Acute Closed Extremity Joint Injuries: Compression Wrapping

Last Full Review: ILCOR 2020
Last Update: 2022

Ligamentous and tendonous injuries to joints, such as ankles or knees, are common and occur when a joint is forced to move into an unnatural position, such as with a twisting movement. Soft tissue injuries may also result from blunt trauma and include hematomas or contusions that can cause painful swelling. Elastic wraps are commonly available and provide compression and relief from discomfort due to extremity soft tissue or joint injuries.

When should elastic wraps be used in the first aid setting?

 

 

 

Evidence Summary

An International Liaison Committee on Resuscitation (ILCOR) systematic review (Borra et al. 2020, 789) identified two randomized controlled trials (RCTs) (Boyce, Quigley and Campbell 2005, 91; O’Connor and Martin 2011, 225) and one non-RCT (Bilgic et al. 2015, 1496) with 122 adults with ankle sprains. No reduction of pain was found from the use of a compression bandage compared with no compression bandage, a splint or an air splint (standardized mean difference, 0.34; 95% CI, -1.0–0.79, P=0.12) (Borra et al. 2020, 789). A similar lack of benefit was found for the outcomes of pain at rest and pain with walking after 6 days to 9 days in one RCT (Bendahou et al. 2014, 1005), while three RCTs (Bendahou et al. 2014, 1005; Boyce, Quigley and Campbell 2005, 91; Rucinkski et al. 1991, 65) and one non-RCT (Bilgic et al. 2015, 1496) showed no reduction of swelling or edema with the use of a compression bandage compared with no compression bandage, or with a noncompressive stocking, a splint or an air splint. No new studies of compression wrapping for first aid were identified in an ILCOR 2022 evidence update (Wyckoff et al. 2022, e645).

 

Insights and Implications

The studies included in the ILCOR review were conducted in outpatient healthcare settings with follow-up over several days, and thus provide very indirect evidence for first aid. An acute joint injury in the first aid setting cannot be diagnosed as a sprain or fracture. While a compression bandage or wrap may provide comfort for ankle injuries, further evaluation by a qualified healthcare professional is necessary to determine the exact injury and appropriate treatment. In addition, the proper application of a compression wrap requires training, and an improper, too-tight application may worsen outcomes by exacerbating pain or swelling from a tourniquet effect. No studies were identified that evaluated use of a compression wrap for joints other than the ankle.

 

Mild Traumatic Brain Injury (Concussion): First Aid

Last Full Review: American Red Cross Scientific Advisory Council 2021; ILCOR 2019
Last Update: 2022

Concussion remains a common injury in the United States and is defined by the Centers for Disease Control (CDC) as “a bump, blow or jolt to the head or a hit to the body that causes the head and brain to move quickly back and forth.” This movement can cause damage to brain cells leading to a temporary impairment in brain function and information processing, or mild traumatic brain injury (TBI). These classifications of injuries produced around 223,000 hospitalizations in 2019 and 190 deaths in Americans daily in 2021, according to public data from the CDC (Centers for Disease Control and Prevention 2023).

Mild TBI may cause a myriad of symptoms—ranging from subtle confusion, headache and drowsiness to loss of consciousness, irritability, nausea, vomiting, difficulty speaking and difficulty with balance or dizziness. While concussions can occur with accidental injury, they are frequently seen in different sporting activities and affect athletes of every age and skill. Sports concussion is now described in news headlines along with reports of the consequences of premature return to play and repeat concussions. Studies describe the long-term effects from concussion. The key to caring for a person with an acute concussion is its recognition and proper treatment with referral to specialists as needed. Lifeguards, first aid providers and healthcare professionals alike must be aware of the wide range of symptoms due to concussion to be able to recognize the condition.

 

 

 

Evidence Summary

Concussion scoring tools are available for athletic trainers and first aid providers in sports settings that require a baseline score prior to injury, but these two-stage scoring systems are not applicable to the acute first aid setting. Past systematic reviews by the International Liaison Committee on Resuscitation and the American Red Cross Scientific Advisory Council have sought to identify a simple, single stage scoring tool for use in the first aid setting to help identify a concussion, but no such tool has been identified.

The 2021 systematic review by the American Red Cross Scientific Advisory Council included three new articles that focused on symptoms of mild TBI that can be used in assessment. Ultimately, none of these studies are applicable to the first aid setting and acute mild TBI. There are multiple assessment tests that can be used to help determine if someone has sustained a mild TBI, such as the Sport Concussion Assessment Tool (SCAT), Standard Assessment of Concussion (SAC) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and balance testing, which are designed to be used by healthcare trained professionals, and not by a lay first aid provider.

The review concludes that providers of first aid must first recognize that no two mild TBIs (i.e., concussions) are identical in both the cause and presentation. The American Red Cross Scientific Advisory Council review summarizes the signs and symptoms of concussion that are described most frequently with concussion and that are included in existing concussion scoring systems (See Table: Signs and Symptoms of Mild Traumatic Brain Injury or Concussion).

The degree of the resulting signs and symptoms from the physical trauma can be very different and difficult to visualize by a first aid provider depending upon a variety of factors. To help recognize a concussion, providers of first aid should observe for two signs/symptoms. First, the person sustaining a mild TBI should experience a forceful bump, blow or jolt to the head or body that results in rapid movement of the head and brain. Second, providers of first aid should observe for any change in the person’s physical, cognitive, emotional or sleeping patterns. Note that these signals may or may not appear immediately and that some people do not recognize or admit that they are having problems.

 

Insights and Implications

To be able to recognize a concussion, lifeguards and first aid responders should be familiar with the common signs and symptoms of a concussion as listed in the table and should consider if the events preceding the onset of symptoms may have been associated with direct or indirect trauma to the head. Persons with unwitnessed trauma may not recall an injury, and thus lifeguards and first aid providers must have a high index of suspicion when caring for a person with symptoms that may be attributable to a concussion.

 

Avulsed Permanent Tooth: Temporary Storage

Last Full Review: American Red Cross Scientific Advisory Council 2018; ILCOR 2020
Last Update: 2021

Dental avulsion is the complete, traumatic displacement of a tooth from its socket and is estimated to occur in more than 5 million people per year in the United States (Welch, Thomson and Kennedy 2010, 137). Avulsion of a tooth takes considerable force and is most commonly the result of a fall, sports-related injury, assault or motor vehicle collision (Young, Macias and Stephens 2015, 250). While immediate replantation of the avulsed tooth is considered the best way to save or restore tooth structure, this may not be possible in the first aid setting due to lack of personal protective equipment, pain, associated fractures of the bone surrounding the tooth, or due to lack of skills and willingness of the first aid provider to attempt replantation. This has led to the use of temporary storage solutions to help preserve a tooth prior to replantation by a dental or other healthcare professional. Storage solutions are intended to minimize the time a tooth dries outside of the socket and desiccation of periodontal ligament cells on the root surface, thereby increasing the chances of healing after replantation.

Which solution is best for storing an acutely avulsed tooth?

 

 

Evidence Summary

A systematic review by the International Liaison Committee on Resuscitation (ILCOR) (De Brier et al. 2020 453; Singletary et al. 2020, S284) evaluated storage solutions appropriate for temporary storage of an avulsed permanent tooth. Thirty-three studies were included and 23 comparisons reported; comparisons were made between whole milk or the patient’s saliva and Hank’s Balanced Salt Solution, propolis solution, oral rehydration salts, coconut water, egg white, rice water, cling film plastic wrap, tap water, buttermilk, another person’s saliva and multiple other solutions. Success of the intervention was measured in most studies by the viability of periodontal ligament cells, expressed as the number of, or percent of, viable cells.

The randomized controlled trials included in the review provided evidence that storage of avulsed teeth in saliva and whole milk were equally effective for cell viability rates. Two studies reported lower cell viability rates (i.e., harm to cells) following immersion of teeth in tap water and saline as compared with (cow’s) milk. Compared with any form of cow’s milk, improved preservation of tooth or cell viability was reported with storage of an avulsed tooth in (saliva and thereafter) Hanks Balanced Salt Solution, propolis solution, oral rehydration salt solutions, rice water and cling film. There was insufficient evidence to recommend for or against storage in saliva compared with alternative solutions.

An American Red Cross Scientific Advisory Council scientific review of dental avulsion and temporary storage of the tooth updated in 2021 used findings from the ILCOR 2020 systematic review of dental avulsion storage to inform the Red Cross guidelines.

 

Insights and Implications

Avulsion of a permanent tooth is best treated by immediate replantation, when possible. This is not typically considered a first aid skill; care providers may be concerned about exposure to blood, uncertainty about how to replace the avulsed tooth, causing additional pain, or causing further injury, especially if there are surrounding fractures in the bone forming the socket. Thus, the goal is to help the person with an avulsed tooth to receive care by a dentist or healthcare professional trained in replantation of the tooth. Storage of a tooth in a suitable media can prolong the viability of attached periodontal ligament cells, helping to improve the chances of successful replantation.

The recommendation for Hanks Balanced Salt Solution is supported by the greatest number of randomized controlled trials included in the ILCOR review; this solution is found in over-the-counter dental storage kits sold in most pharmacies and can be added to first aid supplies for sporting events where dental avulsion is a risk. Storing an avulsed tooth in the patient’s mouth and saliva seems an attractive intervention, but can lead to accidental swallowing or aspiration of the tooth. The recommendation for the use of plastic cling film, while based on a single very-low certainty study, is viewed as particularly useful for first aid in the austere environment where liquid storage solutions may not be available, but additional studies are needed to confirm this benefit. It may help by keeping the tooth moist and creating a physiological environment that is necessary for periodontal ligament cell survival.

The choice of a temporary solution of medium for storage of an avulsed tooth will ultimately depend on the setting and the availability of a storage solution or product.

 

Burn Care and Cooling

Last Full Review: ILCOR 2021; American Red Cross Scientific Advisory Council 2019
Last Update: 2022

Immediate cooling of thermal burns with cool running water is the recommended immediate first aid intervention. How long should a burn be cooled in this manner, and are there any precautions?

 

 

 

Evidence Summary

A 2021 systematic review by the International Liaison Committee on Resuscitation (ILCOR) (Djärv et al. 2022, 251; Wyckoff et al. 2022, e645) evaluated the use of immediate cooling of thermal burns using running water for 20 minutes, compared with cooling with running water for alternatives durations of time. Four studies met inclusion criteria with 48% of burns cooled for 20 minutes of more. While a positive outcome of size and depth of burn or need for skin grafting could not be shown for burns cooled 20 minutes or longer compared with burns cooled less than 20 minutes, the evidence was considered limited due to study designs, risk of bias and other concerns, such as differences in the initial size or depth of burn, when the cooling began and by what type of responder or healthcare provider. The review concluded that an optimal duration of cooling for thermal burns is not clear, and additional research is needed to better define the duration.

A 2022 American Red Cross Scientific Advisory Council scientific review (American Red Cross Scientific Advisory Council 2022) also looked for evidence to support a specific duration of cooling of thermal burns; the review identified three randomized control trials, six observational cohort (two prospective, four retrospective) studies and two statistical modeling studies. These studies support the use of cool running water for the first aid treatment of burns. Cool water was reported to improve pain scores, reduce the need for skin grafting, and decrease intensive care unit admission rates and length of hospital stay. One observational cohort study demonstrated a dose-response relationship with length of cooling with benefit anywhere from 10 minutes to 40 minutes (Wood et al. 2016, e0147259). In addition, one statistical model (Log 2017, 1374) highlighted the importance of clothing removal as fast as possible (i.e., in the first few seconds), the thickness of the clothing, skin thickness and temperature of the water correlated with time to more severe injuries. There is some evidence of harm with cooling times over 40 minutes (Wood et al. 2016, e0147259). Thus, it is not recommended to cool a burn for longer than 40 minutes.

 

Insights and Implications

Most studies evaluating the optimal duration of time to cool a burn with running water are older studies and performed on animals. Human studies of first aid for thermal burns tend to use 20 minutes as a standard that the researcher’s term “adequate first aid.” The evidence is far from clear as to how long a burn should be cooled, but a minimum of 10 minutes is associated with improved outcomes, while 20 minutes is recommended in many guidelines. At 40 minutes of cooling, the risk of hypothermia exceeds the benefit for burn care, particularly in small children or infants with large body surface areas. One study (Griffin et al. 2020, 75) demonstrated a dose-response relationship for cooling up to 20 minutes; any duration of cooling over 5 minutes decreased the odds of a full thickness burn or needing a skin graft, and longer durations of cooling had progressively improved outcomes up 20 minutes.

Although cooling of a burn should begin immediately, transporting a person with a burn to a healthcare facility should not be delayed allowing time for burn cooling. Rather, cooling should continue during transport, using nonfreezing cold packs or cold-water immersion.

 

Spinal Motion Restriction

Last Full Review: American Red Cross Scientific Advisory Council 2023; ILCOR 2015
Last Update: 2023

Spinal immobilization using a cervical collar and long backboard with straps and head blocks to secure a person was once a common practice for persons with suspected spine injury. The practice was recommended, despite a lack of evidence showing any benefit with the use of spinal immobilization. The concern for missing a cervical spine fracture and possible delayed paralysis caused widespread use of spinal immobilization of trauma patients. This led to the unnecessary full immobilization of patients following minor mechanisms for trauma and without neurological injury or fracture—who would sometimes wait for hours in emergency departments to have their spine “cleared” before being removed from a backboard.

By 2018, there was evidence suggesting harm from spinal immobilization, including pain, pressure sores, agitation, aspiration and respiratory compromise, and increased use of radiography (Fischer et al. 2018, 659; Ham et al. 2017, 13; Sparke, Voss and Benger 2013, 81). Management of patients with potential spine injuries evolved from complete spinal immobilization to a policy of spinal motion restriction, with clear criteria for the use of spinal motion restriction proposed by multiple organizations. While spinal immobilization was intended to prevent movement of the spine, spinal motion restriction is an attempt to maintain the spine in anatomic position while minimizing gross movement irrespective of adjuncts or devices.

Has the change from widespread use of spinal immobilization to spinal motion restriction for persons meeting criteria for spinal motion restriction changed the outcomes of patients? What are current recommendations for lifeguards and other prehospital healthcare professionals caring for a person with a suspected spine injury? When should spinal immobilization be used in the aquatic setting?

 

 

 

Evidence Summary

An American Red Cross Scientific Advisory Council scientific review of cervical spine immobilization and spinal motion restriction, updated in 2023 (American Red Cross Scientific Advisory Council 2023), focused on spinal immobilization or spinal motion restriction in the aquatic setting, with recommendations for trained lifeguards and aquatic personnel. Previous American Red Cross Scientific Advisory Council reviews have focused on (untrained) lay first aid providers in the setting of a traumatic injury.

In the updated American Red Cross Scientific Advisory Council review, several small or retrospective studies were included, as well as the 2018 Joint Consensus Statement (Fischer et al. 2018, 659) by the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians and the National Association of EMS Physicians. No studies specifically pertained to the use of cervical spine motion restriction by lay providers. The included studies show a continued transition to selective spinal motion restriction as opposed to strict spine immobilization.

The 2018 Joint Position Statement on Spinal Motion Restriction in the Trauma Patient from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians (Fischer 2018, 659) advocates for the selective use of spinal motion restriction only in certain individuals with blunt trauma, and includes:

• An altered level of consciousness (e.g., Glasgow Coma Scale score less than 15, evidence of intoxication).
• Midline neck or back pain and/or tenderness.
• Focal neurological signs and/or symptoms (e.g., numbness or motor weakness).
• Anatomic deformity of the spine.
• Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc.) or any similar injury that impairs the patient’s ability to contribute to a reliable examination.

 

The consensus statement clarifies that while “spinal motion restriction” is now the favored term over “spinal immobilization,” both terms refer to the same concept and with a goal to minimize undesired movement of a potentially injured spine. Because an injury to the spine may be associated with other noncontiguous spinal injuries in adults, the entire spine requires spinal motion restriction. This statement also notes that a long spine board can be used for patient transfers or extrications; however, the long spine board could be removed once the person is placed on an ambulance cot if enough appropriately trained persons are present.

In a prospective, observational study enrolling 1372 children (Browne et al. 2021, 553), seven factors were identified that were associated with cervical spine injuries in children:

1. Axial load
2. Altered mental status
3. Signs of basilar skull fracture
4. Substantial torso injury
5. Substantial thoracic injury
6. Respiratory distress
7. Decreased oxygen saturation

 

In addition, the Pediatric Emergency Care Applied Research Network (PECARN) criteria for spine injury, which include a diving mechanism, neck pain, decreased neck mobility, altered mental status and neurological deficits, were sensitive in identifying cervical spine injury in children in this study.

A retrospective observational review (Thom et al. 2023, 18) of 574 cervical spine injuries occurring in a body of water with risk of drowning reported that only four (4.3%) of these patients had a simultaneous drowning injury (0.8% of drowning presentations). The primary mechanism of cervical spine injury was wave force impact (71.91 or 78%) and a history of axial loading was 100% sensitive when indicating imaging. The authors conclude that cervical spine injury and drowning is uncommon, and cervical spine precautions are only required in drowning patients with signs or a history or at high-risk of axial loading of the spine. The authors proposed that this supports the move away from routine cervical spine precautions.

A case control analysis (Kane et al. 2015, e813) evaluating the epidemiology of aquatic and recreational water sports injuries evaluated a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a trauma center over 3 years, finding that personal watercrafts accounted for most injury types being, with cervical (33.3%), closed-head (25.7%) and thoracolumbar injuries (21.9%).

Two retrospective studies (Castro-Marin et al. 2020, 401; Clemency et al. 2021, 708) found no increase in spinal cord injury after implementing selective spinal motion restriction protocols compared with strict spinal immobilization using long spine boards.

The American Red Cross Scientific Advisory Council scientific review concludes that the evidence on whole supports the selective spinal motion restriction by lifeguards trained in this technique and in the setting of possible spine trauma. High-risk injuries occur in diving, wave or watercraft situations, and spinal motion restriction may be implemented when the person has altered mental status, cervical spine pain or tenderness, or focal neurological defects. Extrication and/or transfer from an aquatic (including pools) setting using a long spine board aligns with the 2018 Joint Position Statement (Fischer 2018, 659), but should be discontinued as soon as safely possible when a higher level of care is reached.

 

Insights and Implications

Previous reviews by the American Red Cross with the American Heart Association (Part 10: First Aid 2005, III-115–III-125) have shown that drowning persons are unlikely to have a spinal injury unless they have had a high-impact, high-risk activity, such as shallow water diving, water skiing accident or the use of a motorized vehicle and have clinical signs of injury or obvious neurological deficit. On the other hand, drowning associated with a history of high-impact, high-risk activity and intoxication or other unreliability or obvious signs of injury can be considered at higher risk of spinal injuries.

Past International Liaison Committee on Resuscitation reviews have recommended spinal motion restriction and immobilization during transport for persons injured in a high-impact, high-risk activity as described above, or being on beaches with moderate-to-severe shore breaks, signs of unreliability or injury. Signs of unreliability or injury was defined as intoxication, altered level of consciousness, an excited or uncooperative patient, the presence of a distracting injury, abnormal motor or sensory neurological signs and spinal tenderness or pain.

The Red Cross lifeguard program does not currently include use of cervical collars, as per the American Red Cross Scientific Advisory Council Aquatic Subcouncil guidance.