First aid

First Aid symbol

First aid is the provision of initial care for an illness or injury. It is usually performed by a non-expert person to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care past the first aid intervention. It generally consists of a series of simple and in some cases, potentially life-saving techniques that an individual can be trained to perform with minimal equipment.

While first aid can also be performed on animals, the term generally refers to care of human patients.

History

The instances of recorded first aid were provided by religious knights, such as the Knights Hospitaller, formed in the 11th century, providing care to pilgrims and knights, and training other knights in how to treat common battlefield injuries.^[1] The practice of first aid fell largely in to disuse during the High Middle Ages, and organized societies were not seen again until in 1859 Henry Dunant organized local villagers to help victims of the Battle of Solferino, including the provision of first aid. Four years later, four nations met in Geneva and formed the organization which has grown into the Red Cross, with a key stated aim of "aid to sick and wounded soldiers in the field".^[1] This was followed by the formation of St. John Ambulance in 1877, based on the principles of the Knights Hospitaller, to teach first aid, and numerous other organization joined them with the term first aid first coined in 1878 as civilian ambulance services spread as a combination of 'first treatment' and 'national aid'^[1] in large railway centres and mining districts as well as with police forces. First aid training began to spread through the empire through organisations such as St John, often starting, as in the UK, with high risk activities such as ports and railways.^[2]

Many developments in first aid and many other medical techniques have been driven by wars, such as in the case of the American Civil War, which prompted Clara Barton to organize the American Red Cross.^[3] Today, there are several groups that promote first aid, such as the military and the Scouting movement. New techniques and equipment have helped make today’s first aid simple and effective.

Aims

The key aims of first aid can be summarized in three key points:^[4]

• Preserve life - the overriding aim of all medical care, including first aid, is to save lives
• Prevent further harm - also sometimes called prevent the condition from worsening, this covers both external factors, such as moving a patient away from any cause of harm, and applying first aid techniques to prevent worsening of the condition, such as applying pressure to stop a bleed becoming dangerous.
• Promote recovery - first aid also involves trying to start the recovery process from the illness or injury, and in some cases might involve completing a treatment, such as in the case of applying a plaster to a small wound

First aid training also involves the prevention of initial injury and responder safety, and the treatment phases.

Key skills

In case of tongue fallen backwards, blocking the airway, it is necessary to hyperextend the head and pull up the chin, so that the tongue lifts and clears the airway.

Certain skills are considered essential to the provision of first aid and are taught ubiquitously. Particularly the "ABC"s of first aid, which focus on critical life-saving intervention, must be rendered before treatment of less serious injuries. ABC stands for Airway, Breathing, and Circulation. The same mnemonic is used by all emergency health professionals. Attention must first be brought to the airway to ensure it is clear. Obstruction (choking) is a life-threatening emergency. Following evaluation of the airway, a first aid attendant would determine adequacy of breathing and provide rescue breathing if necessary. Assessment of circulation is now not usually carried out for patients who are not breathing, with first aiders now trained to go straight to chest compressions (and thus providing artificial circulation) but pulse checks may be done on less serious patients.

Some organizations add a fourth step of "D" for Deadly bleeding or Defibrillation, while others consider this as part of the Circulation step. Variations on techniques to evaluate and maintain the ABCs depend on the skill level of the first aider. Once the ABCs are secured, first aiders can begin additional treatments, as required. Some organizations teach the same order of priority using the "3Bs": Breathing, Bleeding, and Bones (or "4Bs": Breathing, Bleeding, Brain, and Bones). While the ABCs and 3Bs are taught to be performed sequentially, certain conditions may require the consideration of two steps simultaneously. This includes the provision of both artificial respiration and chest compressions to someone who is not breathing and has no pulse, and the consideration of cervical spine injuries when ensuring an open airway.

Preserving life

In order to stay alive, all persons need to have an open airway - a clear passage where air can move in through the mouth or nose through the pharynx and down in to the lungs, without obstruction. Conscious people will maintain their own airway automatically, but those who are unconscious (with a GCS of less than 8) may be unable to maintain a patent airway, as the part of the brain which automatically controls breathing in normal situations may not be functioning.

If the patient was breathing, a first aider would normally then place them in the recovery position, with the patient leant over on their side, which also has the effect of clearing the tongue from the pharynx. It also avoids a common cause of death in unconscious patients, which is choking on regurgitated stomach contents.

The airway can also become blocked through a foreign object becoming lodged in the pharynx or larynx, commonly called choking. The first aider will be taught to deal with this through a combination of ‘back slaps’ and ‘abdominal thrusts’.

Once the airway has been opened, the first aider would assess to see if the patient is breathing. If there is no breathing, or the patient is not breathing normally, such as agonal breathing, the first aider would undertake what is probably the most recognized first aid procedure - Cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually massaging the heart to promote blood flow around the body.

Promoting recovery

The first aider is also likely to be trained in dealing with injuries such as cuts, grazes or bone fracture. They may be able to deal with the situation in its entirety (a small adhesive bandage on a paper cut), or may be required to maintain the condition of something like a broken bone, until the next stage of definitive care (usually an ambulance) arrives.

Training

First aid scenario training in progress

Basic principles, such as knowing to use an adhesive bandage or applying direct pressure on a bleed, are often acquired passively through life experiences. However, to provide effective, life-saving first aid interventions requires instruction and practical training. This is especially true where it relates to potentially fatal illnesses and injuries, such as those that require cardiopulmonary resuscitation (CPR); these procedures may be invasive, and carry a risk of further injury to the patient and the provider. As with any training, it is more useful if it occurs before an actual emergency, and in many countries, emergency ambulance dispatchers may give basic first aid instructions over the phone while the ambulance is on the way.

Training is generally provided by attending a course, typically leading to certification. Due to regular changes in procedures and protocols, based on updated clinical knowledge, and to maintain skill, attendance at regular refresher courses or re-certification is often necessary. First aid training is often available through community organizations such as the Red Cross and St. John Ambulance, or through commercial providers, who will train people for a fee. This commercial training is most common for training of employees to perform first aid in their workplace. Many community organizations also provide a commercial service, which complements their community programmes.

Australia

In Australia, Nationally recognized First Aid certificates may only be issued by Registered training organisations who are accredited on the National Training Information System (NTIS). Most First Aid certificates are issued at one of 3 levels:

• Level 1 (or “Basic First Aid”, or “Basic Life Support”): is a 1-day course covering primarily life-threatening emergencies: CPR, bleeding, choking and other life-threatening medical emergencies.
• Level 2 (“Senior First Aid”) is a 2 day course that covers all the aspects of training in Level 1, as well as specialized training for treatment of burns, bites, stings, electric shock and poisons. Level 2 reaccreditation is a 1 day course which must be taken every three years, but CPR reaccrediation may be required more frequently (typically yearly).
• Level 3 (“Occupational First Aid”) is a 4-day course covering advanced first aid, use of oxygen and automated external defibrillators and documentation. It is suitable for workplace First Aiders and those who manage First Aid facilities.

Other courses outside these levels are commonly taught, including CPR-only courses, Advanced Resuscitation, Remote Area or Wilderness First Aid, Administering Medications (such as salbutamol or the Epi-Pen) and specialized courses for parents, school teachers, community first responders or hazardous workplace first aiders. CPR Re-accreditation courses are sometimes required yearly, regardless of the length of the overall certification.

Canada

In Canada, first aid certificates are awarded by one of several national organizations including the Red Cross, the Lifesaving Society and St. John Ambulance. Or they can also be issued by sub-national organizations. The terms "Emergency First Aid" and "Standard First Aid" are generic and based on a Health Canada (a federal department of the Government of Canada) review and approval of a training organization's curriculum / syllabus (training content), standards and other factors. Workplace safety regulations and standards for first aid vary by province depending on occupation. However, as some occupations are governed by federal, not provincial, workplace safety regulations, such as the transportation industry (marine, aviation, rail), trainees need to confirm with their employer as to exactly what specific training and certification standards comply with the applicable regulatory agencies, federal or provincial.

• Emergency First Aid: is an 8-hour course covering primarily life-threatening emergencies: CPR, bleeding, choking and other life-threatening medical emergencies.
• Standard First Aid: is a 16-hour course that covers the same material as Emergency First Aid and will include training for some, but not all, of the following: breaks; burns; poisons, bites and stings; eye injuries; head and neck injuries; chest injuries; wound care; emergency child birth; and multiple casualty management.
• Medical First Responder (BTLS - known by different names among different Canadian organizations): is a 40 hour course. It requires Standard First Aid certification as a prerequisite. Candidates are trained in the use of oxygen, automated external defibrillators, airway management, and the use of additional emergency equipment.

CPR certification in Canada is broken into several levels. Depending on the level, the lay person will learn the basic one-person CPR and choking procedures for adults, and perhaps children, and infants. Higher-level designations also require two-person CPR to be learned. Depending on provincial laws, trainees may also learn the basics of automated external defibrillation (AED).^[5]

• Level A is the lowest level of CPR training. Trainees learn how to perform the standard one-rescuer CPR and choking procedures on adults.
• Level B requires the same procedures as Level A, but trainees learn to perform these maneuvers on children and infants in addition to adults.
• Level C requires the same maneuvers as Level B, and trainees are also taught how to perform two-person CPR.
• Level HCP (Health Care Professional) was introduced in Canada in response to new guidelines set by the International Liaison Committee on Resuscitation.^[6] In addition to the techniques taught in Level C, artificial resuscitation, AED use (to certification standards), and bag-valve-mask use is taught. Anyone with CPR-HCP certification is considered AED certified.

Ireland

In Ireland, the workplace qualification is the Occupational First Aid Certificate. The Health and Safety Authority issue the standards for first aid at work and hold a register of qualified instructors, examiners and organisations that can provide the course. A FETAC Level 5 certificate is awarded after passing a three day course and is valid for two years from date of issue. Occupational First Aiders are more qualified than Cardiac First Responders (Cardiac First Response and training on the AED is now part of the OFA course) but less qualified than Emergency First Responders but strangely Occupational First Aid is the only one of the three not certified by PHECC. Organisations offering the certificate include, Ireland's largest first aid organisation, the Order of Malta Ambulance Corps, the St John Ambulance Brigade, and the Irish Red Cross. The Irish Red Cross also provides a Practical First Aid Course aimed at the general public dealing primarily with family members getting injured. Many other (purely commercially run) organisations offer training.

The Netherlands

In the Netherlands first aid training and certification for lay persons are provided mostly by specialised (commercial) first aid training companies or voluteers of the "Dutch Red Cross" and the foundations "Het Oranje Kruis" and "LPEV". They offer a variety of levels in first aid training, from basic CPR to First Responder. Medical first aid must be provided by certified ambulance crews, physicians and in hospitals.

United Kingdom

In the U.K., there are two main types of first aid courses offered. An “Emergency First Aid at Work” course typically lasts one day, and covers the basics, focusing on critical interventions for conditions such as cardiac arrest and severe bleeding, and is usually not formally assessed. A “First Aid at Work” course is usually a three-day course (two days for a re-qualification) that covers the full spectrum of first aid, and is formally assessed by recognized Health and Safety Executive assessors. Certificates for the “First Aid at Work” course are issued by the training organization and are valid for a period of three years from the date the delegate passes the course. Other courses offered by training organizations such as St. John Ambulance, St Andrew’s First Aid or the British Red Cross include Baby and Child Courses, manual handling, people moving, and courses geared towards more advanced life support, such as defibrillation and administration of medical gases such as oxygen and entonox.

The British Forces use First Aid ranging from levels 1-3, to assist the medical staff on their Ship, Squadron, Section, Base or any other purpose required. They are trained in both Military and Civilian First Aid and often utilise their knowledge in aid stricken regions around the world. First Aid is vital on board HM Ships because of the number of people in a small area and the space given to perform their task, it is also vital for the Army and Royal Marines to know basic first aid to help the survival rate of the soldiers when in combat.

United States

In the United States, there is no universal schedule of First Aid levels that are applicable to all agencies that provide first aid training. Training is provided typically through the American Red Cross, but may also be completed by local fire departments and the American Heart Association (AHA) in terms of CPR. The American Red Cross, however, offers the following courses:^[7]

• CPR
  • CPR-Adult (CPR-A)
  • CPR-Child and Infant (CPR-CI)
  • CPR-Adult and Child (CPR-AC)
  • CPR-Adult, Child, and Infant (CPR-ACI)
• CPR/Automated External Defibrillator (AED)
  • CPR/AED-Adult (CPR/AED-A)
  • CPR/AED-Adult and Child (CPR/AED-AC)
• First Aid
  • Standard First Aid (SFA)
  • Standard First Aid plus any of the above CPR or CPR/AED courses
• Specialty
  • Babysitter's Training
  • Lifeguarding (Lifeguard training)
  • Dog, Cat, and Dog/Cat First Aid
  • Professional Rescuer Training (CPR, First Aid, and AED to meet Lifeguard, EMT, and Nursing regulations)
  • Bloodborne Pathogens Training
  • Wilderness Training
  • First Responder in the Workplace training (CPR/AED/First Aid)
  • Instructor Certification

Red Cross training programs may vary by Chapter and season. Layman First Responders in the United States are subject to Good Samaritan law protections as long as their treatment does not extend beyond training or certification. First Aid training in the United States is limited to basic life support functions needed to sustain life, and training instills the importance of activating the Emergency Medical System before beginning assistance (through the Three C's: Check, Call, Care). Training classes range from a few hours for a specific course, or several days for combination, specialty, and instructor courses. Red Cross volunteers are required to be Standard First Aid plus CPR/ACI certified (AED is encouraged but not required as of 2009), as well as passing the FEMA NIMS Introductory certification.

Specific disciplines

There are several types of first aid (and first aider) which require specific additional training. These are usually undertaken to fulfill the demands of the work or activity undertaken.

• Aquatic/Marine first aid - Usually practiced by professionals such as lifeguards, professional mariners or in diver rescue, and covers the specific problems which may be faced after water-based rescue and/or delayed MedEvac.
• Battlefield first aid - This takes in to account the specific needs of treating wounded combatants and non-combatants during armed conflict.
• Hyperbaric first aid - Which may be practiced by SCUBA diving professionals, who need to treat conditions such as the bends.
• Oxygen first aid - Providing oxygen to casualties who suffer from conditions resulting in hypoxia.
• Wilderness first aid is the provision of first aid under conditions where the arrival of emergency responders or the evacuation of an injured person may be delayed due to constraints of terrain, weather, and available persons or equipment. It may be necessary to care for an injured person for several hours or days.
• Hydrofluoric Acid first aid - taught to first aiders in the chemical industry where hydrofluoric acid may be used. Instructs the first aider how to initially treat (with calcium gluconate) any skin that has been splashed with the acid.

Symbols

Although commonly associated with first aid, the symbol of a red cross is an official protective symbol of the Red Cross. According to the Geneva Conventions and other international laws, the use of this and similar symbols is reserved for official agencies of the International Red Cross and Red Crescent, and as a protective emblem for medical personnel and facilities in combat situations. Use by any other person or organization is illegal, and may lead to prosecution.

The internationally accepted symbol for first aid is the white cross on a green background shown at the start of the page.

Some organizations may make use of the Star of Life, although this is usually reserved for use by ambulance services, or may use symbols such as the Maltese Cross, like the Order of Malta Ambulance Corps and St John Ambulance. Other symbols may also be used.

ISO First Aid Symbol

Symbol of the Red Cross

Maltese or Amalfi Cross

Star of life

Conditions that often require first aid

Also see medical emergency.

• Altitude sickness, which can begin in susceptible people at altitudes as low as 5,000 feet, can cause potentially fatal swelling of the brain or lungs.^[8]
• Anaphylaxis, a life-threatening condition in which the airway can become constricted and the patient may go into shock. The reaction can be caused by a systemic allergic reaction to allergens such as insect bites or peanuts. Anaphylaxis is initially treated with injection of epinephrine.
• Battlefield first aid - This protocol refers to treating shrapnel, gunshot wounds, burns, bone fractures, etc. as seen either in the ‘traditional’ battlefield setting or in an area subject to damage by large scale weaponry, such as a bomb blast or other terrorist activity.
• Bone fracture, a break in a bone initially treated by stabilizing the fracture with a splint.
• Burns, which can result in damage to tissues and loss of body fluids through the burn site.
• Choking, blockage of the airway which can quickly result in death due to lack of oxygen if the patient’s trachea is not cleared, for example by the Heimlich Maneuver.
• Childbirth.
• Cramps in muscles due to lactic acid build up caused either by inadequate oxygenation of muscle or lack of water or salt.
• Diving disorders, drowning or asphyxiation.^[9]
• Gender-specific conditions, such as dysmenorrhea and testicular torsion.
• Heart attack, or inadequate blood flow to the blood vessels supplying the heart muscle.
• Heat stroke, also known as sunstroke or hyperthermia, which tends to occur during heavy exercise in high humidity, or with inadequate water, though it may occur spontaneously in some chronically ill persons. Sunstroke, especially when the victim has been unconscious, often causes major damage to body systems such as brain, kidney, liver, gastric tract. Unconsciousness for more than two hours usually leads to permanent disability. Emergency treatment involves rapid cooling of the patient.
• Heat syncope, another stage in the same process as heat stroke, occurs under similar conditions as heat stroke and is not distinguished from the latter by some authorities.
• Heavy bleeding, treated by applying pressure (manually and later with a pressure bandage) to the wound site and elevating the limb if possible.
• Hyperglycemia (diabetic coma) and Hypoglycemia (insulin shock).
• Hypothermia, or Exposure, occurs when a person’s core body temperature falls below 33.7°C (92.6°F). First aid for a mildly hypothermic patient includes rewarming, but rewarming a severely hypothermic person could result in a fatal arrhythmia, an irregular heart rhythm.
• Insect and animal bites and stings.
• Joint dislocation.
• Poisoning, which can occur by injection, inhalation, absorption, or ingestion.
• Seizures, or a malfunction in the electrical activity in the brain. Three types of seizures include a grand mal (which usually features convulsions as well as temporary respiratory abnormalities, change in skin complexion, etc.) and petit mal (which usually features twitching, rapid blinking, and/or fidgeting as well as altered consciousness and temporary respiratory abnormalities).
• Muscle strains and Sprains, a temporary dislocation of a joint that immediately reduces automatically but may result in ligament damage.
• Stroke, a temporary loss of blood supply to the brain.
• Toothache, which can result in severe pain and loss of the tooth but is rarely life threatening, unless over time the infection spreads into the bone of the jaw and starts osteomyelitis.
• Wounds and bleeding, including lacerations, incisions and abrasions, Gastrointestinal bleeding, avulsions and Sucking chest wounds, treated with an occlusive dressing to let air out but not in.

References

External links

• First Aid Guide at the Mayo Clinic
• First Aid References at the U.S.A. Center for Disease Control
• First Aid at BBC Health

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