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class="eckb-article-toc__title">TOPICS</div></div> </div> <article id="eckb-article-content" data-article-id="1028" > <div id="eckb-article-content-header-v2"><div id="eckb-article-content-header-row-1"><div class="eckb-article-content-header-row-left-group"><div id="eckb-article-back-navigation-container"><div class="eckb-navigation-back " style="margin-top: 4px; margin-right: 15px; margin-bottom: 4px; margin-left: 4px;" ><div tabindex="0" class="eckb-navigation-button" style="padding-top: 5px; padding-right: 10px; padding-bottom: 5px; padding-left: 10px; color: #1c4b76; background-color: #ffffff; font-size:14px;border-radius: 3px; border-style: solid; border-width: 1px; border-color: #b5b5b5;" onclick="history.go(-1);" >< All Topics</div></div></div><div id="eckb-article-content-breadcrumb-container"> <div class="eckb-breadcrumb" style="padding-top: 0px; padding-right: 4px; padding-bottom: 0px; padding-left: 4px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font-size:14px;" > <nav class="eckb-breadcrumb-outline" aria-label="Breadcrumb"> <ul class="eckb-breadcrumb-nav"> <li style="font-size:14px;" > <span class="eckb-breadcrumb-link"><a tabindex="0" href="https://redcrossdb.wpengine.com/aquatics-guidelines/"><span style="color: #1c4b76;" >Main</span></a><span class="eckb-breadcrumb-link-icon ep_font_icon_arrow_carrot_right" aria-hidden="true"></span> </span></li><li style="font-size:14px;" > <span class="eckb-breadcrumb-link"><a tabindex="0" href="https://redcrossdb.wpengine.com/aquatics-guidelines/category/lifeguarding/"><span style="color: #1c4b76;" >Lifeguarding</span></a><span class="eckb-breadcrumb-link-icon ep_font_icon_arrow_carrot_right" aria-hidden="true"></span> </span></li><li style="font-size:14px;" > <span class="eckb-breadcrumb-link"><span aria-current="page" style="color: #1c4b76;" >Setting the Stage for Safety</span> </span></li> </ul> </nav> </div> </div></div><div class="eckb-article-content-header-row-right-group"><div id="eckb-article-content-toolbar-container"> <div class="eckb-article-content-toolbar-button-container"> <span class="eckb-print-button-container"> <span class="eckb-toolbar-button-text">Print</span><span class="eckb-toolbar-button-icon epkbfa epkbfa-print"></span> </span> </div> </div></div></div><div id="eckb-article-content-header-row-2"><div class="eckb-article-content-header-row-left-group"><div id="eckb-article-content-title-container"><h1 class="eckb-article-title">Setting the Stage for Safety</h1></div></div></div></div><div id="eckb-article-content-body"><h2><img decoding="async" class="alignnone wp-image-564" src="https://redcrossdb.wpengine.com/wp-content/uploads/2023/06/Asset-1@2-300x300.png" alt="" width="50" height="50" srcset="https://redcrossdb.wpengine.com/wp-content/uploads/2023/06/Asset-1@2-300x300.png 300w, https://redcrossdb.wpengine.com/wp-content/uploads/2023/06/Asset-1@2-150x150.png 150w, https://redcrossdb.wpengine.com/wp-content/uploads/2023/06/Asset-1@2.png 337w" sizes="(max-width: 50px) 100vw, 50px" /></h2> <h2>Public Access Defibrillation Programs for Adults</h2> <p><strong>Last Full Review: ILCOR 2020<br /> </strong><strong>Last Update: 2023</strong></p> <p>Bystander use of automated external defibrillators (AEDs) has been shown to improve the odds of survival to hospital discharge and favorable neurological outcome following out-of-hospital cardiac arrest <a href="/lifeguarding-references/">(Holmberg 2017, 77)</a>. Despite this, public access defibrillators (PADs) are used in less than 3% of out-of-hospital cardiac arrests prior to the arrival of emergency medical services (EMS) <a href="/lifeguarding-references/">(Brooks et al. 2022, e776)</a>. Identifying barriers to the use of PADs can help generate novel strategies for public access to AEDs and for their deployment, thus allowing for earlier defibrillation and improved survival from an out-of-hospital cardiac arrest.</p> <p> </p> <div style='background-color: #f0f0f0; padding: 3%;'> </p> <h3 class="p3">Red Cross Guidelines and Best Practices</h3> <ul> <li>Public access defibrillation programs should be an essential part of the management of out-of-hospital cardiac arrest.</li> <li>Community leaders may consider determining the locations that have a high incidence of cardiac arrest in the local area and develop methods to have public access defibrillators available at these locations at the time of arrests.</li> </ul> <p class="p1"> </div> <p> </p> <p> </p> <h3>Evidence Summary</h3> <p>A 2017 American Red Cross Scientific Advisory Council literature update <a href="/lifeguarding-references/">(American Red Cross Scientific Advisory Council 2017)</a> of a scientific review identified observational studies showing improved survival outcomes following the use of PAD programs for out-of-hospital cardiac arrest. Other studies were identified evaluating strategies for placement and novel deployment of public AEDs. A 2023 International Liaison Committee on Resuscitation (ILCOR) evidence update <a href="/lifeguarding-references/">(Berg et al. 2023, e187)</a> identified one new randomized controlled trial <a href="/lifeguarding-references/">(Shibahashi et al. 2021, 164)</a> showing an improved odds of favorable neurological outcomes following bystander defibrillation for witnessed out-of-hospital cardiac arrest at metropolitan railroad stations, compared with patients who received defibrillation by EMS—supporting previous recommendations for implementation of PAD programs for patients with out-of-hospital cardiac arrest.</p> <p>Recently, a scientific statement from ILCOR sought to identify known barriers to PAD use and early defibrillation, to review current and new strategies to address barriers and to identify knowledge gaps to guide future research <a href="/lifeguarding-references/">(Brooks et al. 2022, e776)</a>. Suggestions made to improve PAD implementation centered on:<br /> • Improving public awareness and willingness to use an AED.<br /> • Optimizing AED availability, reliability and usability.<br /> • Automated external defibrillator signage, including design, visibility, location information and maintenance.<br /> • Mobile device application use for crowdsourcing cardiopulmonary resuscitation (CPR) and early AED use.<br /> • Use of mobile community health, fire and police personnel for early community AED deployment and defibrillation.</p> <p> </p> <h3>Insights and Implications</h3> <p>Survival to hospital discharge with a favorable neurological outcome following an out-of-hospital cardiac arrest remains low, at about 10% internationally <a href="/lifeguarding-references/">(Dyson et al. 2019, 138)</a>. Immediate CPR and AED use can greatly improve the odds of neurologically favorable survival. Public access defibrillator use bridges the temporal gap between out-of-hospital cardiac arrest and EMS arrival, but continues to be underutilized. While AED proximity to out-of-hospital cardiac arrests is key to bystander defibrillation, many other known and potential barriers exist. The ILCOR scientific statement can serve as blueprint for future research and consideration in PAD program development <a href="/lifeguarding-references/">(Brooks et al. 2022, e776)</a>.</p> <p> </p> <h2>Lightning Safety for Aquatic Facilities</h2> <p><strong>Last Full Review: American Red Cross Council on First Aid, Aquatics, Safety and Preparedness, 2009<br /> Last Update: 2023<br /> </strong></p> <p>Lightning is a frequent and potentially deadly natural phenomenon that has implications for all aquatic facilities. Lightning ranks as the second most common weather-related cause of fatalities (behind flooding) over the past century. Importantly, somewhere between 40% and 60% of lightning casualties were engaged in sports or recreational activities, such as swimming<a href="https://redcrossdb.wpengine.com/lifeguarding-references/"> (American Red Cross Scientific Advisory Council 2023)</a>.</p> <p> </p> <div style='background-color: #f0f0f0; padding: 3%;'> </p> <h3 class="p3">Red Cross Guidelines and Best Practices</h3> <ul> <li>Lightning safety actions (i.e., immediate pool evacuation, provision of lightning-safe shelter immediately upon first hearing thunder or seeing lightning) must be included within each aquatic facility’s Emergency Action Plan.</li> <li>Indoor aquatic facilities should consider evacuating the water (including avoiding contact with electrical outlets, plumbing and showers) during electrical storms.</li> <li>The ongoing monitoring of weather conditions is a strongly encouraged option for all aquatic facilities, especially indoor facilities without direct observation of outside weather.</li> </ul> <p class="p1"> </div> <p> </p> <p> </p> <h3>Evidence Summary</h3> <p>The American Red Cross Scientific Advisory Council scientific review <a href="/lifeguarding-references/">(American Red Cross Scientific Advisory Council 2023)</a> of a 2009 review recommends that all aquatic facilities include a specific lightning safety section within their Emergency Action Plan (EAP) and to implement that EAP in the event of an electrical storm. This information serves as the basis for the Red Cross guidelines related to aquatic facility lightning safety practices mandating the evacuation and sheltering of patrons.</p> <p>The American Meteorological Society issued a Lightning Safety Information Statement <a href="/lifeguarding-references/">(American Meteorological Society 2018)</a> with a recommendation that operators of large venues have lighting safety plans in place and establish lightning safety procedures. The statement also provides recommendations for the public to follow before a storm, while outside, while inside, while in safe and unsafe places, and what to do if someone is struck by lightning.</p> <p>The National Oceanic and Atmospheric Administration<a href="/lifeguarding-references/"> (National Oceanic and Atmospheric Administration 2023) </a>also provides guidance to the public about lightning safety and the importance of planning for any outdoor event.</p> <p>The National Athletic Trainer Association has also released two position statements <a href="/lifeguarding-references/">(Walsh et al. 2013, 258; Casa et al. 2012, 96)</a> that deal with lightning safety from the perspective of sports and recreational activities.</p> <p>There is a lack of empirical research supporting lightning safety recommendations. However, the message is consistent across the societies and agencies—which is that due to the potential severity of being struck by lightning, a proactive approach to prevent lightening-related injuries should be taken by aquatic facilities <a href="/lifeguarding-references/">(Walsh et al. 2013, 258)</a>.</p> <p>The limited evidence available has led to a standard that all aquatic facilities, particularly those located outdoors, must have an EAP that includes specific reference to the facility’s responses to an approaching electrical storm <a href="/lifeguarding-references/">(Casa et al. 2012, 96; Popp, Berry and Judge 2018, 633; Walsh et al. 2013, 258)</a>. A lightning safety section of the EAP should emphasize the requirement that aquatic facilities must immediately evacuate the facilities upon the initial sound of thunder due to a potential 10-mile radius for lightning strikes <a href="/lifeguarding-references/">(Popp, Berry and Judge 2018, 633; Walsh et al. 2013, 258)</a>. No one should re-enter the pool or pool deck area until 30 minutes after the last sound of thunder or evidence of lightning.</p> <p>There is a lack of evidence to support clearing an indoor pool during an electrical storm. However, a conservative approach is to clear all patrons from the water (as well as showers and contact with plumbing) for the duration of an electrical storm. Since swimming pools are large bodies of water connected to external plumbing and electrical sources (e.g., filters, drains, heaters), the logic has been that, despite required ground-fault systems in pools, the enormity and chaotic nature of electrical charges from lightning (i.e., 50,000 volts) may theoretically compromise the ground-fault system. Although there are no case reports of a person injured in an indoor pool during a lightning strike with a ground-fault system, there is a question of the reliability of ground-fault systems due to aging and corrosion <a href="/lifeguarding-references/">(Gazzana et al. 2014, 88)</a>.</p> <p> </p> <h3>Insights and Implications</h3> <p>There are many variables that impact how lightning will behave in an aquatic facility, including any structural lightning protection system, the potential travel of lightning along pool perimeter framing, piping or wiring, arcing between metallic systems and conduction through treated pool water. The Red Cross Guidelines and Best Practices for inclusion of lightning safety procedures in an EAP are a conservative, proactive approach intended to maximize safety for aquatic facility patrons and staff alike.</p> <p>Despite the extremely dangerous nature of lightning injuries and fatalities, much of the extant literature on lightning safety practices is based on expert opinion, descriptive statistics and common sense—without published empirical scientific evidence guiding recommendations.</p> <p>The Red Cross Aquatics Subcouncil scientific review <a href="/lifeguarding-references/">(American Red Cross Scientific Advisory Council 2023)</a> suggests that in addition to immediately clearing the facility, the EAP must indicate how patrons will be provided shelter in appropriate buildings or structures. Appropriate structures include enclosed structures with a substantial solid roof, floors and walls. Automobiles with metal roofs and closed windows are also considered safe. Open structures, such as picnic shelters and gazebos or storage units with open garage doors, are not safe from lightning. In cases of outdoor aquatic venues without a solid structure that can accommodate all patrons, some other safe alternative must be provided. Signage is suggested stating the thunder and lightning policy to alert patrons about the standard operating procedure for clearing the water during thunderstorms.</p> <p> </p> <h2>Exposure to Pool Chemicals</h2> <p><strong>Last Full Review: American Red Cross Scientific Advisory Council 2020<br /> Last Update: 2023<br /> </strong></p> <p>Chemicals used in pool treatments are typically caustic, with the primary agent being chlorine or (alternatively) bromine. Chlorine comes in different forms, either liquid or solid, and is used to disinfect pools and spas. Muriatic acid is commonly used to lower the pH in pools and spas. Direct exposure to these chemicals have been linked to eye, pulmonary, cardiac and other less serious complaints.</p> <p>It is estimated that more than 4500 visits to emergency departments related to pool chemicals occur annually in the United States <a href="/lifeguarding-references/">(Esschert et al. 2019, 433)</a>.</p> <p>A 2020 American Red Cross Scientific Advisory Council review updated in 2023 <a href="/lifeguarding-references/">(American Red Cross Scientific Advisory Council 2023)</a> sought to evaluate the evidence to answer the question: “What is the recommended first aid for exposure to pool chemicals?”</p> <p> </p> <div style='background-color: #f0f0f0; padding: 3%;'> </p> <h3 class="p3">Red Cross Guidelines and Best Practices</h3> <ul> <li>Following eye, skin or inhalation exposure to pool chemicals, the injured person should be removed from the source and taken to an area with fresh air. Contaminated materials (e.g., clothing, contact lenses) should be removed.</li> <li>Irrigation of the exposed area should take place immediately with fresh water for at least 15 minutes.</li> <li>When providing first aid for chemical eye injury, irrigation with normal saline, lactated ringer’s solution or a commercial eye wash solution is a reasonable alternative to water, when available immediately.</li> <li>Following exposure to industrial chemicals, consider contacting a poison control center (i.e., the National Capital Poison Center, 1-800-222-1222) for additional specific guidance. Emergency medical services should be contacted for pool chemical exposure that is accompanied by respiratory distress.</li> </ul> <p class="p1"> </div> <p> </p> <p> </p> <h3>Evidence Summary</h3> <p>A 2020 American Red Cross Scientific Advisory Council review of pool chemical injuries, updated in 2023 <a href="/lifeguarding-references/">(American Red Cross Scientific Advisory Council 2023)</a> identified one epidemiological report and several observational studies or case series of injuries due to pool chemicals.</p> <p>The 2019 epidemiological report by the Centers for Disease Control and Prevention describes the incidence of pool chemical injuries in the United States between 2008 and 2017 <a href="/lifeguarding-references/">(Esschert et al. 2019, 433)</a>. During this time, pool chemical injuries led to 13,508 emergency department visits. Most injuries were relatively minor, with 93.9% of patients treated and released from the emergency department. No deaths were reported. Of the reported injuries, 90% were inhalational with the remaining injuries including burns, conjunctivitis and dermatitis.</p> <p>An observational study reported that first aid with water irrigation between 5 and 60 minutes resulted in significantly shorter healing time and lower degree of caustic eye injury, compared with those without initial eye irrigation <a href="/lifeguarding-references/">(Ikeda et al. 2006, 225)</a>. Evidence for the management of inhalational injury comes from a case series of patients with chlorine exposures from swimming pools, treated with supplementary oxygen and bronchodilators <a href="/lifeguarding-references/">(Lehavi et al. 2008, 424)</a>. Evidence for dermal injuries comes from observational studies following caustic injury with treatment using irrigation within 10 minutes and with a large volume of water for at least 15 minutes <a href="/lifeguarding-references/">(Leonard, Scheulen and Munster 1982, 420)</a>.</p> <p>More recently, a case series described 61 individuals who were referred to the emergency department following inhalational exposure to a mixture of sodium hypochlorite and trichloroisocyanuric acid, which liberated chlorine gas <a href="/lifeguarding-references/">(Na et al. 2021, 513)</a>. Of the 61 patients, 22 were treated. The most common symptom was cough. Among the 22 patients, 18 (81.8%) had pulmonary complaints (specifics unknown), two (9.1%) had cardiac complaints (specifics unknown), six (27.3%) had dizziness, 14 (63.6%) had eye irritation, eight (36.4%) had throat irritation and two (9.1%) had gastrointestinal complaints (specifics unknown). Treatments included oxygen and bronchodilators, but overall are not well described.</p> <p> </p> <h3>Insights and Implications</h3> <p>The Red Cross continues to recommend that the care of a person directly exposed to pool chemicals should include removing the person from the source, removing contaminated materials and irrigating the exposed area with water for at least 15 minutes. Emergency medical services should be activated for individuals with respiratory distress following exposure to pool chemicals. The National Capital Poison Center (1-800-222-1222) should be called for product-specific advice. The Safety Data Sheets specific to the chemical involved should be referenced for additional first aid procedures. 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