RECOVER 2026 First Aid Guidelines: 50 Recommendations That Change Triage

The 2026 RECOVER First Aid guidelines, published as a three-paper series in the Journal of Veterinary Emergency and Critical Care, contain 50 treatment recommendations — 38 on general first aid and 12 on acute allergy and anaphylaxis — and they reverse several of the most familiar answers companion practices give on after-hours calls. The RECOVER Initiative, the group behind the 2012 and 2024 evidence-based CPR guidelines for dogs and cats, built the new set through a systematic evidence- and consensus-based process, the first of its kind in veterinary first aid.

Bystanders — owners, handlers, passersby — perform the first aid, but the guidelines are written for veterinary professionals whose task is to educate those providers.

What changes on the triage line for allergic reactions?

The guidelines draw a treatment-determining distinction. An uncomplicated allergic reaction — hives, facial swelling or itching of sudden onset within minutes to hours, sometimes with a single self-limiting bout of vomiting or diarrhea — is not immediately life-threatening. Anaphylaxis is a severe systemic hypersensitivity reaction that may involve respiratory, cardiovascular, gastrointestinal and cutaneous signs, and skin signs may be absent. In a peracute suspected hypersensitivity reaction, collapse, hypotension or severe respiratory distress identifies severe anaphylaxis even when only one body system is obviously affected.

For uncomplicated reactions, the guidelines recommend an oral histamine-1 receptor antagonist such as diphenhydramine or cetirizine in the prehospital setting and an H1R antagonist in the practice setting. Antihistamines should not be relied on to treat respiratory or cardiovascular consequences of established anaphylaxis. In one canine experiment, antihistamine pretreatment blocked administered histamine but did not prevent cardiovascular collapse when researchers triggered anaphylaxis with an allergen; human observational studies associated early antihistamine use with lower odds of progression.

Glucocorticoids lose their routine place. In two veterinary retrospective studies covering 880 dogs and 73 cats, adding dexamethasone to diphenhydramine did not improve immediate response, persistence or resolution of signs, or need for additional care. A short, low-dose course — 0.5 mg/kg/day or less of prednisolone equivalent, five days or fewer — is suggested only when an uncomplicated reaction fails to respond to an H1 antagonist. For anaphylaxis, the guidelines recommend against routine systemic glucocorticoids outright, citing multiple large human studies after a 2020 meta-analysis that found no consistent benefit, including no reliable reduction in biphasic reactions.

Epinephrine remains the treatment of choice. When breathing is affected, the guidelines recommend against oral antihistamines altogether, because coaxing a tablet into a dyspneic dog delays transport, delays epinephrine and invites a bite. Prehospital intramuscular epinephrine is suggested when it does not delay transport; a 0.15-mg pediatric autoinjector matches the 0.01 mg/kg dose for a 15-kg patient. Studies suggest epinephrine drawn aseptically into recapped plastic syringes and stored at room temperature away from light may remain stable and sterile for up to 90 days, making prefilled syringes practical for smaller patients. For pets with a prior anaphylactic event, the guidelines suggest veterinarian-dispensed, weight-based prefilled syringes for properly instructed owners. In-hospital, severe anaphylaxis with hypotension calls for a continuous epinephrine infusion titrated to a mean arterial pressure of 70 mm Hg rather than bolus dosing; in experimental canine anaphylactic shock, IM and SC boluses did not improve hemodynamics over placebo.

Why not hydrogen peroxide?

"My dog just ate..." may be the most common after-hours call in companion practice, and the guidelines recommend against routine prehospital emesis induction after acute ingestion of a non-caustic toxin. Multiple human studies found induced vomiting improved neither survival nor clinical course nor length of stay, while delaying activated charcoal, which appeared more effective than gastric emptying in alert patients. Hydrogen peroxide at emetic doses has caused meaningful gastrointestinal injury in both dogs and cats. One narrow exception applies: when a veterinary facility is genuinely out of reach and a veterinarian or animal poison control center directs emesis, follow that advice. Veterinarians may consider prescribing ropinirole ophthalmic solution in advance for pica-prone dogs in remote areas.

Cool first, transport second

For heat stroke, the guidance inverts instinct: move the animal somewhere cool and actively cool on scene before transport. In one canine study, about half of surviving dogs had been cooled by owners before transport, versus a fifth of those that died. The technique is cool running water caudal to the neck, aimed at the thinnest hair coat, soaked to the skin — running water over a single dousing because still water forms an insulating layer. RECOVER does not recommend whole-body immersion, citing drowning and handling risk. Cool to a rectal temperature of 39.7 to 40.0 C (103.5 to 104.0 F), then stop and dry, or cool for 15 minutes without a thermometer. In animals with stertor or stridor, keep cooling until panting clearly improves or temperature reaches 38.6 C (101.5 F).

Back blows before the Heimlich

For a conscious choking dog or cat, the guidelines recommend up to five firm back blows over the caudodorsal thorax, to either side of the spine, before abdominal thrusts. In the only direct human comparison, back blows were roughly twice as likely to relieve obstruction, and abdominal thrusts carry documented complications including aortic and gastric rupture. Never perform a blind finger sweep. If the animal loses consciousness, start chest compressions immediately — 30 compressions at 100 to 120 per minute, brief airway check, two mouth-to-nose breaths — an explicit change to RECOVER's own single-rescuer algorithm. Twenty-three observational studies of roughly a million people found bystander CPR raised survival two to three times.

For hypoglycemia in insulin-treated patients without seizure, owners can apply 0.2 to 10 mL of corn or glucose syrup to the buccal mucosa; in healthy dogs, buccal corn syrup raised blood glucose within 15 minutes. Never place anything in the mouth of a seizing animal.

What this means for practices

The work falls into four areas: telephone triage condensed into single sentences; education at the moment of prescribing; team training on updated CPR algorithms; and community education using layperson-language figures for waiting rooms and puppy classes. Two rules run throughout — first aid should not be attempted when provider risk is high, and first aid never replaces the visit. As the guidelines note, the chain of survival now begins in living rooms, backyards and trailheads, and the profession's job is to make sure the people standing there know the first link.