Part 17: First Aid
2010 American Heart Association and American Red Cross Guidelines for
David Markenson, Co-Chair*; Jeffrey D. Ferguson, Co-Chair*; Leon Chameides; Pascal Cassan;
Kin-Lai Chung; Jonathan Epstein; Louis Gonzales; Rita Ann Herrington; Jeffrey L. Pellegrino;
Norda Ratcliff; Adam Singer
Modern, organized first aid evolved from military experi-
Red Cross (Red Cross) cofounded the National First Aid
ences when surgeons taught soldiers how to splint and
Science Advisory Board to review and evaluate the scien-
bandage battlefield wounds. Two British officers, Peter Shep-
tific literature on first aid in preparation for the 2005
herd and Francis Duncan, are said to have been the first to
American Heart Association (AHA) and American Red
expand the concept to civilians and to develop the first
Cross Guidelines for First Aid.
1 In preparation for the 2010
curriculum in first aid.4 Organized training in civilian first aid
evidence evaluation process, the National First Aid Advi-
began in the United States in 1903 when Clara Barton,
sory Board was expanded to become the International First
president of the Red Cross, formed a committee to establish
Aid Science Advisory Board with the addition of repre-
instruction in first aid among the nation's industrial workers,
sentatives from a number of international first aid organi-
where, under dangerous conditions, accidents and deaths
zations (see Table). The goal of the board is to reduce
were all too frequent.
morbidity and mortality due to emergency events bymaking treatment recommendations based on an analysis
The Evidence Evaluation Process
of the scientific evidence that answers the following
The International First Aid Science Advisory Board first
identified 38 questions in first aid practice that either were not
raised in previous evidence evaluations or were in need of
In which emergency conditions can morbidity or mortality
updating. Two or more board members volunteered to review
be reduced by the intervention of a first aid provider?
the scientific literature independently and develop an
How strong is the scientific evidence that interventions
evidence-based review worksheet summarizing the literature
performed by a first aid provider are safe, effective, and
relevant to each question (see Part 2: "Evidence Evaluation
and Management of Potential or Perceived Conflicts of
A critical review of the scientific literature by members of
Interest"). After each worksheet was presented to, and re-
the International First Aid Science Advisory Board is sum-
viewed by, the full board, a summary draft of the scientific
marized in the 2010 International Consensus on First Aid
evidence and a treatment recommendation were crafted. The
Science With Treatment Recommendations
evidence-based review for each question was presented and
from which these guidelines are derived.2
discussed a second time at a subsequent board meeting. All
That critical review evaluates the literature and identifies
first aid worksheets, co-copyrighted by the American Heart
knowledge gaps that might be filled through future scientific
Association and the American Red Cross, can be viewed
through hyperlinks in the 2010 American Heart Associationand American Red Cross International Consensus on First
Aid Science with Treatment Recommendations.2 Each ques-
The history of first aid can be traced to the dawn of organized
tion, evidence-based review, draft summary of science, and
human societies. For example, Native American Sioux med-
draft treatment recommendation was presented, discussed,
icine men of the Bear Society were noted for treating battle
and debated on 2 separate occasions until a consensus was
injuries, fixing fractures, controlling bleeding, removing ar-
reached. These guidelines are based on the scientific consen-
rows, and using a sharp flint to cut around wounds and
sus findings reported in the 2010 International Consensus on
First Aid Science with Treatment Recommendations
The American Heart Association and the American Red Cross request that this document be cited as follows: Markenson D, Ferguson JD, Chameides
L, Cassan P, Chung K-L, Epstein J, Gonzales L, Herrington RA, Pellegrino JL, Ratcliff N, Singer A. Part 17: first aid: 2010 American Heart Associationand American Red Cross Guidelines for First Aid. Circulation
. 2010;122(suppl 3):S934 –S946.
*Co-chairs and equal first co-authors.(Circulation. 2010;122[suppl ]:S934 –S946.)
2010 American Heart Association, Inc., and American Red Cross.
Circulation is available at http://circ.ahajournals.org
Markenson et al
Part 17: First Aid
International First Aid Science Advisory Board
sound and based on scientific evidence or, in the absence
of such evidence, on expert consensus. Administration offirst aid must not delay activation of the emergency
American Academy of Pediatrics
medical services (EMS) system or other medical assistance
American Burn Association
when required. We strongly believe that education in first
American College of Emergency Physicians
aid should be universal: everyone can learn first aid and
American College of Occupational and Environmental Medicine
American College of Surgeons
The scope of first aid is not purely scientific; it is
American Heart Association
influenced by both training and regulatory issues. The defi-
American Pediatric Surgical Association
nition of scope is therefore variable, and should be defined
American Red Cross
according to circumstances, need, and regulatoryrequirements.
American Red Cross Advisory Council on First Aid, Aquatics, Safety andPreparedness (ACFASP)
American Safety & Health Institute (ASHI)
Calling for Help
Austrian Red Cross
A first aid provider must be able to recognize when help is
Canadian Red Cross
needed and how to get it. First aid providers should learn
Divers Alert Network
how and when to access the EMS system, how to activatethe on-site emergency response plan (ERP), and how to
European Reference Center on First Aid Education
contact the Poison Control Center (see "Poison Emergen-
Egyptian Red Crescent
Grenada Red Cross
Positioning the Victim
Hong Kong Red Cross
As a general rule a victim should not be moved, especially if
Hungarian Red Cross
you suspect, from the victim's position or the nature of the
International Federation of Red Cross and Red Crescent Societies
injury, that the victim may have a spinal injury (see "Spine
Medic First Aid International
Stabilization" below). There are times, however, when the
National Association of EMS Educators
victim should be moved:
National Association of EMS Physicians
If the area is unsafe for the rescuer or the victim, move the
National Athletic Trainers' Association
victim to a safe location if it is safe to do so.
National Safety Council
If the victim is face down and is unresponsive, turn the
Norwegian Red Cross
victim face up.
Occupational Safety and Health Administration
If the victim has difficulty breathing because of copious
Red Cross Society of China
secretions or vomiting, or if you are alone and have to leave
Resuscitation Council of Asia
an unresponsive victim to get help, place the victim in a
St. John Ambulance, UK
rm IN E
recovery position:9,10 Extend one of the victim's arms
above the head and roll the body to the side so the victim's
Previous reports5–8 have noted the paucity of scientific
head rests on the extended arm. Bend both legs to stabilize
evidence supporting many interventions in prehospital emer-
the victim (Class IIb, LOE C).
gency care. In reviewing the medical literature, members of
If a victim shows evidence of shock, have the victim lie
the International First Aid Science Advisory Board once
supine. If there is no evidence of trauma or injury, raise the
again found a paucity of evidence to guide first aid interven-
feet about 6 to 12 inches (about 30° to 45°) (Class IIb, LOE
tions. Very little research is being conducted in first aid, and
C). Do not raise the feet if the movement or the position
many of the following recommendations are extrapolated
causes the victim any pain.
from the experience of healthcare professionals. It is impor-tant to recognize the limitations of the evidence that supports
The evidence for a benefit to raising the feet is extrapolated
many of these guidelines so that research can be undertaken
from leg raising studies on volume expansion; there are no
and future guidelines can be based on a larger body of
studies on the effect of leg raising as a first aid maneuver for
shock. The results of the volume expansion studies arecontradictory with some showing an increase in cardiac
Definition of First Aid
output,11–13 while others show no change in cardiac output ormean arterial pressure14–18 with leg raising.
We define first aid as the assessments and interventionsthat can be performed by a bystander (or by the victim)with minimal or no medical equipment. A first aid provider
is defined as someone with formal training in first aid,
There is insufficient evidence to recommend routine use of
emergency care, or medicine who provides first aid. First
supplementary oxygen by a first aid provider for victims
aid assessments and interventions should be medically
complaining of chest discomfort19,20 or shortness of breath21
November 2, 2010
(Class IIb, LOE C). Supplementary oxygen administration
epinephrine may be given if symptoms of anaphylaxis
may be beneficial as part of first aid for divers with a
persist (Class IIb, LOE C).
decompression injury (Class IIb, LOE C22).
The general principles of first aid management of seizuresare to
Ensure an open airway.
The incidence of acute asthma is increasing, especially in
urban populations.23 Many victims with asthma take a pre-scribed bronchodilator medication and can self-administer
Do not restrain the victim during a seizure. Do not try to
it.24–26 First aid providers are not expected to make a
open the victim's mouth or try to place any object between
diagnosis of asthma, but they may assist the victim in using
the victim's teeth or in the mouth. Restraining the victim
the victim's prescribed bronchodilator medication (Class IIa,
may cause musculoskeletal or soft-tissue injury. Placing an
LOE B) under the following conditions:
object in the victim's mouth may cause dental damage or
The victim states that he or she is having an asthma attack
aspiration (Class IIa, LOE C). It is not unusual for the
or symptoms associated with a previously diagnosed
victim to be unresponsive or confused for a short time after
breathing disorder, and the victim has the prescribed
medications or inhaler in his or her possession.
The victim identifies the medication and is unable to
administer it without assistance.24
Because it is very difficult, even for the healthcare profes-sional, to differentiate chest discomfort of cardiac origin from
First aid providers should become familiar with inhalers so
other chest discomfort, the first aid provider should assume
that they can assist a victim with an acute asthma attack in
that chest discomfort is cardiac until proven otherwise.
using the inhaler.
Cardiac chest discomfort is often described as "crushing" or"pressing" and is often accompanied by shortness of breath or
perspiration. But cardiac chest discomfort may not have these
Allergies are relatively common, but only a small proportion
classical characteristics, especially in women. Call EMS
of people with allergies develop anaphylactic reactions. An
immediately for anyone with chest discomfort. Do not delay
anaphylactic reaction is a progressive series of signs and
and do not try to transport the patient to a healthcare facility
symptoms characterized by swelling, breathing difficulty,
an itching rash, and eventually shock, which, if left
While waiting for EMS to arrive, the first aid provider may
untreated, may lead to death. Some of these signs and
encourage the victim to chew 1 adult (not enteric coated) or
symptoms can also be present in other conditions, and first
2 low-dose "baby" aspirin if the patient has no allergy to
aid rescuers should not be expected to make a diagnosis of
aspirin or other contraindication to aspirin, such as evidence
of a stroke or recent bleeding (Class IIa, LOE A).44–46
Older patients who suffer from anaphylactic reactions
know their signs and symptoms and many carry a lifesavingepinephrine auto-injector. With proper training, parents can
be taught to correctly use an auto-injector to administerepinephrine to their allergic children.31 All too often, how-
ever, neither the victim nor family members know how to
Control of bleeding is a basic skill of first aid and one of the
correctly use an auto-injector.32–34 First aid providers should
few actions with which a first aid provider can critically
be familiar with the epinephrine auto-injector so that they can
help a victim with an anaphylactic reaction to self-administerit. First aid providers should also know how to administer the
auto-injector if the victim is unable to do so, provided that the
Bleeding is best controlled by applying pressure until bleed-
medication has been prescribed by a physician and state law
ing stops47–53 or EMS rescuers arrive (Class I, LOE A). The
permits it (Class IIb, LOE B).
amount of pressure applied and the time the pressure is held
In retrospective studies35–37 18% to 35% of patients
are the most important factors affecting successful control of
having signs of anaphylaxis required a second dose of
bleeding. The pressure must be firm, and it must be main-
epinephrine if symptoms persisted or progressed after the
tained for a long time. Methods of applying pressure include
first dose. Because of the difficulty in making a diagnosisof anaphylaxis27–30,38,39 and the potential harm from epi-
Manual pressure on gauze or other cloth placed over the
nephrine if the diagnosis is incorrect,40 – 43 first aid provid-
bleeding source. If bleeding continues, do not remove the
ers are advised to seek medical assistance if symptoms
gauze; add more gauze on top and apply more pressure.
persist, rather than routinely administering a second dose
If it is not possible to provide continuous manual pressure,
of epinephrine. In unusual circumstances, when advanced
wrap an elastic bandage firmly over gauze to hold it in
medical assistance is not available, a second dose of
place with pressure.54–57
Markenson et al
Part 17: First Aid
Although tourniquets have been shown to control bleedingeffectively on the battlefield58–60 and during surgery and have
been used by paramedics in a civilian setting without com-
Cool thermal burns with cold (15° to 25°C) tap water as soon
plications,61 there are no studies on controlling bleeding with
as possible and continue cooling at least until pain is relieved
first aid provider use of a tourniquet. Potential dangers of
(Class I, LOE B).86–93 Cooling reduces pain, edema, and
prolonged tourniquet application include temporary62 or per-
depth of injury. It speeds healing and may reduce the need for
manent63 injury to the underlying nerves and muscles,64 and
excision and grafting of deep burns. Don't apply ice directly
systemic complications resulting from limb ischemia,65 in-
to a burn; it can produce tissue ischemia (Class III, LOE B).
cluding acidemia, hyperkalemia, arrhythmias, shock, and
Prolonged cold exposure to small burns, and even brief
death. Complications are related to tourniquet pressure66 and
exposure if the burn is large, can cause further local tissue
duration of occlusion,67 but there is insufficient evidence to
injury93–95 and hypothermia.
determine a minimal critical time beyond which irreversiblecomplications may occur. Because of the potential adverse
effects of tourniquets and difficulty in their proper applica-
Loosely cover burn blisters with a sterile dressing but leave
tion, use of a tourniquet to control bleeding of the extremities
blisters intact because this improves healing and reduces pain
is indicated only if direct pressure is not effective or possible
(Class IIa, LOE B).96–99
(Class IIb, LOE B). Specifically designed tourniquets appearto be better than ones that are improvised,60,68–71 but tourni-
quets should only be used with proper training (Class IIa,
The severity of electric injuries can vary widely, from an
LOE B). If a tourniquet is used, make sure that you note the
unpleasant tingling sensation caused by low-intensity cur-
time it was applied and communicate that time to EMS
rent to thermal burns, cardiopulmonary arrest, and death.
Thermal burns may result from burning clothing that is incontact with the skin or from electric current traversing a
Pressure Points and Elevation
portion of the body. When current traverses the body,
Elevation and use of pressure points are not recommended to
thermal burns may be present at the entry and exit points
control bleeding (Class III, LOE C). This new recommenda-
and along its internal pathway. Cardiopulmonary arrest is
tion is made because there is evidence that other ways of
the primary cause of immediate death from electrocu-
controlling bleeding are more effective. The hemostatic effect
tion.100 Cardiac arrhythmias, including ventricular fibrilla-
of elevation has not been studied. No effect on distal pulses
tion, ventricular asystole, and ventricular tachycardia that
was found in volunteers when pressure points were used.72
progresses to ventricular fibrillation, may result from
Most important, these unproven procedures may compromise
exposure to low- or high-voltage current.101 Respiratory
the proven intervention of direct pressure, so they could be
arrest may result from electric injury to the respiratory
center in the brain or from tetanic contractions or paralysisof respiratory muscles.
Do not place yourself in danger by touching an electro-
Among the large number of commercially available hemo-
cuted victim while the power is on (Class III, LOE C).
static agents, some have been shown to be effective.73–76
Turn off the power at its source; at home the switch is
However, their routine use in first aid cannot be recom-
usually near the fuse box. In case of high-voltage electro-
mended at this time because of significant variation in
cutions caused by fallen power lines, immediately notify
effectiveness by different agents and their potential for
the appropriate authorities (eg, 911 or fire department). All
adverse effects, including tissue destruction with induction of
materials conduct electricity if the voltage is high enough,
a proembolic state and potential thermal injury (Class IIb,
so do not enter the area around the victim or try to remove
wires or other materials with any object, including awooden one, until the power has been turned off by
Wounds and Abrasions
Superficial wounds and abrasions should be thoroughly
Once the power is off, assess the victim, who may need
irrigated with a large volume of warm or room temperature
CPR, defibrillation, and treatment for shock and thermal
potable water with or without soap77–82 until there is no
burns. All victims of electric shock require medical assess-
foreign matter in the wound (Class I, LOE A). Cold water
ment because the extent of injury may not be apparent.
appears to be as effective as warm water, but it is not ascomfortable. If running water is unavailable, use any source
of clean water. Wounds heal better with less infection if they
There is approximately a 2% risk of injury to the cervical
are covered with an antibiotic ointment or cream and a clean
spine after blunt trauma that is serious enough to require
occlusive dressing (Class IIa, LOE A).83–85 Apply antibiotic
spinal imaging in an emergency department,102,103 and this
ointment or cream only if the wound is an abrasion or a
risk is tripled in patients with craniofacial injury.104 Most
superficial injury and only if the victim has no known
victims with spinal injuries are males between the ages of
allergies to the antibiotic.
10 and 30 years. Motor vehicles cause approximately half
November 2, 2010
of all spinal injuries; many of the remainder are caused by
thin towel, between the cold container and the skin (Class IIb,
falls (especially from a height or diving), sports, and
It is not clear whether a compression bandage is helpful for
If the cervical spine is injured, the spinal cord may be
a joint injury. Heat application to a contusion or injured joint
unprotected, and further injury (secondary spinal cord
is not as good a first aid measure as cold application.115
injury) could result from stresses to the cord that occurwhen the victim is manipulated or moved. This could
result in permanent neurological damage including quad-
Assume that any injury to an extremity includes a bone
riplegia.106,107 Only one controlled but underpowered study
fracture. Cover open wounds with a dressing. Do not move
with some methodological problems108 has examined this
or try to straighten an injured extremity (Class III, LOE C).
question. In the study, the group of injured victims with
There is no evidence that straightening an angulated
spinal immobilization by emergency medical technicians
suspected long bone fracture shortens healing time or
using equipment failed to show any neurological benefit
reduces pain prior to permanent fixation. Expert opinion
compared with a group of injured victims without spinal
suggests that splinting may reduce pain130 and prevent
further injury. So, if you are far from definitive health care,
Because of the dire consequences if secondary injury
stabilize the extremity with a splint in the position found
does occur, maintain spinal motion restriction by manually
(Class IIa, LOE C). If a splint is used, it should be padded
stabilizing the head so that the motion of head, neck, and
to cushion the injury. If an injured extremity is blue or
spine is minimized (Class IIb, LOE C). First aid providers
extremely pale, activate EMS immediately because this
should not use immobilization devices because their ben-
could be a medical emergency. A victim with an injured
efit in first aid has not been proven and they may be
lower extremity should not bear weight until advised to do
harmful (Class III, LOE C). Immobilization devices may
so by a medical professional.
be needed in special circumstances when immediate extri-cation (eg, rescue of drowning victim) is required, but first
Human and Animal Bites
aid providers should not use these devices unless they have
Irrigate human and animal bites with copious amounts of
been properly trained in their use.
water (Class I, LOE B). This irrigation has been shown to
First aid rescuers cannot conclusively identify a victim
prevent rabies from animal bites131,132 and bacterial
with a spinal injury, but they should suspect spinal injury
if an injured victim has any of the following risk factors(these have been modified slightly from the 2005 Ameri-
can Heart Association and American Red Cross First Aid
Do not apply suction as first aid for snakebites (Class III,
LOE C). Suction does remove some venom, but the amountis very small.134 Suction has no clinical benefit135 and it may
aggravate the injury.136–138
Driver, passenger, or pedestrian, in a motor vehicle, mo-
Applying a pressure immobilization bandage with a pres-
torized cycle, or bicycle crash
sure between 40 and 70 mm Hg in the upper extremity and
Fall from a greater than standing height
between 55 and 70 mm Hg in the lower extremity around the
Tingling in the extremities
entire length of the bitten extremity is a reasonable way to
Pain or tenderness in the neck or back
slow the dissemination of venom by slowing lymph flow
Sensory deficit or muscle weakness involving the torso or
(Class IIa, LOE C139,140). For practical purposes pressure is
sufficient if the bandage is comfortably tight and snug but
Not fully alert or is intoxicated
allows a finger to be slipped under it. Initially it was theorized
Other painful injuries, especially of the head and neck
that slowing lymphatic flow by external pressure would only
Children 2 years of age or older with evidence of head or
benefit victims bitten by snakes producing neurotoxic
venom,140 but the effectiveness of pressure immobilizationhas also been demonstrated for bites by non-neurotoxic
American snakes in an animal model.141 This treatmentrequires further study to prove its efficacy in humans. The
Sprains and Strains
challenge is to find a way to teach the application of the
Soft-tissue injuries include joint sprains and muscle contu-
correct snugness of the bandage because inadequate pressure
sions. Cold application decreases hemorrhage, edema, pain,
is ineffective and too much pressure may cause local tissue
and disability,115–120 and it is reasonable to apply cold to a
damage. It has also been demonstrated that, once learned,
soft-tissue injury. Cooling is best accomplished with a plastic
retention of the skill of proper pressure and immobilization
bag or damp cloth filled with a mixture of ice and water; the
application is poor.142,143
mixture is better than ice alone.121–123 Refreezable gel packsdo not cool as effectively as an ice-water mixture.124,125 To
prevent cold injury, limit each application of cold to periods
This section is new to the First Aid Guidelines. First aid
ⱕ20 minutes.126–128 If that length of time is uncomfortable,
for jellyfish stings consists of two important actions:
limit application to 10 minutes.129 Place a barrier, such as a
preventing further nematocyst discharge and pain relief.
Markenson et al
Part 17: First Aid
To inactivate venom load and prevent further envenoma-
clude placing the victim near a heat source and placing
tion, jellyfish stings should be liberally washed with
containers of warm, but not hot, water in contact with the
vinegar (4% to 6% acetic acid solution) as soon as possible
for at least 30 seconds (Class IIa, LOE B). The inactivationof venom has been demonstrated for Olindias sambaquien-
144 and for Physalia physalis (Portuguese man-of-
Frostbite usually affects an exposed part of the body such as
war).145 If vinegar is not available, a baking soda slurry
the extremities and nose. In case of frostbite, remove wet
may be used instead.145
clothing and dry and cover the victim to prevent hypothermia.
For the treatment of pain, after the nematocysts are
Transport the victim to an advanced medical facility as
removed or deactivated, jellyfish stings should be treated with
rapidly as possible. Do not try to rewarm the frostbite if there
hot-water immersion when possible (Class IIa, LOE B). The
is any chance that it might refreeze161,162 or if you are close to
victim should be instructed to take a hot shower or immerse
a medical facility (Class III, LOE C).
the affected part in hot water (temperature as hot as tolerated,
Minor or superficial frostbite (frostnip) can be treated with
or 45°C if there is the capability to regulate temperature), as
simple, rapid rewarming using skin-to-skin contact such as a
soon as possible, for at least 20 minutes or for as long as pain
persists.146–149 If hot water is not available, dry hot packs or,
Severe or deep frostbite should be rewarmed within 24
as a second choice, dry cold packs may be helpful in
hours of injury and this is best accomplished by immersing
decreasing pain but these are not as effective as hot water
the frostbitten part in warm (37° to 40°C or approximately
(Class IIb, LOE B146,150,151). Topical application of aluminum
body temperature) water for 20 to 30 minutes (Class IIb, LOE
sulfate or meat tenderizer, commercially available aerosol
C161–170). Chemical warmers should not be placed directly on
products, fresh water wash, and papain, an enzyme derived
frostbitten tissue because they can reach temperatures that
from papaya used as a local medicine, are even less effective
can cause burns (Class III, LOE C171). Following rewarming,
in relieving pain (Class IIb, LOE B147,152).
efforts should be made to protect frostbitten parts from
Pressure immobilization bandages are not recommended
refreezing and to quickly evacuate the patient for further care.
for the treatment of jellyfish stings because animal stud-
The effectiveness of ibuprofen or other nonsteroidal antiin-
ies153,154 show that pressure with an immobilization bandage
flammatory drugs (NSAIDs) in frostbite has not been well
causes further release of venom, even from already fired
established in human studies.170,172–175
nematocysts (Class III, LOE C).
Heat-induced symptoms, often precipitated by vigorous ex-
Traumatic dental injuries are common. The first aid for an
ercise, may include heat cramps, heat exhaustion, and heat
avulsed tooth is as follows:
Heat cramps are painful involuntary muscle spasms that
Clean bleeding wound(s) with saline solution or tap water.
most often affect the calves, arms, abdominal muscles, and
Stop bleeding by applying pressure with gauze or cotton.
back. First aid includes rest, cooling off, and drinking an
Handle the tooth by the crown, not the root (ie, do not
electrolyte-carbohydrate mixture, such as juice, milk, or a
handle the part that was beneath the gum).
Place the tooth in milk, or clean water if milk is not
commercial electrolyte-carbohydrate drink.176–185 Stretching,
icing, and massaging the painful muscles may be helpful.
Contact the patient's dentist or take the tooth and victim to
Exercise should not be resumed until all symptoms have
an emergency care center as quickly as possible (Class IIa,
Heat exhaustion is caused by a combination of exercise-
induced heat and fluid and electrolyte loss as sweat. Signs andsymptoms may start suddenly and include: nausea, dizziness,
muscle cramps, feeling faint, headache, fatigue, and heavysweating. Heat exhaustion is a serious condition because it
can rapidly advance to the next stage, heat stroke, which can
be fatal. Heat exhaustion must be vigorously treated by
Hypothermia is caused by exposure to cold. The urgency of
having the victim lie down in a cool place, taking off as many
treatment depends on the length of exposure and the victim's
clothes as possible, cooling the victim with a cool water
body temperature. Begin rewarming a victim of hypothermia
spray, and encouraging the victim to drink cool fluids,
immediately by moving the victim to a warm environment,
preferably containing carbohydrates and electrolytes.
removing wet clothing, and wrapping all exposed body
Heat stroke includes all the symptoms of heat exhaustion
surfaces with anything at hand, such as blankets, clothing,
plus signs of central nervous system involvement, including
and newspapers. If the hypothermia victim is far from
dizziness, syncope, confusion, or seizures. The most impor-
definitive health care, begin active rewarming (Class IIa,
tant action by a first aid provider for a victim of heat stroke
LOE B159,160) although the effectiveness of active rewarming
is to begin immediate cooling, preferably by immersing the
has not been evaluated. Active rewarming should not delay
victim up to the chin in cold water.186–189 It is also important
definitive care. Potential methods of active rewarming in-
to activate the EMS system. Heat stroke requires emergency
November 2, 2010
treatment with intravenous fluids. Do not try to force the
victim to drink liquids.
Brush powdered chemicals off the skin with a gloved hand orpiece of cloth. Remove all contaminated clothing from the
victim, making sure you do not contaminate yourself in the
Drowning is a major cause of unintentional death. Methods of
process. In case of exposure to an acid or alkali on the skin196–202
preventing drowning include isolation fencing around swim-
or eye,203–208 immediately irrigate the affected area with copious
ming pools (gates should be self-closing and self-latching),190
amounts of water (Class I, LOE B).
wearing personal flotation devices (life jackets) while in,around, or on water, never swimming alone, and avoidingswimming or operating motorized watercraft while intoxi-
Toxic Eye Injury
cated. Outcome following drowning depends on the duration
Rinse eyes exposed to toxic substances immediately with a
of the submersion, the water temperature, and how promptly
copious amount of water (Class I, LOE C203,209,210), unless a
CPR is started.191,192 Occasional case reports have docu-
specific antidote is available.203,210,211
mented intact neurological survival in children followingprolonged submersion in icy waters.193,194
Remove the victim rapidly and safely from the water, but
do not place yourself in danger. If you have special training,
Treatment With Milk or Water
you can start rescue breathing while the victim is still in the
Do not administer anything by mouth for any poison
water195 providing that it does not delay removing the victim
ingestion unless advised to do so by a poison control center
from the water. There is no evidence that water acts as an
or emergency medical personnel because it may be harmful
obstructive foreign body, so do not waste time trying to
(Class III, LOE C). There is insufficient evidence that
remove it with abdominal or chest thrusts. Start CPR and, if
dilution of the ingested poison with water or milk is of any
you are alone, continue with about 5 cycles (about 2 minutes)
benefit as a first aid measure. Animal studies212–216 have
of chest compressions and ventilations before activating
shown that dilution or neutralization of a caustic agent
EMS. If 2 rescuers are present, send 1 rescuer to activateEMS immediately.
with water or milk reduces tissue injury, but no humanstudies have shown a clinical benefit. Possible adverseeffects of water or milk administration include emesis and
If the patient exhibits any signs or symptoms of a life-threatening condition, (eg, sleepiness, seizures, difficulty
breathing, vomiting) after exposure to a poison, activate the
Do not administer activated charcoal to a victim who has
ingested a poisonous substance unless you are advised to doso by poison control center or emergency medical personnel
Poison Control Centers
(Class IIb, LOE C). There is no evidence that activated
There are many poisonous substances in the home and
charcoal is effective as a component of first aid. It may be
worksite. It is important to understand the toxic nature of the
safe to administer,217,218 but it has not been shown to be
chemical substances in the environment and the proper
beneficial, and there are reports of it causing harm.219–221 In
protective equipment and emergency procedures in case of
addition the majority of children will not take the recom-
toxic exposure. The Poison Help hotline of the American
Association of Poison Control Centers (800-222-1222) is anexcellent resource in the United States for information abouttreating ingestion of, or exposure to, a potential poison.
Further information is available at www.aapcc.org. Similar
Do not administer syrup of ipecac for ingestions of toxins
resources may be available internationally, and their contact
(Class III, LOE B). Several studies223–225 found that there is
information (eg, 112 in Europe) should be standard in
no clinically relevant advantage to administering syrup of
international first aid training. When phoning a poison control
ipecac; its administration is not associated with decreased
center or other emergency medical services, know the nature
healthcare utilization.226 Untoward effects of ipecac admin-
and time of exposure and the name of the product or toxic
istration include intractable emesis and delayed care in an
advanced medical facility.227,228
Markenson et al
Part 17: First Aid
Guidelines Part 17: First Aid: Writing Group Disclosures
NYMC–Interim Chair; EMA–Chief
Brody School of Medicine, East
*Serving as an expert
witness in two ongoing
lawsuits involving EMS
related cases. Billing for
this service has not yet
occurred and will likely
represent less than
$10,000 per 12 months.
This payment is expected
to come directly to me
Emeritus Director Pediatric
Cardiology, Connecticut Children's
Medical Center, Clinical Professor,
University of Connecticut
French Red Cross, National Medical
Advisor and Coordinator of the
European Reference Centre for first
aid education Coordinator of the
Scientific Commission of First Aid
for the French Interior Ministry
Hong Kong Hospital Authority
Hospital Chief Executive
NorthEast Emergency Medical
*Volunteer: American Red
Services, Inc.– Regional EMS
Cross Advisory Council
Council: Provide EMS System
on First Aid, Aquatics,
Oversight. Also provide education
Safety and Preparedness
(First aid and CPR/AED) as an AHA
Training Center. Executive Director;
Isis Maternity: Pre-Natal and Post
Partum edu.- Provide CPR and First
Aid Training via AHA Curriculum.
City of Austin - Office of the
Medical Director: EMS System
Medical Director Staff–Performance
Management & Research
*Beginning July 1, 2009, I will
serve as a paid consultant to the
AHA ECC Product Development
Group as a Senior Science Editor.
This assignment will include
providing Science review of AHA
First Aid Products
Minute Clinic–Family Nurse
Kent State University–Assistant Dir
†Wilderness First Aid
Faculty Professional Dev. Center
consultant for StayWell
Bloomington Hospital Prompt
Stony Brook University-Physician
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under thepreceding definition.
November 2, 2010
26. Simon HK. Caregiver knowledge and delivery of a commonly pre-
scribed medication (albuterol) for children. Arch Pediatr Adolesc Med
1. 2005 American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care part 14: first aid.
27. Kim JS, Sinacore JM, Pongracic JA. Parental use of EpiPen for children
2. Markenson D, Ferguson JD, Chameides L, Cassan P, Chung KL, Epstein
with food allergies. J Allergy Clin Immunol
. 2005;116:164 –168.
JL, Gonzales L, Hazinski MF, Herrington RA, Pelligrino JL, Ratcliff N,
28. Sicherer SH, Simons FE. Quandaries in prescribing an emergency action
Singer AJ; on behalf of the First Aid Chapter Collaborators. Part 13: first
plan and self-injectable epinephrine for first-aid management of ana-
aid: 2010 American Heart Association and American Red Cross Inter-
phylaxis in the community. J Allergy Clin Immunol
national Consensus on First Aid Science With Treatment Recommen-
29. Pouessel G, Deschildre A, Castelain C, Sardet A, Sagot-Bevenot S, de
. 2010;122(suppl 2):S582–S605.
Sauve-Boeuf A, Thumerelle C, Santos C. Parental knowledge and use of
3. Lewis TH. The Medicine Men: Oglala Sioux Ceremony and Healing.
epinephrine auto-injector for children with food allergy. Pediatr Allergy
Lincoln, Neb: University of Nebraska Press; 1992.
4. Pearn J. The earliest days of first aid. BMJ
. 1994;309:1718 –1720.
30. Rainbow J, Browne GJ. Fatal asthma or anaphylaxis? Emerg Med J
5. The American Heart Association in collaboration with the International
Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmo-
31. Dobbie A, Robertson CM. Provision of self-injectable adrenaline for
nary resuscitation and emergency cardiovascular care, part 5: new
children at risk of anaphylaxis: its source, frequency and appropriateness
guidelines for first aid. Circulation.
of use, and effect. Ambul Child Health
6. Neely KW, Drake ME, Moorhead JC, Schmidt TA, Skeen DT, Wilson
32. Clegg SK, Ritchie JM. "Epipen" training: a survey of the provision for
EA. Multiple options and unique pathways: a new direction for EMS?
parents and teachers in West Lothian. Ambul Child Health
Ann Emerg Med
7. Callaham M. Quantifying the scanty science of prehospital emergency
33. Gold MS, Sainsbury R. First aid anaphylaxis management in children
care. Ann Emerg Med
who were prescribed an epinephrine autoinjector device (EpiPen).
8. Spaite DW, Criss EA, Valenzuela TD, Meislin HW. Developing a
J Allergy Clin Immunol
. 2000;106(part 1):171–176.
foundation for the evaluation of expanded-scope EMS: a window of
34. Sicherer SH, Forman JA, Noone SA. Use assessment of self-
opportunity that cannot be ignored. Ann Emerg Med
administered epinephrine among food-allergic children and pedia-
9. Blake WE, Stillman BC, Eizenberg N, Briggs C, McMeeken JM. The
. 2000;105:359 –362.
position of the spine in the recovery position: an experimental com-
35. Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of
parison between the lateral recovery position and the modified HAINES
epinephrine administration for anaphylaxis: how many doses are
. 2002;53:289 –297.
needed? Allergy Asthma Proc
10. Gunn BD, Eizenberg N, Silberstein M, McMeeken JM, Tully EA,
36. Uguz A, Lack G, Pumphrey R, Ewan P, Warner J, Dick J, Briggs D,
Stillman BC, Brown DJ, Gutteridge GA. How should an unconscious
Clarke S, Reading D, Hourihane J. Allergic reactions in the community:
person with a suspected neck injury be positioned? Prehosp Disaster
a questionnaire survey of members of the anaphylaxis campaign. Clin
. 1995;10:239 –244.
. 2005;35:746 –750.
11. Wong DH, O'Connor D, Tremper KK, Zaccari J, Thompson P, Hill D.
37. Rudders SA, Banerji A, Corel B, Clark S, Camargo CA Jr. Multicenter
Changes in cardiac output after acute blood loss and position change in
study of repeat epinephrine treatments for food-related anaphylaxis.
man. Crit Care Med
. 1989;17:979 –983.
. 2010;125:e711– e718.
12. Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G.
38. Sicherer SH, Simons FE. Self-injectable epinephrine for first-aid man-
Changes in BP induced by passive leg raising predict response to fluid
agement of anaphylaxis. Pediatrics
. 2007;119:638 – 646.
loading in critically ill patients. Chest
39. Gaca AM, Frush DP, Hohenhaus SM, Luo X, Ancarana A, Pickles A,
13. Teboul JL, Monnet X. Prediction of volume responsiveness in critically
Frush KS. Enhancing pediatric safety: using simulation to assess
ill patients with spontaneous breathing activity. Curr Opin Crit Care
radiology resident preparedness for anaphylaxis from intravenous
contrast media. Radiology
. 2007;245:236 –244.
14. Gaffney FA, Bastian BC, Thal ER, Atkins JM, Blomqvist CG. Passive
40. Pumphrey RS. Lessons for management of anaphylaxis from a study of
leg raising does not produce a significant or sustained autotransfusion
fatal reactions. Clin Exp Allergy
. 2000;30:1144 –1150.
effect. J Trauma
. 1982;22:190 –193.
41. Horowitz BZ, Jadallah S, Derlet RW. Fatal intracranial bleeding asso-
15. Ostrow CL. Use of the Trendelenburg position by critical care nurses:
ciated with prehospital use of epinephrine. Ann Emerg Med
Trendelenburg survey. Am J Crit Care
16. Shammas A, Clark AP. Trendelenburg positioning to treat acute hypo-
42. Davis CO, Wax PM. Prehospital epinephrine overdose in a child
tension: helpful or harmful? Clin Nurse Spec
resulting in ventricular dysrhythmias and myocardial ischemia. Pediatr
17. Reich DL, Konstadt SN, Raissi S, Hubbard M, Thys DM. Trendelenburg
. 1999;15:116 –118.
position and passive leg raising do not significantly improve cardiopul-
43. Anchor J, Settipane RA. Appropriate use of epinephrine in anaphylaxis.
monary performance in the anesthetized patient with coronary artery
Am J Emerg Med
. 2004;22:488 – 490.
disease. Crit Care Med
44. Zijlstra F, Ernst N, De Boer M-J, Nibbering E, Suryapranata H, Hoorntje
18. Johnson BA. Stark II, phase II: positive changes and lingering uncer-
JCA, Dambrink J-HE, Van't Hof AWJ, Verheugt FWA. Influence of
tainties. MGMA Connex.
2004;4:48 –51, 1.
prehospital administration of aspirin and heparin on initial patency of the
19. Rawles JM, Kenmure AC. Controlled trial of oxygen in uncomplicated
infarct-related artery in patients with acute ST elevation myocardial
myocardial infarction. BMJ
infarction. J Am Coll Cardiol
20. Nicholson C. A systematic review of the effectiveness of oxygen in
45. ISIS-2 (Second International Study of Infarct Survival) Collaborative
reducing acute myocardial ischaemia. J Clin Nurs
. 2004;13:996 –1007.
Group. Randomised trial of intravenous streptokinase, oral aspirin, both,
21. Austin M, Wood-Baker R. Oxygen therapy in the pre-hospital setting for
or neither among 17,187 cases of suspected acute myocardial infarction:
acute exacerbations of chronic obstructive pulmonary disease. Cochrane
Database Syst Rev.
46. Barbash IM, Freimark D, Gottlieb S, Hod H, Hasin Y, Battler A, Crystal
22. Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ. First aid
E, Matetzky S, Boyko V, Mandelzweig L, Behar S, Leor J. Outcome of
normobaric oxygen for the treatment of recreational diving injuries.
myocardial infarction in patients treated with aspirin is enhanced by
Undersea Hyperb Med
. 2007;34:43– 49.
pre-hospital administration. Cardiology
23. Mannino DM, Homa DM, Pertowski CA, Ashizawa A, Nixon LL,
47. Lehmann KG, Heath-Lange SJ, Ferris ST. Randomized comparison of
Johnson CA, Ball LB, Jack E, Kang DS. Surveillance for asthma: United
hemostasis techniques after invasive cardiovascular procedures. Am
States, 1960 –1995. MMWR CDC Surveill Summ
. 1999;138(part 1):1118 –1125.
24. Hamid S, Kumaradevan J, Cochrane GM. Single centre open study to
48. Koreny M, Riedmuller E, Nikfardjam M, Siostrzonek P, Mullner M.
compare patient recording of PRN salbutamol use on a daily diary card
Arterial puncture closing devices compared with standard manual com-
with actual use as recorded by the MDI compliance monitor. Respir
pression after cardiac catheterization: systematic review and meta-anal-
. 1998;92:1188 –1190.
. 2004;291:350 –357.
25. O'Driscoll BR, Kay EA, Taylor RJ, Weatherby H, Chetty MC, Bernstein
49. Mlekusch W, Dick P, Haumer M, Sabeti S, Minar E, Schillinger M.
A. A long-term prospective assessment of home nebulizer treatment.
Arterial puncture site management after percutaneous transluminal pro-
cedures using a hemostatic wound dressing (Clo-Sur P.A.D.) versus
Markenson et al
Part 17: First Aid
conventional manual compression: a randomized controlled trial.
73. Ersoy G, Kaynak MF, Yilmaz O, Rodoplu U, Maltepe F, Gokmen N.
J Endovasc Ther
Hemostatic effects of microporous polysaccharide hemosphere in a rat
50. Upponi SS, Ganeshan AG, Warakaulle DR, Phillips-Hughes J,
model with severe femoral artery bleeding. Adv Ther
. 2007;24:485– 492.
Boardman P, Uberoi R. Angioseal versus manual compression for hae-
74. McManus J, Hurtado T, Pusateri A, Knoop KJ. A case series describing
mostasis following peripheral vascular diagnostic and interventional
thermal injury resulting from zeolite use for hemorrhage control in
procedures: a randomized controlled trial. Eur J Radiol
combat operations. Prehosp Emerg Care
75. Rhee P, Brown C, Martin M, Salim A, Plurad D, Green D, Chambers L,
51. Simon A, Bumgarner B, Clark K, Israel S. Manual versus mechanical
Demetriades D, Velmahos G, Alam H. QuikClot use in trauma for
compression for femoral artery hemostasis after cardiac catheterization.
hemorrhage control: case series of 103 documented uses. J Trauma
Am J Crit Care
. 1998;7:308 –313.
52. Walker SB, Cleary S, Higgins M. Comparison of the FemoStop device
76. Wedmore I, McManus JG, Pusateri AE, Holcomb JB. A special report
and manual pressure in reducing groin puncture site complications
on the chitosan-based hemostatic dressing: experience in current combat
following coronary angioplasty and coronary stent placement. Int J Nurs
operations. J Trauma
. 2006;60:655– 658.
. 2001;7:366 –375.
77. Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in
53. Yadav JS, Ziada KM, Almany S, Davis TP, Castaneda F. Comparison of
the emergency department. Ann Emerg Med
. 1990;19:704 –708.
the QuickSeal Femoral Arterial Closure System with manual com-
78. Moscati R, Mayrose J, Fincher L, Jehle D. Comparison of normal saline
pression following diagnostic and interventional catheterization pro-
with tap water for wound irrigation. Am J Emerg Med
cedures. Am J Cardiol.
54. Naimer SA, Chemla F. Elastic adhesive dressing treatment of bleeding
79. Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for irrigation
wounds in trauma victims. Am J Emerg Med
. 2000;18:816 – 819.
of lacerations. Am J Emerg Med
. 2002;20:469 – 472.
55. Pillgram-Larsen J, Mellesmo S. Not a tourniquet, but compressive dress-
80. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF. Wound
ing: experience from 68 traumatic amputations after injuries from mines
irrigation in children: saline solution or tap water? Ann Emerg Med
[in Norwegian]. Tidsskr Nor Laegeforen
. 1992;112:2188 –2190.
2003;41:609 – 616.
56. Naimer SA, Nash M, Niv A, Lapid O. Control of massive bleeding from
81. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A mul-
facial gunshot wound with a compact elastic adhesive compression
ticenter comparison of tap water versus sterile saline for wound irri-
dressing. Am J Emerg Med
. 2004;22:586 –588.
gation. Acad Emerg Med
. 2007;14:404 – 409.
57. Naimer SA, Anat N, Katif G. Evaluation of techniques for treating the
82. Longmire AW, Broom LA, Burch J. Wound infection following high-
bleeding wound. Injury
. 2004;35:974 –979.
pressure syringe and needle irrigation. Am J Emerg Med
58. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M,
Ben-Abraham R. Tourniquets for hemorrhage control on the battlefield:
83. Claus EE, Fusco CF, Ingram T, Ingersoll CD, Edwards JE, Melham
a 4-year accumulated experience. J Trauma
TJ. Comparison of the effects of selected dressings on the healing of
standardized abrasions. J Athl Train
59. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS,
84. Beam JW. Occlusive dressings and the healing of standardized
Baer DG, Walters TJ, Mullenix PS, Holcomb JB. Prehospital tourniquet
abrasions. J Athl Train
. 2008;43:600 – 607.
use in Operation Iraqi Freedom: effect on hemorrhage control and
85. Hinman CD, Maibach H. Effect of air exposure and occlusion on
outcomes. J Trauma
. 2008;64(suppl):S28 –S37.
experimental human skin wounds. Nature
60. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J,
86. Huang HM, Wang JH, Yang L, Yi ZH. Effect of local treatment with
Holcomb JB. Practical use of emergency tourniquets to stop bleeding in
cooling and spray film on early edema of superficial II degree scald
major limb trauma. J Trauma.
burns in rats [in Chinese]. Nan Fang Yi Ke Da Xue Xue Bao
61. Kalish J, Burke P, Feldman J, Agarwal S, Glantz A, Moyer P, Serino R,
804 – 806.
Hirsch E. The return of tourniquets: original research evaluates the
87. Cuttle L, Kempf M, Kravchuk O, Phillips GE, Mill J, Wang XQ, Kimble
effectiveness of prehospital tourniquets for civilian penetrating
RM. The optimal temperature of first aid treatment for partial thickness
extremity injuries. JEMS.
2008;33:44 – 46, 49 –50, 52, 54.
burn injuries. Wound Repair Regen
. 2008;16:626 – 634.
62. Savvidis E, Parsch K. Prolonged transitory paralysis after pneumatic
88. Yuan J, Wu C, Holland AJ, Harvey JG, Martin HC, La Hei ER,
tourniquet use on the upper arm [in German]. Unfallchirurg
Arbuckle S, Godfrey TC. Assessment of cooling on an acute scald burn
injury in a porcine model. J Burn Care Res
. 2007;28:514 –520.
63. Kornbluth ID, Freedman MK, Sher L, Frederick RW. Femoral,
89. Ofeigsson OJ, Mitchell R, Patrick RS. Observations on the cold water
saphenous nerve palsy after tourniquet use: a case report. Arch Phys Med
treatment of cutaneous burns. J Pathol
. 2003;84:909 –911.
90. Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of
64. Landi A, Saracino A, Pinelli M, Caserta G, Facchini MC. Tourniquet
immediate cooling: a case series of childhood burns in Vietnam. Burns
paralysis in microsurgery. Ann Acad Med Singapore
91. Tung KY, Chen ML, Wang HJ, Chen GS, Peck M, Yang J, Liu CC. A
65. Wakai A, Wang JH, Winter DC, Street JT, O'Sullivan RG, Redmond
seven-year epidemiology study of 12,381 admitted burn patients in
HP. Tourniquet-induced systemic inflammatory response in extremity
Taiwan: using the Internet registration system of the Childhood Burn
surgery. J Trauma
66. Mohler LR, Pedowitz RA, Lopez MA, Gershuni DH. Effects of tour-
92. Li C, Yu D, Li MS. Clinical and experiment study of cooling therapy on
niquet compression on neuromuscular function. Clin Orthop Relat Res.
burned wound [in Chinese]. Zhonghua Yi Xue Za Zhi
. 1997;77:586 –588.
93. Matthews RN, Radakrishnan T. First-aid for burns. Lancet
67. Kokki H, Vaatainen U, Penttila I. Metabolic effects of a low-pressure
tourniquet system compared with a high-pressure tourniquet system in
94. Purdue GF, Layton TR, Copeland CE. Cold injury complicating burn
arthroscopic anterior crucial ligament reconstruction. Acta Anaesthesiol
therapy. J Trauma
. 1998;42:418 – 424.
95. Sawada Y, Urushidate S, Yotsuyanagi T, Ishita K. Is prolonged and
68. King RB, Filips D, Blitz S, Logsetty S. Evaluation of possible tourniquet
excessive cooling of a scalded wound effective? Burns
systems for use in the Canadian Forces. J Trauma
96. Swain AH, Azadian BS, Wakeley CJ, Shakespeare PG. Management of
69. Wenke JC, Walters TJ, Greydanus DJ, Pusateri AE, Convertino VA.
blisters in minor burns. BMJ (Clin Res Ed)
Physiological evaluation of the U.S. Army one-handed tourniquet. Mil
97. Cope O. The treatment of the surface burns. Ann Surg
. 2005;170:776 –781.
70. Calkins D, Snow C, Costello M, Bentley TB. Evaluation of possible
98. Forage AV. The effects of removing the epidermis from burnt skin.
battlefield tourniquet systems for the far-forward setting. Mil Med
. 1962;2:690 – 693.
99. Gimbel NS, Kapetansky DI, Weissman F, Pinkus HK. A study of
71. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, Baer
epithelization in blistered burns. AMA Arch Surg
. 1957;74:800 – 803.
DG. Effectiveness of self-applied tourniquets in human volunteers.
100. Homma S, Gillam LD, Weyman AE. Echocardiographic observations in
Prehosp Emerg Care
. 2005;9:416 – 422.
survivors of acute electrical injury. Chest
72. Swan KG Jr, Wright DS, Barbagiovanni SS, Swan BC, Swan KG.
101. Jensen PJ, Thomsen PE, Bagger JP, Norgaard A, Baandrup U. Electrical
Tourniquets revisited. J Trauma
. 2009;66:672– 675.
injury causing ventricular arrhythmias. Br Heart J
. 1987;57:279 –283.
November 2, 2010
102. Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower
124. McMaster WC, Liddle S, Waugh TR. Laboratory evaluation of various
WR. Epidemiology of cervical spine injury victims. Ann Emerg Med
cold therapy modalities. Am J Sports Med
125. Chesterton LS, Foster NE, Ross L. Skin temperature response to cryo-
103. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio
therapy. Arch Phys Med Rehabil
VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D,
126. Graham CA, Stevenson J. Frozen chips: an unusual cause of severe
Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L,
frostbite injury. Br J Sports Med
Reardon M, Worthington J. The Canadian C-spine rule for radiography
127. Moeller JL, Monroe J, McKeag DB. Cryotherapy-induced common
in alert and stable trauma patients. JAMA
peroneal nerve palsy. Clin J Sport Med
104. Hackl W, Hausberger K, Sailer R, Ulmer H, Gassner R. Prevalence of
128. Bassett FH III, Kirkpatrick JS, Engelhardt DL, Malone TR.
cervical spine injuries in patients with facial trauma. Oral Surg Oral
Cryotherapy-induced nerve injury. Am J Sports Med
. 1992;20:516 –518.
Med Oral Pathol Oral Radiol Endod
. 2001;92:370 –376.
129. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy
105. Kennedy E. Spinal Cord Injury: The Facts and Figures.
for acute ankle sprains: a randomised controlled study of two different
Ala: University of Alabama Press; 1986.
icing protocols. Br J Sports Med
. 2006;40:700 –705.
106. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course
130. Auerbach PS, Geehr EC, Ryu RK. The Reel Splint: experience with a
of missed spine fractures. J Trauma
. 1987;27:980 –986.
new traction splint apparatus in the prehospital setting. Ann Emerg Med
107. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of
1984;13:419 – 422.
missed cervical spine injuries. J Trauma
131. Kaplan MM, Cohen D, Koprowski H, Dean D, Ferrigan L. Studies on
108. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal
the local treatment of wounds for the prevention of rabies. Bull World
immobilization: its effect on neurologic injury. Acad Emerg Med
132. Dean DJ, Baer GM, Thompson WR. Studies on the local treatment of
109. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI; National
rabies-infected wounds. Bull World Health Organ
. 1963;28:477– 486.
Emergency X-Radiography Utilization Study Group. Validity of a set of
133. Callaham ML. Treatment of common dog bites: infection risk factors.
clinical criteria to rule out injury to the cervical spine in patients with
. 1978;7:83– 87.
blunt trauma. N Engl J Med
. 2000;343:94 –99.
134. Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite: a
110. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman
study of "mock venom" extraction in a human model. Ann Emerg Med
JR. A prospective multicenter study of cervical spine injury in children.
135. Lawrence WT, Giannopoulos A, Hansen A. Pit viper bites: rational
111. Touger M, Gennis P, Nathanson N, Lowery DW, Pollack CV Jr,
management in locales in which copperheads and cottonmouths pre-dominate. Ann Plast Surg
. 1996;36:276 –285.
Hoffman JR, Mower WR. Validity of a decision rule to reduce cervical
136. Leopold RS, Huber GS. Ineffectiveness of suction in removing snake
spine radiography in elderly patients with blunt trauma. Ann Emerg
venom from open wounds. U S Armed Forces Med J
. 1960;11:682– 685.
137. Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects
112. Panacek EA, Mower WR, Holmes JF, Hoffman JR. Test performance of
of a negative pressure venom extraction device (Extractor) on local
the individual NEXUS low-risk clinical screening criteria for cervical
tissue injury after artificial rattlesnake envenomation in a porcine model.
spine injury. Ann Emerg Med
Wilderness Environ Med
. 2000;11:180 –188.
113. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA
138. Holstege CP, Singletary EM. Images in emergency medicine: skin
Jr, Wales PW, Brown RL, Gaines BA, McKenna C, Moore FO, Goslar
damage following application of suction device for snakebite. Ann
PW, Inaba K, Barmparas G, Scaife ER, Metzger RR, Brockmeyer DL,
Upperman JS, Estrada J, Lanning DA, Rasmussen SK, Danielson PD,
139. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and
Hirsh MP, Consani HF, Stylianos S, Pineda C, Norwood SH, Bruch SW,
first-aid in simulated peripheral snake or spider envenomation. Med J
Drongowski R, Barraco RD, Pasquale MD, Hussain F, Hirsch EF,
McNeely PD, Fallat ME, Foley DS, Iocono JA, Bennett HM, Waxman
140. German BT, Hack JB, Brewer K, Meggs WJ. Pressure-immobilization
K, Kam K, Bakhos L, Petrovick L, Chang Y, Masiakos PT. Clinical
bandages delay toxicity in a porcine model of eastern coral snake
clearance of the cervical spine in blunt trauma patients younger than 3
(Micrurus fulvius fulvius) envenomation. Ann Emerg Med
years: a multi-center study of the American Association for the Surgery
of Trauma. J Trauma
141. Bush SP, Green SM, Laack TA, Hayes WK, Cardwell MD, Tanen DA.
114. Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J,
Pressure immobilization delays mortality and increases intracompart-
Frederiksen SM, Shork MA. The reliability of prehospital clinical eval-
mental pressure after artificial intramuscular rattlesnake envenomation
uation for potential spinal injury is not affected by the mechanism of
in a porcine model. Ann Emerg Med
. 2004;44:599 – 604.
injury. Prehosp Emerg Care
142. Norris RL, Ngo J, Nolan K, Hooker G. Physicians and lay people are
115. Cote DJ, Prentice WE Jr, Hooker DN, Shields EW. Comparison of three
unable to apply pressure immobilization properly in a simulated
treatment procedures for minimizing ankle sprain swelling. Phys Ther
snakebite scenario. Wilderness Environ Med
. 2005;16:16 –21.
143. Simpson ID, Tanwar PD, Andrade C, Kochar DK, Norris RL. The
116. Meeusen R, Lievens P. The use of cryotherapy in sports injuries. Sports
Ebbinghaus retention curve: training does not increase the ability to
. 1986;3:398 – 414.
apply pressure immobilisation in simulated snake bite: implications for
117. Hocutt JE Jr, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle
snake bite first aid in the developing world. Trans R Soc Trop Med Hyg
sprains. Am J Sports Med
. 1982;10:316 –319.
118. Airaksinen OV, Kyrklund N, Latvala K, Kouri JP, Gronblad M, Kolari
144. Mianzan HW, Fenner PJ, Cornelius PF, Ramirez FC. Vinegar as a
P. Efficacy of cold gel for soft tissue injuries: a prospective randomized
disarming agent to prevent further discharge of the nematocysts of the
double-blinded trial. Am J Sports Med
. 2003;31:680 – 684.
stinging hydromedusa Olindias sambaquiensis. Cutis
. 2001;68:45– 48.
119. Basur RL, Shephard E, Mouzas GL. A cooling method in the treatment
145. Burnett JW, Rubinstein H, Calton GJ. First aid for jellyfish enveno-
of ankle sprains. Practitioner
. 1976;216:708 –711.
mation. South Med J
. 1983;76:870 – 872.
120. Ayata R, Shiraki H, Fukuda T, Takemura M, Mukai N, Miyakawa S.
146. Loten C, Stokes B, Worsley D, Seymour JE, Jiang S, Isbister GK. A
The effects of icing after exercise on jumper's knee. Jpn J Phys Fitness
randomised controlled trial of hot water (45 degrees C) immersion
versus ice packs for pain relief in bluebottle stings. Med J Aust
121. Merrick MA, Jutte LS, Smith ME. Cold modalities with different ther-
modynamic properties produce different surface and intramuscular tem-
147. Nomura JT, Sato RL, Ahern RM, Snow JL, Kuwaye TT, Yamamoto LG.
peratures. J Athl Train
. 2003;38:28 –33.
A randomized paired comparison trial of cutaneous treatments for acute
122. Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael TJ, Baker
jellyfish (Carybdea alata) stings. Am J Emerg Med
. 2002;20:624 – 626.
RJ. Comparisons of cubed ice, crushed ice, and wetted ice on intra-
148. Yoshimoto CM, Yanagihara AA. Cnidarian (coelenterate) enveno-
muscular and surface temperature changes. J Athl Train
mations in Hawai'i improve following heat application. Trans R Soc
Trop Med Hyg
. 2002;96:300 –303.
123. Kanlayanaphotporn R, Janwantanakul P. Comparison of skin surface
149. Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an
temperature during the application of various cryotherapy modalities.
effective treatment for marine envenomation? Emerg Med J
Arch Phys Med Rehabil
Markenson et al
Part 17: First Aid
150. Thomas J. Dermatology in the new millennium. Indian J Dermatol
175. Foray J. Mountain frostbite: current trends in prognosis and treatment
. 2001;67:100 –103.
(from results concerning 1261 cases). Int J Sports Med.
151. Exton DR, Fenner PJ, Williamson JA. Cold packs: effective topical
analgesia in the treatment of painful stings by Physalia and other jel-
176. Kenefick RW, O'Moore KM, Mahood NV, Castellani JW. Rapid IV
lyfish. Med J Aust
. 1989;151:625– 626.
versus oral rehydration: responses to subsequent exercise heat stress.
152. Thomas CS, Scott SA, Galanis DJ, Goto RS. Box jellyfish (Carybdea
Med Sci Sports Exerc
alata) in Waikiki: the analgesic effect of sting-aid, Adolph's meat ten-
177. Michell MW, Oliveira HM, Kinsky MP, Vaid SU, Herndon DN, Kramer
derizer and fresh water on their stings: a double-blinded, randomized,
GC. Enteral resuscitation of burn shock using World Health Organi-
placebo-controlled clinical trial. Hawaii Med J.
zation oral rehydration solution: a potential solution for mass casualty
153. Pereira PL, Carrette T, Cullen P, Mulcahy RF, Little M, Seymour J.
care. J Burn Care Res
. 2006;27:819 – 825.
Pressure immobilisation bandages in first-aid treatment of jellyfish
178. Barclay RL, Depew WT, Vanner SJ. Carbohydrate-electrolyte rehy-
envenomation: current recommendations reconsidered. Med J Aust
dration protects against intravascular volume contraction during colonic
2000;173:650 – 652.
cleansing with orally administered sodium phosphate. Gastrointest
154. Seymour J, Carrette T, Cullen P, Little M, Mulcahy RF, Pereira PL. The
. 2002;56:633– 638.
use of pressure immobilization bandages in the first aid management of
179. Currell K, Urch J, Cerri E, Jentjens RL, Blannin AK, Jeukendrup AE.
cubozoan envenomings. Toxicon
Plasma deuterium oxide accumulation following ingestion of different
155. Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol
carbohydrate beverages. Appl Physiol Nutr Metab
180. Jeukendrup AE, Currell K, Clarke J, Cole J, Blannin AK. Effect of
156. Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hanks
beverage glucose and sodium content on fluid delivery. Nutr Metab
balanced salt solution and Viaspan storage media. Endod Dent
. 1991;7:69 –72.
181. Evans GH, Shirreffs SM, Maughan RJ. Postexercise rehydration in man:
157. Chan AW, Wong TK, Cheung GS. Lay knowledge of physical education
the effects of osmolality and carbohydrate content of ingested drinks.
teachers about the emergency management of dental trauma in Hong
Kong. Dent Traumatol
. 2001;17:77– 85.
182. Greenleaf JE, Jackson CG, Geelen G, Keil LC, Hinghofer-Szalkay H,
158. Sae-Lim V, Lim LP. Dental trauma management awareness of Sin-
Whittam JH. Plasma volume expansion with oral fluids in hypohydrated
gapore pre-school teachers. Dent Traumatol
men at rest and during exercise. Aviat Space Environ Med
159. Greif R, Rajek A, Laciny S, Bastanmehr H, Sessler DI. Resistive heating
is more effective than metallic-foil insulation in an experimental model
183. Maughan RJ, Leiper JB. Sodium intake and post-exercise rehydration in
of accidental hypothermia: a randomized controlled trial. Ann Emerg
man. Eur J Appl Physiol Occup Physiol
184. Merson SJ, Maughan RJ, Shirreffs SM. Rehydration with drinks dif-
160. Steele MT, Nelson MJ, Sessler DI, Fraker L, Bunney B, Watson WA,
fering in sodium concentration and recovery from moderate exercise-
Robinson WA. Forced air speeds rewarming in accidental hypothermia.
induced hypohydration in man. Eur J Appl Physiol
Ann Emerg Med
. 1996;27:479 – 484.
185. Shirreffs SM, Taylor AJ, Leiper JB, Maughan RJ. Post-exercise rehy-
161. Mills WJ Jr, Whaley R, Fish W. Frostbite: experience with rapid
dration in man: effects of volume consumed and drink sodium content.
rewarming and ultrasonic therapy: part II: 1960. Alaska Med
Med Sci Sports Exerc
. 1996;28:1260 –1271.
186. Clapp AJ, Bishop PA, Muir I, Walker JL. Rapid cooling techniques in
162. Mills WJ Jr, Whaley R, Fish W. Frostbite: experience with rapid
joggers experiencing heat strain. J Sci Med Sport
. 2001;4:160 –167.
rewarming and ultrasonic therapy: part III: 1961. Alaska Med
187. Clements JM, Casa DJ, Knight J, McClung JM, Blake AS, Meenen PM,
Gilmer AM, Caldwell KA. Ice-water immersion and cold-water
163. Fuhrman FA, Crismon JM. Studies on gangrene following cold injury:
immersion provide similar cooling rates in runners with exercise-
treatment of cold injury by means of immediate rapid warming. J Clin
induced hyperthermia. J Athl Train
. 2002;37:146 –150.
. 1947;26:476 – 485.
188. Proulx CI, Ducharme MB, Kenny GP. Effect of water temperature on
164. Entin MA, Baxter H. Influence of rapid warming on frostbite in exper-
cooling efficiency during hyperthermia in humans. J Appl Physiol
imental animals. Plast Reconstr Surg (1946)
165. Fuhrman FA, Fuhrman GJ. The treatment of experimental frostbite by
189. Armstrong LE, Crago AE, Adams R, Roberts WO, Maresh CM.
rapid thawing: a review and new experimental data. Medicine (Bal-
Whole-body cooling of hyperthermic runners: comparison of two field
. 1957;36:465– 487.
166. Malhotra MS, Mathew L. Effect of rewarming at various water bath
therapies. Am J Emerg Med
temperatures in experimental frostbite. Aviat Space Environ Med
190. American Academy of Pediatrics Committee on Injury, Violence, and
49:874 – 876.
Poison Prevention. Prevention of drowning in infants, children, and
167. Purkayastha SS, Chhabra PC, Verma SS, Selvamurthy W. Experimental
studies on the treatment of frostbite in rats. Indian J Med Res
191. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT.
Impact of age, submersion time and water temperature on outcome in
168. Martinez Villen G, Garcia Bescos G, Rodriguez Sosa V, Morandeira
Garcia JR. Effects of haemodilution and rewarming with regard to
192. Graf WD, Cummings P, Quan L, Brutocao D. Predicting outcome in
digital amputation in frostbite injury: an experimental study in the rabbit.
pediatric submersion victims. Ann Emerg Med
J Hand Surg Br
. 2002;27:224 –228.
193. Modell JH, Idris AH, Pineda JA, Silverstein JH. Survival after pro-
169. Purkayastha SS, Bhaumik G, Chauhan SK, Banerjee PK, Selvamurthy
longed submersion in freshwater in Florida. Chest
W. Immediate treatment of frostbite using rapid rewarming in tea
decoction followed by combined therapy of pentoxifylline, aspirin &
194. Mehta SR, Srinivasan KV, Bindra MS, Kumar MR, Lahiri AK. Near
vitamin C. Indian J Med Res
. 2002;116:29 –34.
drowning in cold water. J Assoc Physicians India
. 2000;48:674 – 676.
170. Bilgic S, Ozkan H, Ozenc S, Safaz I, Yildiz C. Treating frostbite. Can
195. Szpilman D, Soares M. In-water resuscitation: is it worthwhile?
171. Sands WA, Kimmel WL, Wurtz BR, Stone MH, McNeal JR. Com-
196. Latenser BA, Lucktong TA. Anhydrous ammonia burns: case presenta-
parison of commercially available disposable chemical hand and foot
tion and literature review. J Burn Care Rehabil
. 2000;21(part 1):40 – 42.
warmers. Wilderness Environ Med
197. Wibbenmeyer LA, Morgan LJ, Robinson BK, Smith SK, Lewis RW II,
172. Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM,
Kealey GP. Our chemical burn experience: exposing the dangers of
Boertman JA, Smith DJ Jr, Sachs RJ. Experimental and clinical obser-
anhydrous ammonia. J Burn Care Rehabil
. 1999;20:226 –231.
vations on frostbite. Ann Emerg Med
. 1987;16:1056 –1062.
198. Yano K, Hosokawa K, Kakibuchi M, Hikasa H, Hata Y. Effects of
173. McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a
washing acid injuries to the skin with water: an experimental study using
rational approach based on the pathophysiology. J Trauma
. 1995;21:500 –502.
199. Kono K, Yoshida Y, Watanabe M, Tanioka Y, Dote T, Orita Y, Bessho
174. Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the
Y, Yoshida J, Sumi Y, Umebayashi K. An experimental study on the
safety and efficacy of tissue plasminogen activator in treatment of severe
treatment of hydrofluoric acid burns. Arch Environ Contam Toxicol
frostbite. J Trauma
. 2005;59:1350 –1354.
1992;22:414 – 418.
November 2, 2010
200. Murao M. Studies on the treatment of hydrofluoric acid burn. Bull
215. Homan CS, Singer AJ, Henry MC, Thode HC Jr. Thermal effects of
Osaka Med Coll
. 1989;35:39 – 48.
neutralization therapy and water dilution for acute alkali exposure in
201. Lorette JJ Jr, Wilkinson JA. Alkaline chemical burn to the face requiring
canines. Acad Emerg Med
full-thickness skin grafting. Ann Emerg Med
. 1988;17:739 –741.
216. Homan CS, Singer AJ, Thomajan C, Henry MC, Thode HC Jr. Thermal
202. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of
characteristics of neutralization therapy and water dilution for strong
prompt first aid. J Trauma
. 1982;22:420 – 423.
acid ingestion: an in-vivo canine model. Acad Emerg Med
203. Kompa S, Schareck B, Tympner J, Wustemeyer H, Schrage NF. Com-
parison of emergency eye-wash products in burned porcine eyes.
217. Spiller HA, Rodgers GC Jr. Evaluation of administration of activated
Graefes Arch Clin Exp Ophthalmol
. 2002;240:308 –313.
charcoal in the home. Pediatrics
204. McCulley JP. Ocular hydrofluoric acid burns: animal model, mechanism
218. Lamminpaa A, Vilska J, Hoppu K. Medical charcoal for a child's
of injury and therapy. Trans Am Ophthalmol Soc
. 1990;88:649 – 684.
poisoning at home: availability and success of administration in Finland.
205. Hojer J, Personne M, Hulten P, Ludwigs U. Topical treatments for
Hum Exp Toxicol
. 1993;12:29 –32.
hydrofluoric acid burns: a blind controlled experimental study. J Toxicol
219. Donoso A, Linares M, Leon J, Rojas G, Valverde C, Ramirez M,
. 2002;40:861– 866.
Oberpaur B. Activated charcoal laryngitis in an intubated patient.
206. Herr RD, White GL Jr, Bernhisel K, Mamalis N, Swanson E. Clinical
Pediatr Emerg Care
. 2003;19:420 – 421.
comparison of ocular irrigation fluids following chemical injury. Am J
220. Dorrington CL, Johnson DW, Brant R. The frequency of complications
. 1991;9:228 –231.
associated with the use of multiple-dose activated charcoal. Ann Emerg
207. Ingram TA III. Response of the human eye to accidental exposure to
. 2003;41:370 –377.
sodium hypochlorite. J Endod
221. Givens T, Holloway M, Wason S. Pulmonary aspiration of activated
208. Burns FR, Paterson CA. Prompt irrigation of chemical eye injuries may
charcoal: a complication of its misuse in overdose management. Pediatr
avert severe damage. Occup Health Saf
209. Kompa S, Redbrake C, Hilgers C, Wustemeyer H, Schrage N, Remky A.
222. Scharman EJ, Cloonan HA, Durback-Morris LF. Home administration
Effect of different irrigating solutions on aqueous humour pH changes,
of charcoal: can mothers administer a therapeutic dose? J Emerg Med
intraocular pressure and histological findings after induced alkali burns.
Acta Ophthalmol Scand
. 2005;83:467– 470.
223. Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of
210. Spoler F, Frentz M, Forst M, Kurz H, Schrage NF. Analysis of hydro-
acutely poisoned patients without gastric emptying. Ann Emerg Med
fluoric acid penetration and decontamination of the eye by means of
time-resolved optical coherence tomography. Burns
. 2008;34:549 –555.
224. Pond SM, Lewis-Driver DJ, Williams GM, Green AC, Stevenson NW.
211. Rihawi S, Frentz M, Schrage NF. Emergency treatment of eye burns:
Gastric emptying in acute overdose: a prospective randomised con-
which rinsing solution should we choose? Graefes Arch Clin Exp Oph-
trolled trial. Med J Aust
. 2006;244:845– 854.
225. Caravati EM. Unintentional acetaminophen ingestion in children and the
212. Homan CS, Maitra SR, Lane BP, Geller ER. Effective treatment of acute
potential for hepatotoxicity. J Toxicol Clin Toxicol
alkali injury of the rat esophagus with early saline dilution therapy. Ann
226. Bond G. Home syrup of ipecac use does not reduce emergency
. 1993;22:178 –182.
department use or improve outcome. Pediatrics
213. Homan CS, Maitra SR, Lane BP, Thode HC, Sable M. Therapeutic
227. Kornberg AE, Dolgin J. Pediatric ingestions: charcoal alone versus
effects of water and milk for acute alkali injury of the esophagus. Ann
ipecac and charcoal. Ann Emerg Med
. 1991;20:648 – 651.
. 1994;24:14 –20.
228. Czajka PA, Russell SL. Nonemetic effects of ipecac syrup. Pediatrics
214. Homan CS, Maitra SR, Lane BP, Thode HC Jr, Davidson L. Histo-
pathologic evaluation of the therapeutic efficacy of water and milkdilution for esophageal acid injury. Acad Emerg Med
KEY WORDS: emergency 䡲 injury
EMPRESA DE DESARROLLO URBANO DE BOLÍVAR S.A. NIT: 890.481.123-1 NOTAS A LOS ESTADOS FINANCIEROS A JUNIO 30 DE 2015 1. NOTAS DE CARÁCTER GENERAL 1. NATURALEZA JURIDICA, OBJETO SOCIAL ACTIVIDADES QUE DESAROLLA O COMETIDO ESTATAL. NATURALEZ-A JURIDICA La Empresa de Desarrollo Urbano de Bolívar -EDURBE S.A., es una Empresa Industrial y Comercial del estado, del Orden Distrital, constituida el 24 de Diciembre de 1981, mediante Escritura Número 2069 de la Notaria 2da de Cartagena, su capital es netamente público y sus
Full-mouth disinfection: another choice for periodontal therapy Artículo extraído de la revista RAOA, Revista de la Asociación Odontológica Argentina, Vol. 97 – Nº4 – Agosto/Septiembre de 2009 Resumen El raspaje radicular realizado por sectores ha mostrado mejorar el cuadro de la patología gingivo-periodontal. Este insume varias sesiones y determinado tiempo de tratamiento.