundreds of stings from honeybees.^2–4

The honeybee has a barbed stinger that often remains in the skin after the sting and can continue to deliver venom for up to 60 seconds.⁵ Other species of bees, wasps, and hornets have smooth stingers and can sting multiple times.

Many people with a history of anaphylaxis have epinephrine autoinjectors, which they are instructed to self-administer at the first sign of anaphylaxis. First aid providers may be called on to assist people experiencing anaphylaxis to self-administer this medication.^3,6,7 Intranasal and sublingual formulations of epinephrine for the treatment of anaphylaxis were not available in the United States or Canada at the time of guideline development.

Treatment for local reactions to bee and wasp stings is intended to reduce local symptoms of pain, swelling, and itching at the site of the sting.

A literature search was performed by the writing group in 2023.

1–3. Strong international consensus, based primarily on observational data, endorses early administration of epinephrine as the primary treatment of anaphylaxis regardless of the triggering agent.^8–16 Few experimental data were identified pertaining specifically to the treatment of anaphylaxis from bee, wasp, or hornet stings. In 1 observational study detailing 8 cases of anaphylactic reactions to bee stings, 5 of the cases were treated with epinephrine.⁷

4. Although rare, stings to the eye itself (as opposed to stings to the eyelid or to the face near the eye) can lead to permanent vision loss and may require immediate medical attention.^17–19

5. In an observational study evaluating honeybee stings in human volunteers, there was no significant difference in the size of wheal when the retained stinger was plucked out compared with scraping for removal.²⁰ The area of the wheal corresponded directly to the time the bee stinger remained in the skin. In a second observational study conducted in rabbits, the amount of honeybee venom delivered corresponded directly to the amount of time the stinger was embedded in the skin, up to ≈30 seconds.⁵

6–10. Few experimental data were identified to guide treatment of local symptoms from bee, wasp, or hornet stings. Clinical trials support the use of oral antihistamines and topical corticosteroid for local itching from mosquito bites,²¹ but data for bee, wasp, and hornet stings are lacking. Pain can be treated with oral over-the-counter analgesic agents such as acetaminophen and ibuprofen. Pain and swelling can be treated with topical ice or cold packs.^3,6,22–25

There are many tick species in the United States, with activity dependent on the season and geographic location. Some species of tick are carriers of organisms that can cause illness such as Lyme disease or Rocky Mountain Spotted Fever if transmitted to a human host.¹ The Centers for Disease Control and Prevention reports that at least 48 000 cases of tick-borne diseases are diagnosed in the United States annually and >100 000 people seek treatment in EDs for tick bite exposure.¹

The risk of contracting a tick-borne illness is increased if the tick is attached for >24 to 48 hours (Figure 4.) Early tick removal may prevent disease transmission.^2,3

The Centers for Disease Control and Prevention recommends antibiotic prophylaxis for Lyme disease when a tick bite occurs in a highly endemic region and tick attachment is estimated to have been ≥36 hours (based on the degree of engorgement with blood), if the tick is an Ixodes scapularis tick, if antibiotics can be started within 72 hours, and if there is no contraindication to doxycycline.⁴ In areas where Rocky Mountain Spotted Fever is endemic, prophylactic antibiotic administration is not recommended, but doxycycline is recommended at the first sign of fever or rash.⁵ Antibiotic prescribing is performed by health care practitioners.

A literature search was performed by the writing group in 2023.

1. Several clinical trials found that a single dose of prophylactic doxycycline given within 72 hours after an Ixodes scapularis tick bite could prevent Lyme disease.^6–8 Doxycycline prescribing requires treatment by a health care professional. Although the risk is decreased, some people develop Lyme disease despite receiving prophylactic doxycycline, and additional treatment is required.
2. The risk of infection from tick-borne illness increases with the time of tick attachment (Figure 4). Although the risk of contracting a tick- borne illness appears to be more substantial if the tick is attached for >24 to 48 hours, the tick should be removed as soon as possible to minimize the risk of infection^2,9,10 (Figure 5).
3. The risk of damaging tick mouthparts appears to be lower when health care professionals remove ticks with tweezers compared with laypeople removing ticks by hand.¹² In tick removal by dermatologists, successful removal was most common when tweezers were used to grasp the tick near the mouthparts compared with lasso and traction devices, card slit devices, and freezing.¹³ Other methods of removal, including application of gasoline, nail polish, methylated spirits, petroleum jelly, 70% isopropyl alcohol, or a hot kitchen match, appear to be less effective.¹⁴ Mechanical removal is accepted by most experts.^15–17 Although squeezing the abdomen of the tick on removal has not been definitively linked to transmission of disease, some evidence links squeezing the abdomen of the tick on removal to anaphylaxis resulting from tick bites.¹⁸ As with any injury, hand washing and wound cleansing should follow tick removal. Steps for tick removal are shown in Figure 5.

Contact dermatitis from Toxicodendron species (formerly Rhus), including poison ivy, poison oak, and poison sumac, is a common problem that affects millions of Americans annually, resulting in millions of visits to health care facilities each year.^1,2 Approximately 50% to 75% of individuals react to urushiol, the allergic compound in Toxicodendron. Skin effects include redness, papules and vesicles, and itching, typically starting within days of exposure and lasting up to 3 weeks.² The extent and severity of symptoms are proportional to the area and duration of urushiol contact with the skin. Therefore, initial treatment is aimed at preventing or removing exposure to urushiol, and later first aid is aimed at management of symptoms. Although most affected individuals do well with home- based care, advanced medical care is sometimes needed for those with severe symptoms. Data on treatment effectiveness are limited, with few clinical trials.

A literature search was performed by the writing group in 2023.

1. Washing with soap and water can remove up to 100% of poison ivy oils if done immediately after contact. This falls to 50% at 10 minutes, 25% at 15 minutes, and 10% at 30 minutes.³ In 1 study of healthy volunteers who were exposed to crushed poison ivy leaves, washing with a commercial decontamination product, commercial hand cleaner, or dishwashing soap and water produced 55% to 70% reductions in local symptoms compared with control, even when used 2 hours after urushiol application; no significant difference was found among the 3 treatments.⁴

2. Topical corticosteroids are often recommended for symptomatic treatment of local symptoms.^5,6 However, those corticosteroids that have been demonstrated to improve local symptoms are not available over the counter. In 1 randomized, blinded trial involving 92 cases of Toxicodendron dermatitis, 0.2% hydrocortisone lotion, 1.0% hydrocortisone ointment, 2.5% hydrocortisone ointment, and 2.5% hydrocortisone cream were not reported to improve symptoms.⁷ An expert consensus panel recommended the use of midpotency or high-potency topical corticosteroids for mild and moderate symptoms of Toxicodendron dermatitis, respectively.⁵ An observational study enrolling 89 participants found that the combination of systemic corticosteroids and high-potency topical corticosteroids reduced the duration of itching.⁸ In this same study, the use of low-potency corticosteroids was not associated with symptom improvement.

3–4. Although supported by little evidence, cool compresses and oatmeal baths are frequently recommended for symptomatic relief of itching from Toxicodendron exposure.^5,9

5. Although oral antihistamines have been recommended as a treatment for local itching, few data support their use.^2,5,6,8,10 An expert consensus and 2 review articles suggested the use of oral antihistamines for help with sleep at night but questioned their efficacy for itching.^2,5,6 One observational study enrolling 89 participants did not find a statistically significant reduction in symptoms with the use of oral antihistamine.⁸

Approximately 8000 to 10 000 people are treated for snakebite in the United States each year.^1–3 Two families of venomous snakes (Crotalinae and Elapidae) are indigenous to the United States.⁴ Most snakebites occur in the warmer months and involve the extremities.^5–7

More than 95% of venomous bites in North America are caused by crotaline snakes (Crotalinae, also known as pit vipers), specifically rattlesnakes, copperheads, and cottonmouths.⁸ Venom from crotaline snakes causes tissue injury and may also cause low blood pressure, bleeding, and muscle fasciculations leading to paralysis. Wounds are generally red, warm, tender, and swollen.

In the United States, bites from coral snakes (Elapidae) occur in the Southeast (primarily Florida) and the Southwest (Texas, New Mexico, Arizona).⁷ These bites do not cause tissue injury; coral snake venom is primarily neurotoxic and can cause paralysis within minutes to hours.

There is a relative paucity of literature about the most effective first aid treatments for snake envenomation. Application of tourniquets, pressure bandage immobilization, incision, suction, ice application or immersion, and application of electrical current have been advocated, with known risks and unclear benefits.^9–11

These recommendations are specific to snakebites occurring in the United States and Canada and involving indigenous snakes. Snakes in other parts of the world have different venom effects and may require different first aid measures.

A literature search was performed by the writing group in 2023.

1. The definitive treatment for snake bite is antivenom, which is not available for use in the first aid setting. It is not practical to treat shock, internal bleeding, or severe neurotoxicity in the first aid setting. A person bitten by a snake that is venomous or might be venomous should seek prompt medical attention. Transport by EMS allows delivery of supportive and stabilizing care before arrival at the hospital.
2. A pit viper bite typically deposits venom intradermally or into the subcutaneous space. In a human experimental study, flow of an intradermally or subcutaneously injected radiotracer increased when the subject walked for ≥10 minutes.¹² This could lead to increased systemic absorption of venom. The ideal response in each situation requires balancing the goals of reducing exertion with avoiding delay to care.
3. Swelling of an envenomated limb may cause rings to constrict and damage the finger. Although never studied, removal of rings and other constricting jewelry is a reasonable first aid action.
4. Ice has not been studied as a first aid treatment for snakebite,¹³ and case reports show tissue injury from aggressive cryotherapy.¹⁰ Ice application is not generally recommended for the treatment of snakebite.^4,14,15
5. Suction, with or without incision, is not effective in venom removal^11,16 and may cause tissue injury.^17,18
6. Systematic reviews of human experience and animal experiments suggest that electric shock therapy is ineffective and potentially harmful in snakebite.^15,19,20
7. Tourniquet application was found to be ineffective or to worsen local tissue injury in systematic reviews of human and animal studies.^13,15,19
8. The results of human and animal studies of pressure immobilization bandaging are mixed with regard to both intended effects (delayed onset of systemic toxicity) and to harms (worsening tissue injury).^13,19 Several studies show that medical personnel and lay rescuers had a low rate of appropriate pressure immobilization bandage placement, even under ideal conditions.^21–23 Although a properly placed pressure immobilization bandage may have a role in the management of neurotoxic snakebite, >95% of snake envenomation in North America involves snakes with cytotoxic venom. Given this uncertainty, pressure immobilization bandaging is not currently recommended for use in North America.²⁴

Jellyfish stings are a common summertime occurrence and can cause local pain and discomfort. In North America, most people are treated at the scene of the injury, but some require more advanced medical care.¹ Allergic reactions can occur but are uncommon. Data on treatment recommendations are limited; there is a paucity of clinical trials, and it is not clear that all species of Cnidaria respond to available first aid treatments the same way. Within these limitations, hot water immersion appears to be the most effective for pain relief. Various topical products, including vinegar, baking soda, urea, and meat tenderizer, have been evaluated but have not consistently demonstrated a reduction in pain, and some increase nematocyst discharge.

A literature search was performed by the writing group in 2023.

1. Most jellyfish stings in North America result only in local symptoms, but severe local symptoms and systemic symptoms from venom can occur.¹ The ideal period of observation is unknown, but most severe reactions occur soon after envenomation.
2. A study of model envenomation evaluated the effect of scraping or pulling Alatina alata (sea wasp) tentacles off simulated tissue compared with rinsing with a number of test solutions. Scraping resulted in more hemolysis than pulling off the tentacle or rinsing with seawater. Rinsing with both seawater and ethanol resulted in increased hemolysis compared with pulling tentacles with tweezers.²
3. Data from human studies^1–6 generally show benefit from hot water immersion or irrigation compared with alternative treatments such as cold application, papain, vinegar, meat tenderizer, or no treatment. This finding has been confirmed by systematic reviews.^7–9 The most commonly studied water temperature was 40° C (104° F).
4. Topical application of lidocaine (in either 10%– 15% or 4%–5% formulations) appears to inhibit nematocyst discharge or decrease pain from stings by the tentacles of multiple jellyfish species.^6,10

Spider bites and scorpion stings are common occurrences in the United States.^1–5 Although many are benign and cause only self-limited local symptoms, some species of spider such as the black widow and brown recluse and some species of scorpion, for example, the bark scorpion, can cause more severe localized and systemic symptoms.^5,6

Bites from black widow and related spiders (genus Latrodectus) cause severe crampy pain, muscle rigidity, diaphoresis, and hypertension; although a rash is sometimes observed around the bite site, widow spider bites do not cause local tissue injury. Bites from brown recluse and related spiders (genus Loxosceles) cause painful ulcerated wounds that progress over days to weeks, sometimes associated with hemolysis and rhabdomyolysis. Bark scorpion (Centruroides) stings cause severe localized pain and muscle cramping that may impair breathing in children.

First aid treatment involves localized wound care and over-the-counter analgesics for pain. Data on first aid treatment are limited, with few randomized trials of first aid interventions. Advanced medical care is sometimes needed for the more severe symptoms.

The effects of spider and scorpion envenomation vary widely around the world. These guidelines are relevant to spider bites and scorpion stings occurring in the United States and Canada.

A literature search was performed by the writing group in 2023.

1–2. Although many bites and stings of spiders and scorpions result only in local symptoms, severe manifestations can compromise breathing or cause muscle injury and kidney failure.^5,6 These conditions require treatment in a health care setting.

3–5. A randomized trial of 130 adults with scorpion stings occurring in Turkey showed pain improvement with application of topical 5% lidocaine, administration of intravenous acetaminophen, or topical application of ice; the greatest pain reduction was from lidocaine.⁷ However, a similar study, also from Turkey, found slightly better pain relief in 106 adult patients who received intravenous acetaminophen or intravenous dexketoprofen (a nonsteroidal anti-inflammatory drug [NSAID]) compared with topical 5% lidocaine or placebo.⁸ Although 5% topical lidocaine, oral acetaminophen, and oral NSAIDs are available in the United States without a prescription, intravenous formulations of acetaminophen and NSAIDs are not available in the first aid setting. Overall, these studies provide indirect evidence for the use of acetaminophen, NSAIDs, topical lidocaine, and ice for scorpion stings occurring in the United States. Although ice is commonly recommended, no studies assessing the use of these therapies for spider bites were found.

Accidental hypothermia is an environmental emergency that may be encountered in urban, rural, and austere settings. The very young, the very old, and people with impaired temperature perception, regulation, and ability to communicate are at increased risk of hypothermia. In the United States, hypothermia is responsible for ≈1300 deaths annually.¹ Death rates are highest among men, the elderly, and people who live in rural areas.^2,3

Heat loss occurs through 4 methods: conduction, convection, radiation, and evaporation (Table 10(link opens in new window)). Hypothermia occurs when the core body temperature drops below the normal temperature range near 37° C. Individuals may be “cold” or “cold stressed” with temperatures of 35° C to 37° C. Mild hypothermia begins when the core temperature falls below 35° C. Hypothermia progresses through predictable stages in a continuum to death (Table 11(link opens in new window)). First aid providers are unlikely to be able to obtain core body temperatures, so assessment and treatment decisions must be guided by signs and symptoms.

Rewarming may use passive measures (protecting from further heat loss and allowing the body to rewarm itself) or active measures (applying external sources of heat to the body).

These recommendations address mild to severe/ profound hypothermia in children and adults and are not applicable to infants <60 days of age and to cardiac arrest in all age groups.

A literature search was performed by the writing group in 2023.

1. In studies of active torso-warming modalities using a healthy volunteer model of induced severe hypothermia, active rewarming methods were faster than passive spontaneous rewarming methods. In 3 human volunteer studies, core rewarming rates were highest when using forced air or contact heaters with surface insulation, hot water bottles, or heating blankets (rewarming rates, 0.57° C/h– 1.45° C/h) and body-to-body warming (0.52° C/h) compared with passive spontaneous warming under a blanket (0.1° C/h–0.36° C/h).^4–6 Subjects in all 3 studies received medication to suppress shivering.
2. In a small, randomized study of volunteers who were dressed in moistened clothing and exposed to a cold and windy environment, use of a vapor- tight layer and an additional dry insulating layer (the Hibler method) is the most efficient wrapping method to prevent heat loss.⁷ Although exposure of the head to cold and wet conditions does not contribute disproportionately to heat loss, head exposure causes a disproportionate increase in core cooling rate, likely due to redistribution of blood flow to the scalp, neck, and face.⁸
3. The risk of burns from active external rewarming was described in a 3-patient case series. The authors, who are subject matter experts, concluded that first aid providers should ensure that manufacturer instructions are followed, insulation (eg, cloth) is placed between the skin and the heat source (unless manufacturer instructions direct otherwise), and regular efforts are made to observe heated skin for signs of impending burn injury (eg, redness).⁹
4. Decreased level of responsiveness, mumbling speech, confusion, the inability to participate in removal of wet clothing, pallor, cyanosis, stumbling, and frozen skin are potential signs of life-threatening hypothermia requiring immediate rewarming and advanced care.¹⁰
5. Shivering is a physiological response to cold exposure, capable of increasing heat production significantly, by ≈5 to 6 times the resting metabolic rate. Although it is an effective method for rewarming, shivering is also highly energy intensive, raising the core temperature of the body but at the cost of substantial calorie expenditure. Providing high-calorie nutrition supports this metabolic demand, aids in maintaining energy reserves, and supports the natural rewarming process of the body. The provided substances should be at a safe temperature to avoid any risk of burning the esophagus.¹¹
6. In many freezing and windy settings, undressing a hypothermic person may further contribute to their heat loss. In a simulation study evaluating a multilayer wrap such as those used in mountain rescue, a chemical heating blanket inside a foil or plastic vapor barrier wrap was effective at transferring heat across dry and damp (but not saturated) fleece clothing. When evaluated in a simulated scenario involving saturated clothing, the excess moisture rendered the chemical heat packs inert. The researchers conclude that rescuers should cut off saturated clothing in a protected environment before wrapping wet, hypothermic people, but damp clothing need not be removed.¹²
7. A simulation study of mildly hypothermic healthy volunteers found that rewarming with an external heat source was more effective than body-to-body heat donation by sharing an insulated bag with an euthermic individual (2.46±1 °C/h compared with 2.55±1.09 °C/h).¹³ Another similarly designed simulation study found that core rewarming rates were highest when using an 850-W heater and rigid cover (1.45 °C/h), charcoal heating and 600-W rigid heater (0.7 °C/h), or 600-W heater and blanket (0.57 °C/h) compared with body- to-body warming (0.52 °C/h).⁵
8. Chemical heat packs used in studies rewarming hypothermic volunteers are large and are often built into panels in blankets and cover the torso. For example, a recent simulation study used a blanket with 6 heating panels with a combined mass of 397 g.¹² In contrast, small chemical heat packs marketed as glove and boot liners are between 15 and 60 g, and their ability to provide heat is highly variable.¹⁴ The mass and heat generation of glove and boot liners are too low to facilitate the active rewarming of a person with hypothermia.
9. A simulation study describing the role of extremity circulation in relation to core temperature found that heating the extremities and promoting the venous return of cold blood from the extremities may result in cooling of the central circulation.¹⁵ Core temperature drop after external rewarming has been confirmed in small human volunteer studies.^13,16
10. Although people with simple cold stress (cold and shivering with normal mental status) were generally able to safely rewarm in a warm shower or warm water immersion in a single- patient experimental study of mild hypothermia (core temperature ≈36° C), warm bath rewarming was associated with transient core temperature drop, decreases in mean arterial pressure, and increases in heart rate and cardiac output.¹⁶ These effects can lead to decreased perfusion to the vital organs and, in severe cases, cause arrhythmia. In addition, attempting to manage a person with hypothermia who is confused or has a decreased level of alertness in a shower or bathtub is potentially dangerous for the person with hypothermia and the first aid provider.

Frostbite is a condition that results from the freezing of skin and, in severe cases, underlying tissues. The formation of ice crystals within the cells causes cellular and tissue damage. The extremities—fingers, toes, nose, and ears—are particularly susceptible to frostbite. The severity of frostbite varies from mild cases in which only the outer layers of the skin are affected (superficial frostbite) to more severe cases involving deeper tissues. Symptoms include numbness, tingling, pain, and changes in skin color (from pale to hardened and dark). In extreme cases, frostbite can cause tissue necrosis leading to digit or limb loss.

A literature search was performed by the writing group in 2023.

1. Several animal model studies have demonstrated that water temperature slightly above normal body temperature (37–40° C [99–104° F]) is best for rapid rewarming with a warm-water immersion technique.^1,2 In one of these studies, rapid rewarming with warm water (45° C [113° F]) was harmful.² More recent human patient case series have demonstrated the safety and efficacy of rewarming frostbitten tissue in the range of 37° C to 40° C for between 20 and 30 minutes.^3,4 Five recent systematic reviews and clinical practice guidelines also endorse lukewarm water immersion at or near this temperature range.^5–9 If a thermometer is not available, water temperature can be tested against one’s wrist, where it should feel slightly warmer than body temperature.
2. The mechanism of tissue damage in frostbite is the development of ice crystals in cells, which can destroy cell membrane integrity. As a result, it is widely recommended that tissue refreezing be strictly avoided and first aid in-field rewarming be considered only if the risk of refreezing is negligible.^6–8,10
3. Animal studies have demonstrated that use of a warm water immersion technique at a temperature of 37° C to 40° C (98.6° F–104.0° F) is best for rapid rewarming of frozen tissue. Limbs left to thaw spontaneously at 27° C to 29° C (81° F–84° F) also had good outcomes. Air rewarming can be used as an alternative rewarming method when warm water immersion is not possible.²
4. Frostbite is a potentially tissue-threatening injury, and estimating the size and severity of frostbitten tissue can be challenging, especially in the first aid setting. Advanced treatment for frostbite such as thrombolytic medication can be administered only in a health care setting and is most effective when given soon after injury.^11,12 Frostbite involving deeper tissue depths may require care at a burn center.⁶
5. Tissue of the frozen extremities will swell, so it is recommended to remove constricting items such as jewelry and tight clothing.
6. Frostbite is a common finding in hypothermic individuals. However, rewarming the core of the person with hypothermia is the treatment priority, and rewarming the extremities first can cause the core temperature to decrease.^13,14
7. A characteristic of acute frostbite and frozen tissue is the inability to sense touch, including ongoing mechanical tissue damage. A person with frostbitten fingers and hands or toes and feet may not be aware of ongoing damage caused by movement, especially walking. Experts recommend that frostbitten tissues be protected and that frostbitten hands and feet not be used for climbing or walking whenever it is avoidable.⁸
8. Frozen and thawed tissues are extremely vulnerable to further injury and infection. Applying bulky dressings provides a protective layer that insulates the tissue, maintaining an optimal healing environment while shielding the area from external contaminants and physical trauma. After thawing, tissues can become wet, increasing the risk of infection and delayed healing. Clean and dry dressings absorb excess moisture, keeping the area dry and reducing the likelihood of bacterial growth. Edema, or swelling, is a common response in tissues damaged by freezing and thawing attributable to increased fluid accumulation and inflammatory processes. Loose, circumferential wrapping allows expansion as swelling increases, which prevents the constriction of blood flow and further tissue damage. Frozen and thawed tissues are susceptible to pressure sores and necrosis. Bulky dressings distribute pressure more evenly, reducing the risk of localized pressure points that can compromise blood flow and tissue viability.⁸
9. NSAIDs decrease the production of prostaglandins and thromboxanes that can cause vasoconstriction, dermal ischemia, and further tissue damage in frostbite. Ibuprofen is recommended by many experts and included in many treatment guidelines, although direct clinical evidence is lacking.^5,8,15
10. Intact skin is an essential barrier for infection. Whenever possible, intact epidermal layers should be left intact.

Exertional hyperthermia occurs when a person performs strenuous exercise in a warm environment or is not adequately able to thermoregulate by sweating. Heatstroke is an emergency condition characterized by severe hyperthermia and organ dysfunction, typically with mental status alteration. The growing incidence of heat-reported illness is of increasing concern because of global urbanization and climate change.

The current heat emergency data have several limitations. Most studies were small and involved inducing hyperthermia in asymptomatic, healthy adult volunteers, resulting in indirect evidence for treating adults with heatstroke. Studies involving people with heatstroke are generally observational and use rapidity of temperature reduction as the end point. Few studies are available on the impact of first aid interventions on crucial clinical outcomes such as mortality, organ damage, and adverse events. No comparative studies of cooling techniques in children were identified.

This topic was the subject of a 2020 ILCOR systematic review,¹ a 2020 AHA/Red Cross focused update,² and a 2022 ILCOR evidence update.³ An updated literature search was performed by the writing group in 2023.

1. Although not formally studied, these safe, readily available measures are commonly included in standard recommendations of heat exhaustion or heatstroke.^4–6

2. Heatstroke (heat stress accompanied by altered mental status) can lead to muscle injury, coagulopathy, organ failure, cardiovascular collapse, and death.^7,8 Heatstroke is a medical emergency that requires rapid cooling, intravenous fluids, and intensive monitoring and support in a hospital setting.

3. Survival from heatstroke is related to the speed at which temperature reduction is achieved; faster cooling is associated with better survival.^9–11 An ILCOR systematic review of 63 studies of cooling techniques for exertional heat exhaustion and heatstroke found faster cooling rates with water immersion compared with passive cooling.¹ There was no significant difference in the rate of body temperature reduction across water temperatures of 2 to 26°C (36° F–79° F), indicating that the act of immersion, rather than water temperature, is most important.

4. The listed cooling methods reduce temperature more slowly than immersion methods but more quickly than passive body cooling or application of ice packs to the axilla and groin.^12–14

5–6. Although much of the hyperthermia literature includes adolescent athletes and military recruits in the studied population, studies enrolling younger children have not been completed.¹⁵ In the absence of pediatric-specific studies, pediatric recommendations mirror recommendations for adolescents and adults.^15–18

7. The primary outcome of active cooling for heat-stroke is core temperature reduction. Although core temperature measurement is typically outside the scope of lay first aid providers, it may be appropriate in some settings and circumstances.^4,15,18

Dehydration associated with exertion is a health concern frequently encountered in the first aid setting, particularly in sporting events. The condition continues to pose significant risks to athletes and participants involved in physically demanding activities. It is characterized by reduced total body water content, often exacerbated by increased perspiration, respiratory water loss, high ambient temperatures, and inadequate fluid intake. This imbalance in fluid homeostasis can lead to diminished physical performance, cognitive impairments, and in severe cases, life-threatening complications such as heatstroke or acute kidney injury. Although various hydration strategies have been used to prevent or mitigate these outcomes, there has been a lack of consistency in past treatment recommendations.

This topic was the subject of a 2-part ILCOR systematic review in 2023.^1,2

1 – 2. A pair of 2023 ILCOR systematic reviews^1,2 identified 22 studies comparing carbohydrate- electrolyte drinks and other beverages with water for effective oral rehydration. These studies used surrogate markers of rehydration, typically urine output. The authors of these studies considered low urine output to represent retention of the administered fluids, an indirect measure of rehydration effectiveness. Although there was variability between studies, the review authors concluded that carbohydrate- electrolyte drinks (4%–9% glucose concentration) were overall associated with the highest net fluid balance. No beverage was superior for all end points studied, and all beverages except beer were equal or superior to potable water for some end points in some studies.

Opioid overdose is a leading cause of death in the United States and worldwide. More than 80 000 people in the United States died of opioid overdose in 2021, with a 14% increase in the age-adjusted death rate from opioid overdose in a single year.¹ In the same year, 1.06 million people were treated in US EDs for nonfatal opioid overdose.² Most overdoses are unintentional.

Opioid overdose causes central nervous system depression (sleepiness, unresponsiveness) and respiratory depression (slowed and stopped breathing), which, if untreated, progresses to cardiac arrest.

Naloxone is an antidote that reverses the effect of opioid overdose, restoring consciousness and breathing. Naloxone can be administered by multiple routes, and naloxone nasal spray is available in the United States without a prescription.

Because it can be difficult to reliably ascertain the presence or absence of a pulse in the first aid setting, these guidelines follow the Opioid-Associated Emergency for Lay Responders Algorithm (Figure 6). This does not preclude people with appropriate training from using the Opioid-Associated Emergency for Health Care Providers Algorithm.

Nothing in these guidelines is intended to preclude the use of other opioid antagonists (eg, nalmefene), which are available by prescription only in the United States at the time of this writing.

These recommendations adapt those found in the 2020 AHA adult basic and advanced life support and pediatric basic and advanced life support guidelines and the “2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning” for the first aid setting.^3–5 An updated literature search was performed by the writing group in 2023.

1. Ten controlled studies assessed the impact of opioid overdose training on the ability of individuals with opioid use disorder to recognize opioid- associated resuscitation emergencies or their willingness to administer naloxone.^6–15 One study¹³ found that the rate of naloxone administration was higher in those who had received opioid training compared with those who had not (32% versus 0%), although another study found no difference in the provision of aid between trained and untrained responders.¹⁴ Interventions that included skills practice (ie, naloxone administration) were more likely to lead to improved clinical performance compared with interventions without skills practice,^7,16–21 and an RCT showed that people who use opioids and their significant others were more likely to administer naloxone if they received hands-on training compared with watching a video.¹⁰ Opioid education and naloxone distribution programs are widely accepted by first aid providers in various settings.^22–33
2. More than 20 studies^34–62 demonstrate that naloxone is a safe and effective treatment for central nervous system and respiratory depression due to opioid overdose when given in various settings. Major complications are rare and dose related. No studies compared naloxone administration with standard resuscitation or ventilatory support alone. In addition to circumstantial evidence of opioid exposure, miosis is strongly correlated with response to naloxone administration,^63,64 although many factors affect pupil size,⁶⁵ and it is not established whether first aid providers can reliably identify miosis. Naloxone has an excellent safety profile and is unlikely to be harmful if given to a person with respiratory depression who does not have an opioid overdose.^66,67 A person who is breathing normally does not require naloxone. Early activation of the emergency response system is critical for people with suspected opioid overdose. Rescuers cannot be certain that the person’s clinical condition is due to opioid-induced respiratory depression alone. This is particularly true in first aid settings, where determination of the presence of a pulse is unreliable,^68,69 but even trained first responders have difficulty rapidly determining pulselessness.⁷⁰ Intranasal naloxone takes several minutes to restore adequate respirations,^{39,55,56,58–60,62} and ventilatory support is crucial during this time. Naloxone is not effective in other medical conditions, including overdose involving nonopioids and cardiac arrest resulting from any cause. People who respond to naloxone administration are at risk of recurrent central nervous system or respiratory depression and require a period of observation before safe discharge from a health care setting.^71–74 The risk of providing CPR to a person who is not in cardiac arrest is low.⁷⁵ Therefore, the safest course for a first aid provider is to immediately activate the emergency response system, delivering high-quality CPR that includes both compressions and ventilation, and administer naloxone. A health care professional who is able to reliably assess for the presence of a pulse can use the appropriate health care professional algorithm.

Exposure to caustic chemicals is a danger both at home and in the workplace. Although caustic injuries make up only ≈3% of burns, they can lead to significant morbidity and mortality.¹ There are many different types of caustic products, but they fall primarily in the categories of acids and alkalis. The extent of the injury from caustic materials is related to the mechanism and concentration of the chemical, its depth of penetration, the volume of chemical that the victim is exposed to, the body site involved, and how long the exposure lasts.^2,3

Rapid removal of the caustic agent is the key to first aid. When first aid is provided for caustic injury, it is important not to contaminate other individuals or areas with the substance. Personal protective equipment should be worn when exposure to the caustic agent is possible. Although some caustic liquids may be more easily removed or treated with specialized agents, running water is a readily available resource that can be used as a decontamination agent.⁴ Poison centers can provide further information on additional treatment recommendations, including duration of irrigation or other decontamination strategies.

A literature search was performed by the writing group in 2023.

1–2, 4. An observational study reported outcomes for 35 patients with caustic dermal injury from various agents.⁵ Patients who received immediate irrigation within 10 minutes and with a “large volume” of water for at least 15 minutes had decreased degree of full-thickness burns, number of full-thickness burns, and mean length of hospital stay compared with those who did not receive immediate irrigation. A second observational study evaluated the effect of immediate first aid, defined as copious water irrigation within 3 minutes of the exposure, compared with delayed irrigation in 83 patients.⁶ The number of full-thickness burns, mean hospital days, and delayed complications were all lower in patients with immediate irrigation compared with those with delayed irrigation. Removal of contaminated clothing and jewelry avoids trapping chemicals against the skin during decontamination.⁷

3. Exposures to some chemicals such as those in the home may result from low concentrations and amounts of the chemical that, if appropriately irrigated, may not result in burns to the skin and do not need more advanced medical care. However, in the industrial setting or with more concentrated or potent chemicals, significant injury may occur and, even with immediate irrigation, needs advanced medical care. Sources of chemical-specific treatment recommendations include Safety Data Sheets and poison centers.

5. Some chemicals such as hydrofluoric acid⁸ and phenol⁹ are best decontaminated with substances other than water and may require treatment other than simple decontamination. Washing with a commercial decontamination solution if available may be more effective than water for some exposures.^10–12 Some poisons can be absorbed through the skin or mucus membranes, leading to systemic toxicity. Recommendations for decontamination in specific circumstances can be obtained from local protocols, hazardous materials references, and regional poison centers.

6. Some dry chemicals such as sodium hydroxide, elemental sodium, or elemental potassium may react with water to cause caustic or thermal injury. Dry decontamination (brushing off as much chemical powder as possible while avoiding spreading the contaminant to other areas) before irrigation of the area with water may reduce this effect.^1,13

Caustic chemical exposure to the eyes is a danger both at home and in the workplace.¹ Chemical injury to the eye represents between 10% to 22% of all eye injuries.^2,3 The extent of the eye injury from caustic materials is related to the chemical involved and how long the exposure lasts.³ Therefore, rapid removal of the caustic agent is the key to first aid. Although some chemicals may have specific decontamination techniques, running water is a readily available resource that has been demonstrated to be an effective decontamination agent.⁴ Regional poison centers or local protocols can provide further information on additional treatment recommendations, including duration of irrigation or other decontamination strategies.

A literature search was performed by the writing group in 2023.

1–3. Early eye irrigation is associated with reduced eye damage in human observational and animal experimental studies.^5–9 Cross-contamination of the contralateral eye, the injured person’s skin, or other people’s skin risks additional injury. Although studies comparing different durations of eye irrigation are not available, 15 minutes of continuous irrigation appeared to be effective in an observational study and an animal experiment.^4,5 Some people may need assistance maintaining open eyelids during irrigation. Although many reviews recommend irrigation until the eye pH is normal, pH test paper is not routinely available in the first aid setting.

4. A prospective observational study enrolling 1495 patients with 2194 corrosive eye injuries demonstrated that patients irrigated with a commercial eye irrigation solution had significantly less severe-grade eye injury compared with those treated with isotonic phosphate buffer, Ringer’s lactate, or 0.9% saline solution.⁴ Irrigation with a balanced salt solution may be more comfortable than irrigation with other irrigation fluids.⁸

5. Approximately 8% of chemical eye injuries in working-aged people occur in the occupational setting. These settings may use chemicals that require specific decontamination techniques for ideal treatment. US poison centers assist in management of >80 000 ocular chemical exposures per year.¹⁰

Trauma is a leading cause of morbidity and mortality throughout the world, resulting in millions of deaths and hospitalizations each year. Uncontrolled bleeding is the most important preventable cause of death in 35% of trauma patients and can occur before the arrival of emergency services.^1–3 Life-threatening bleeding can be recognized by pooling of blood on the ground, blood that is rapidly flowing or spurting from the wound, bleeding that continues despite direct manual pressure, or bleeding that results in systemic symptoms such as drowsiness, dizziness, chest pain, or loss of consciousness. Because death can occur within minutes, first aid providers are essential in providing immediate care. Control of bleeding is a foundational first aid skill, and applying direct pressure is the mainstay of treatment. For extremity bleeding that is not effectively controlled with direct pressure, tourniquet application can be an appropriate intervention.

Direct manual pressure is the hallmark of hemorrhage control. If available, hemostatic dressings (which contain materials that help promote blood clotting), pressure dressings, mechanical pressure devices, and tourniquets may augment the effectiveness of direct manual pressure or avoid the need for ongoing direct manual pressure. These devices may also be useful in a mass casualty event, when there are not adequate resources to provide direct pressure to all victims. Tourniquets are beneficial for extremity hemorrhage only when they can be applied proximal to the wound. Both commercial and improvised tourniquets can be used. No human studies have assessed the effectiveness of manual pressure points in individuals with life-threatening bleeding.

These guidelines are intended for use in the civilian first aid setting. The management of life-threatening bleeding in tactical rescue situations, mass casualty events, and military conflict is outside the scope of these guidelines.

This topic was the subject of several 2020 ILCOR systematic reviews.⁴ An updated literature search was performed by the writing group in 2023.

1, 5. In 3 different RCTs conducted in hospitalized participants undergoing endovascular procedures, there was a shorter time to bleeding cessation for bleeding arterial wounds with the use of direct manual pressure than with the use of at least some mechanical compression devices.^5–7 No studies on mechanical pressure for traumatic injuries or in the first aid setting were identified.

2. In an RCT of 160 patients in the ED with stab wounds to the limbs, the proportion with cessation of bleeding in <5 minutes was higher for participants who received a hemostatic dressing plus direct pressure (51.2%) compared with participants who received direct pressure alone (32.5%).⁸ There are currently no data addressing which type of dressing may be more effective in the first aid setting, but 3 in-hospital RCTs suggest no difference between dressing types in time to cessation of bleeding or complications.^9–11

3. Commercial pressure dressings and elastic adhesive dressings may be effective in maintaining hemorrhage control or even as the primary means of hemorrhage control when applied by people who have received bleeding control training, including by non–health care personnel.^12–14

4. No studies were identified evaluating the effectiveness of manual compression of the femoral or brachial artery (also known as pressure points) to control distal hemorrhage. Data on the use of pressure points for life-threatening bleeding come from manikin studies and studies using healthy human volunteers, with no human studies evaluating pressure points in individuals with life-threatening external bleeding.^4,15 In a volunteer study, manual digital occlusion of the brachial or femoral artery eliminated distal blood flow in most subjects, but the effect was not sustained; distal pulses returned in a median of 40 seconds after brachial artery occlusion and 20 seconds of femoral artery occlusion.¹⁶

1. Observational studies of patients with life-threatening extremity bleeding report lower mortality when a tourniquet is placed in the prehospital setting as opposed to only after hospital arrival.^4,16–18 Tourniquet application by health care professionals and laypeople appears to be safe: In 2 observational studies including 255 people with prehospital tourniquet application by police, EMS personnel, and laypeople, no person had decreased limb function attributed to tourniquet use.^19,20 A recent systematic review found no sign that tourniquet use was associated with increased amputation rates, and nerve palsy rates were low.⁴ Commercial windlass tourniquets appear to be appropriate for use in children as young as 2 years of age^4,21 and to successfully occlude distal extremity pulses in school- aged child volunteers (6–16 years of age).²²
2. Simulation studies with healthy adult volunteers^23–25 and manikins²⁶ reported a higher rate of distal pulse ablation or simulated arterial compression with commercial tourniquets compared with improvised tourniquets. No pediatric studies comparing commercial with improvised tourniquets in children were identified. Some training may be required for successful application of commercial tourniquets by laypeople.^27–29
3. Narrow tourniquets cause more pain and tissue damage and are less effective than wider tourniquets.^16,30,31 Wider cuff tourniquets require less pressure to occlude arterial blood flow than narrow tourniquets.^30,32 High tourniquet pressure is associated with an increased risk of nerve compression injury.³³

An open chest wound (a wound through the chest wall into the lung cavity) is immediately life-threatening. Management of an open chest wound in an out-of-hospital setting while awaiting the arrival of EMS is a challenging scenario for a first aid provider. In patients with chest trauma who are breathing spontaneously, air can enter the pleural space through the chest wall defect or through a lung wound during the inspiratory (negative intrathoracic pressure) phase of the respiratory cycle (a “sucking chest wound”). The goal of a chest seal is to prevent air entry through the wound. Air can exit through the chest wall defect when intrathoracic pressure exceeds ambient pressure such as during the expiratory phase of spontaneous respirations, during positive-pressure ventilation (eg, rescue breathing, bag-mask ventilation), or if a tension pneumothorax is developing. The goal of a chest seal is to prevent air entry into the pleural space. The greatest concern is the improper use of an occlusive dressing or device that could lead to fatal tension pneumothorax by preventing air from exiting through the chest wound. It may be difficult for first aid providers to monitor for signs of tension pneumothorax such as decreased air movement on the affected side and low blood pressure.

A literature search was performed by the writing group in 2023.

1. Open chest wounds, whether from penetrating trauma or massive blunt trauma, are a medical emergency.
2. One possible cause of worsening breathing is the creation of a tension pneumothorax because air is no longer able to leave the pleural cavity after placement of a dressing. Loosening or removing the dressing may relieve tension pneumothorax.
3. The goal of sealing an open chest wound is to increase the airflow resistance through the chest wall defect so that it is greater than resistance through the trachea, allowing proper lung ventilation. This is balanced against the risk of causing tension pneumothorax.
   For stab wounds, most handgun wounds, and many rifle wounds, a small wound does not lead to enough air leak to impair respirations. For larger chest wall defects such as those caused by high-velocity rifle wounds, shotgun wounds, and blast injuries, first aid interventions designed to reduce air entry through the wound are theoretically beneficial. Placement of a nonocclusive specialized dressing such as a vented chest seal may achieve this goal.
   There are no human studies of chest seals to inform our treatment recommendations. The skill required to apply these devices correctly is unknown. The effect of these devices on patient-important outcomes (morbidity and mortality) is unknown. The available evidence comes from porcine models and studies on healthy human volunteers. Reported outcomes across the available evidence are disparate, including device adhesion on soiled porcine chest walls,¹ adhesion of new design for a vented chest seal on healthy volunteers and vent function,² and valve malfunction and labored breathing in a porcine model of tension pneumothorax and hemothorax.³ One porcine study demonstrated that both vented and unvented chest seals provided improvements in breathing and blood oxygenation; however, in the presence of ongoing intrapleural air accumulation, the unvented chest seal eventually led to tension pneumothorax and hypoxemia.⁴
   The risk of occlusive dressing use in penetrating chest trauma has been detailed in the published literature since the 1950s.⁵ Chest seal evaluations in animal models of hemopneumothoraxes have demonstrated how these devices can fail.³ Any dressing or device placed over an opening in the chest wall has the potential to cause a tension pneumothorax, particularly if the device does not allow egress of air. A first aid provider who places a dressing or device should be aware of the potential complications and monitor for its occurrence.

Superficial wounds and abrasions occur when the top-most layer of skin, the epidermis, is damaged. Often resulting from friction against a rough surface, they are frequently seen in outdoor activities, sports, work, and everyday accidents. Proper first aid care can prevent infection, accelerate healing, and reduce scarring.

A literature search was performed by the writing group in 2023.

1. Although a 2022 Cochrane systematic review found no trials reporting wound infection that compared cleansing with tap water with no cleansing,¹ cleansing a wound to prevent infection makes empirical sense. Infection rates of wounds irrigated with tap water are similar to infection rates of wounds irrigated with sterile saline solution.^2,3 Although there is a paucity of evidence to show that any irrigation reduces infection rates in minor traumatic wounds⁴ and simple rinsing may not provide the irrigation pressure needed to remove most bacterial contamination,^5,6 cleansing of traumatic wounds is generally accepted and recommended.^7–9
2. Human and animal bite wounds or wounds contaminated with human or animal saliva are at increased risk for infection.¹⁰ Early administration of antibiotics appears to prevent infection from high-risk human and other mammalian bites to the hand and may be useful for other bites.^10–12
3. Several studies have not demonstrated a benefit of wound cleansing with povidone-iodine in addition to irrigation.^1,13 Similar infection rates appear to occur when wounds are irrigated with tap water, boiled water, distilled water, or sterile saline.^1,14,15
4. Occlusive dressings such as film, petrolatum, hydrogel, and cellulose/collagen dressings result in better wound healing than dry dressings.^16,17 There is no indication that antibiotic or antibacterial dressings improve wound healing or decrease infection rates in clean wounds.^18–20
5. Wound infection often requires treatment with antibiotics, which must be prescribed by a health care professional.

Strategies for spinal immobilization in patients with actual or potential spinal injuries have been used for decades because of concerns that movements associated with extrication and transportation could lead to worsening of original injury or additional new injury. However, these practices (rigid cervical collar and long spine board application) have been driven more by legal considerations and unproven theories than by concrete scientific or clinical evidence. Growing data suggest that they might even be detrimental, leading to their wide-spread deadoption.

These recommendations are intended for the members of the general public providing first aid. Appropriate exceptions may be made for first aid providers with additional training and special duties working in specific circumstances (eg, lifeguards treating a person with a diving injury).

This topic was the subject of a 2015 ILCOR systematic review¹ and a 2019 ILCOR scoping review.²

1. Spinal cord injuries in adults and children are often associated with significant and frequently life-threatening injuries to the head and brain, chest, and abdomen.^3,4 Having the injured person remain still may reduce the risk of worsening spinal cord or other injury while awaiting the arrival of EMS personnel.
2. A systematic review and meta-analysis found that routine spinal immobilization for penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurological deficits.^5,6
3. The gradual de-emphasis and deadoption of the use of spinal immobilization by professional EMS have not been associated with an increase in disabling spinal cord injuries.⁷ Systematic reviews have found that immobilization devices, including rigid cervical collars and spine boards, are associated with patient discomfort and pressure ulcer development.^8–10 Prior treatment guidelines from the AHA, the Red Cross, and ILCOR and a 2019 systematic review provided a weak recommendation against the routine use of cervical collars for stable patients in the first aid setting.^1,11,12

Concussion is a type of mild traumatic brain injury that is caused by an action or injury that rapidly moves the head and brain back and forth. According to the National Center for Health Statistics, in 2022, 2.3 million children and adolescents had ever received a diagnosis of concussion or brain injury.¹ Signs and symptoms of concussions include headache, nausea, impaired balance, difficulties concentrating, confusion, emotional lability, and fatigue.^2,3 Repeated concussions may lead to long-term difficulties with memory, concentrating, fatigue, headache, and other neurological sequelae.^2,4–6

Symptom-based tools have been developed to assess the presence and severity of a concussion during sports; however, they require specific training.^2,5,7–12 To date, there is no validated scoring system for concussion identification in the first aid setting.

ILCOR performed a scoping review on concussion assessment in 2020.¹³ An updated literature search was performed by the writing group in 2023.

1. A broad consensus of health care organizations recommends removing the person with a concussion from sports and other activities posing a risk of reinjury until the injured person has fully recovered.^2,14–17 Specific requirements and timing of return to contact vary and should be determined in consultation with a health care professional.
2. Loss of consciousness, severe or worsening head- ache, repeated vomiting, altered mental status, seizure, neurological signs and symptoms, and skull fracture are all associated with an increased risk of life-threatening brain injury such as epidural hematoma, subdural hematoma, open skull fracture, or brain edema, which may require hospital treatment.

Strains and sprains are common soft tissue injuries that occur after movements or falls that stress joints or muscles. These lead to overstretching or tearing of ligaments, tendons, and muscles. Acute symptoms after the injury include pain, swelling, and limited mobility to the affected extremity or joint. Studies of therapy during the subacute and healing phases of sprain and strain injuries provide indirect evidence for the first aid setting.

The ILCOR performed a systematic review of compression wraps in 2020.¹ An updated literature search was performed by the writing group in 2023.

1. The mainstay of treatment for strains and sprains is rest and limiting the use of the injured extremity. Often in the first aid setting, there is uncertainty about whether an injury is a sprain, strain, or a fracture; limiting use of the injured extremity avoids worsening the injury.
2. Cold application can acutely decrease pain and swelling in joint sprains and muscle strains. In an RCT of 74 patients with sports-related soft tissue injury, cold therapy to soft tissue injuries improved pain scores at weeks 1, 2, and 4 after injury.² Cold therapy improved edema compared with heat therapy in the acute time period.³ However, cold application has not been demonstrated to improve function or time to recovery.⁴ The greatest tissue cooling is achieved by using a bag filled with ice and water surrounded by a damp cloth.^5,6 Other modalities such as refreezable gel packs or ice alone can also be used but do not cool the area as effectively as an ice and water mixture.^6,7 Experts recommend limiting the duration of cold application to 20 to 30 minutes for 3 to 4 times daily.⁸ To prevent cold injury, ice should not be placed directly on the skin.
3. Applying a compression wrap to an acute ankle sprain may provide comfort and relieve pain in the acute time frame.^9,10 Caution should be taken when applying compression to not compromise circulation from overtightening the compression wrap. A systematic review of 6 RCTs and 2 nonrandomized trials concluded that compression wraps did not reduce swelling or pain in ankle sprains or strains during the recovery time frame.¹¹ In addition, compression wraps did not improve ankle joint function, range of motion, or time to recovery.¹² A systematic review of 8 RCTs did not find a significant difference between rigid, semirigid, and flexible compression wraps when analyzing postinjury symptoms and ankle stability.^12,13 No studies were identified that address the utility of compression wraps for other joint injuries.

Extremity fractures are painful injuries that can become life or limb threatening when involving long bones, major blood vessels, or extensive soft tissue damage. Fractures of a long bone such as the femur can cause severe external or internal bleeding, and open fractures (if the fractured bone disrupts the skin) are at high risk for infection. Signs of an extremity fracture may include obvious deformity, swelling, or bruising of a limb; severe pain with movement or inability to move an extremity; or visible, protruding bone.

After an extensive literature review performed by the writing group in 2023, these recommendations were based on consensus from expert opinion because the search identified no published studies on caring for fractures in the first aid setting.

1. Long-bone fractures and open fractures can cause substantial and possibly life-threatening blood loss.
2. Blue, purple, or pale extremities may indicate poor perfusion to the extremity, a limb-threatening injury for which professional medical care should be sought immediately.
3. There is a lack of evidence demonstrating clear benefits from fracture splinting in the prehospital first aid setting. However, fracture immobilization is an essential part of definitive fracture treatment. Splinting as a first aid measure may be helpful to reduce pain, prevent further injury, and facilitate transport.^1,2
4. Splinting an injured extremity in the position found is accepted first aid practice.^3,4 Although reducing angulated fractures may reduce pain and improve blood flow, there are risks, including injury to nerves, blood vessels, and other soft tissue, as well as risk of converting a closed fracture to an open fracture. No study evaluating whether first aid providers are able to perform fracture reduction safely could be found.⁴
5. As with any open wound, covering an open fracture protects against additional contamination.³

Thermal burns are caused by contact with flames, hot liquids, hot surfaces, and hot gases. Burns can lead to damaging physical, functional, cosmetic, and psychosocial consequences.¹ Immediate first aid care can reduce these consequences, and understanding the indications for ED referral can be lifesaving.²

Superficial (first-degree) burns are characterized by skin redness and pain without blistering or other loosening or destruction of the skin surface (Figure 7). The intact skin maintains its barrier function. First-degree burns generally heal without scarring, and the risk of infection is low. Partial-thickness (second-degree) and full-thickness (third-degree) burns involve destruction of the epidermis and injury to deeper layers and often require treatment beyond what can be provided in the first aid setting to speed healing, prevent infection, and reduce scarring.^2,4 Large partial-thickness burns (partial- thickness burns that involve the face, hands, feet, or genitalia), all full-thickness burns, and concern for inhalation injury (soot around the nose or mouth, difficulty breathing) require hospital treatment.

Active cooling to “stop the burn” has long been advocated as essential immediate first aid for thermal burns. Although burn-cooling sprays have also been studied, the majority of studies involve immediate application of cool running water. There is a lack of international consensus about the optimal duration of cooling of thermal burns.

This topic was last reviewed by ILCOR in 2022⁵ and was included in a 2022 update.⁶ An updated literature search was performed by the writing group in 2023.

1. Cooling of burns with running water is an established and beneficial intervention with little risk of harm.^5,6 A meta-analysis of observational data (7 studies, 11 383 adults and children) suggests a decrease in the need for subsequent care in patients with thermal burns who receive immediate active cooling with clean running water.⁷
2. Because of their larger surface area–to–volume ratio, preadolescent children are more likely to develop hypothermia than adolescents and adults. A study of 117 children with thermal burns who received whole-body cooling in the shower reported that 5 children (4%) developed hypothermia or were visibly cold with shivering.⁸ By observing for signs and symptoms of hypothermia and, when possible, monitoring temperature, first aid providers can avoid accidentally causing a child with burn injury to become hypothermic.
3. An ILCOR meta-analysis of 4 studies involving 5978 adults and children did not demonstrate a clear duration of cooling that was most effective and concluded that the ideal cooling duration is unknown.⁵ Leading international organizations recommend active cooling durations of 5 to 20 minutes.^9–12
4. Porcine model thermal burn studies have demonstrated that ice reduces tissue temperatures after thermal burn, but the application of ice has not resulted in faster wound re-epithelializing, or healing with less scarring, compared with no treatment. Of note, there is risk of additional tissue damage when ice is used with compression.¹³ If cool or cold clean running water is unavailable and ice is used, the ice should be placed in a cloth or towel before being applied to the burn area and limited to 10 minutes of application time to prevent frostbite injury.

1. Burns involving the face, hands, feet, and genitals may require surgical intervention to prevent permanent disability. Burns with a large surface area can lead to significant fluid loss and multisystem organ failure. The American Burn Association recommends that patients with second- or third-degree burns involving the face, hands, feet, and genitals and those involving >10% body surface area (5% in children) be treated in a specialized burn center because of the likely need for intravenous fluid resuscitation, surgery, and other specialized treatments.^14,15
2. Inhalation injury from hot smoke can lead rapidly to loss of the airway due to airway swelling. Evidence of inhalation injury can also be indicative of carbon monoxide poisoning. A person with signs of inhalation injury such as facial burns, difficulty breathing, singed nasal hairs, or soot around the nose or mouth should have EMS activated immediately.^15a
3. Because burned tissue swells, expert consensus advocates that jewelry be removed before the onset of swelling to prevent constriction and vascular ischemia.⁹
4. Over-the-counter analgesics such as acetaminophen or NSAIDs are well tolerated and generally recommended for burn pain.^16,17 A prospective study enrolling 61 patients with second- or third-degree burns randomly assigned to either receive 800 mg IV ibuprofen or placebo every 6 hours found no significant incidence in serious adverse events.¹⁸
5. Petrolatum (with or without topical antibiotics such as polymyxin), honey, and aloe have been shown to improve healing time in patients with partial-thickness, “open” burns, including unroofed blisters, compared with no dressing or various controls.^3,19–31 Most studies assessed the use of various burn treatments daily or continuously until complete healing; short-term use in the first aid setting has not been well studied. Specialized burn dressings are assumed not to be available in the first aid setting.
6. Covering a partial- or full-thickness burn with a nonadherent bandage or clean cloth protects the wound and reduces pain while avoiding heat entrapment until the burn can be assessed by a health care professional.¹⁴

After traumatic avulsion of a permanent tooth, the chance of survival of the tooth is greatest if it can be replanted immediately after the time of injury. The injured person may be able to replant the tooth themselves with follow-up care delivered by a dentist; in many cases, however, the individual is unable to replant the tooth themselves, and a dentist or physician is needed for further care.

If immediate intervention cannot occur, minimizing extra-alveolar dry time by transporting the avulsed tooth in a medium that can preserve the viability of the periodontal ligament cells improves the chances of successful reimplantation. The efficacy of various storage materials and methods available to the first aid provider has been evaluated in the literature compared with cow’s milk or the patient’s saliva. In addition to the methods evaluated later, storage in aloe vera gel and coconut water has been proposed; these techniques were not supported by enough consistent evidence to inform a recommendation.^1–3

These recommendations pertain only to the avulsion of permanent teeth; primary teeth (also known as deciduous teeth or baby teeth) are not typically replanted.

The ILCOR performed a systematic review on this topic in 2020.⁴ An updated literature search was performed by the writing group in 2023.

1. The likelihood of successful reimplantation decreases rapidly as long as the tooth remains out of the socket, particularly if the periosteal ligament dies or is injured.^5–7

2. Many people need assistance re-implanting a tooth, particularly if the injured person is a child. Stabilization of the re-implanted tooth by a dentist is often necessary.⁶

3. Storage of an avulsed permanent tooth in Hanks Balanced Salt Solution, oral rehydration salt solutions, propolis, rice water, and cling wrap has demonstrated improved periodontal ligament cell viability compared with storage in cow’s milk.^1,8–11 Oral rehydration salt solution is the nonproprietary name for the balanced mixture of glucose and electrolytes (sodium, chloride, potassium, and citrate) that has been used to treat and prevent clinical dehydration due to diarrheal diseases.¹² Oral rehydration salt solutions can be purchased commercially or made from materials commonly found in the home. Table 12(link opens in new window) provides a ranking of solutions based on the likelihood of successful reimplantation after avulsed tooth storage.

4–5. Observational studies comparing cow’s milk and the injured person’s own saliva as storage media found no difference in the rates of successful replantation.^10,11 Depending on the injured person’s age and mental status, temporary storage of the avulsed tooth in the injured person’s mouth may pose a choking hazard. Storing the tooth in the mouth of another person involves infection risk, although in some cases (eg, a parent), the people involved may consider this risk to be acceptable.^{1,5,7–9,11,13}

6. Two studies found harm to periodontal ligament cell viability when a tooth is stored in tap water.^14,15