Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (David Szpliman)
Task Force Scoping Review Citation
Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, Scapigliati A, Seesink J, Schmidt A, Sempsrott J, Szpliman D, Warner DS, Webber J, Johnson S, Avis S, Mancini MB, Nation K, Brooks S, Castren M, Chung S, Considine J, Kudenchuk P, Nishiyama C, Ristagno G, Semeraro F, Smyth M, Vaillancourt C, Olasveengen T, Morley P, Perkins GD on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force(s).
Automated External Defibrillation in Drowning. Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 7 July 2020. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of the literatures undertaken by Hylmar Elsenga and Cristian Abelairas Gomez and co-ordinated by Gavin Perkins and Joost Bierens. The findings from the review of basic life support were considered by the Basic Life Support Task Force who contributed to the Task Force insights.
Scoping Review
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: AED use
Comparators: no AED use
Outcomes: Any clinical outcome (e.g. survival, survival with a favourable neurological outcome, hospitilisation), CPR quality, physiological end-points
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Manikin studies will only be included if no human studies are available.
Timeframe: From 2000 onwards. All languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols), narrative reviews, animal studies were excluded. Literature search updated to October 2019.
Search Strategies
BLS-856-Drowning-CPR-Search-Strategies
Inclusion and Exclusion criteria
Inclusion criteria:
- Adult and paediatric patients
- Submersion in water (drowning, near drowning)
- Describe use of an AED
- Studies report clinical outcomes e.g. survival, survival with a favourable neurological outcome, hospitilisation
- Other outcomes: CPR quality, physiology
Exclusion criteria:
- Animal studies
- Results reported in the gray literature or abstract only
- Narrative reviews containing no primary data
- Published as an abstract only or in conference proceedings.
- Case studies / series without control groups, unless no or minimal other literature available.
Data tables
Task Force Insights
1. Why this topic was reviewed.
Drowning is the third leading cause of unintentional injury death worldwide, accounting for over 360 000 deaths annually.[World Health Organization, 2020] Whilst the commonest cause of cardiac arrest associated with submersion is hypoxia, in some cases, a primary cardiac arrythmia may be the precipitating event. The use of an automated external defibrillator in such cases may be life-saving, but this needs to be balanced against the risk of harm from interruptions to CPR for patients with non-shockable rhythms. Although ILCOR recommends the use of AEDs, their role in the setting of resuscitation from drowning is not clearly defined. The BLS Task Force and Drowning collaboration considered it timely to undertake a scoping review of the literature to identify any new evidence related to this topic.
2. Narrative summary of evidence identified
The literature search identified 3005 articles (2190 after removal of duplicates). After screening titles and abstracts, 29 studies were identified for full text review.
There were no interventional, observational or case series showing direct evidence on the outcome from on-site AED usage in OHCA due to drowning prior the arrival of emergency medical services (EMS).
Indirect evidence of AED use was found from 15 observational studies. Four studies involving 1044 patients, showed a range of AED usage in cases of suspected drowning prior the arrival of EMS of 5-32%.[Buick, 2014, 314; Tobin, 2017, 39; El-Assaad, 2018, 10; Seesink, 2019, 104] In 12 studies involving 14,920 patients, a shockable rhythm in OHCA due to drowning was uncommon with a reported range of VF/VT between 2-14%.[Claesson, 2008, 381; Youn, 2009, 778; Claesson, 2012, 1072; Dyson, 2013, 1114; Buick, 2014, 314; Claesson, 2014, 644; Vahatalo, 2014, 604; Kieboom, 2015, h418; Tobin, 2017, 39; El-Assaad, 2018, 10; Fukuda, 2019, 111; Seesink, 2019, 104]
Amongst seven observational studies involving 1846 patients in cardiac arrest after drowning, a shockable rhythm was not associated with better survival. [Claesson, 2008, 381; Youn, 2009, 778; Dyson, 2013, 1114; Kieboom, 2015, h418; Tobin, 2017, 39; El-Assaad, 2018, 10; Seesink, 2019, 104] In one study with 776 drowning survivors, only 0.4% was defibrillated at the emergency department.[Reynolds, 2017, 18] In one study involving 529 patients in a multivariable analysis, whilst a shockable rhythm did not improve survival to hospital admission, there was an association between shockable rhythm and increased 30 day survival OR 4.12 (95% CI: 1.13–13.71).[Claesson, 2014, 644]
In one simulation study testing 6 AEDs on 3 different boats in moderate sea conditions, use of AEDs seemed feasible.[de Vries, 2006, 247] (De Vries 2006, 247). In one simulation study with 616 lifeguards, mean time from arrival to defibrillation was 62 seconds (standard deviation 20).[Iserbyt, 2015, 70] In one study, a case of inappropriate shock delivered to a patient in asystole with artefacts on the ECG due to movements was described with no obvious consequences.[Seesink, 2019, 104]
No adverse events were reported in the studies identified in this review.
3. Narrative Reporting of the task force discussions
A limited evidence base was identified in this scoping review, but a systematic review on this topic will be required if a recommendation is intended to be made by the task force.
The writing group considered the studies reviewed showed AED use in cardiac arrest due to drowning appears feasible and safe. The chances of a shockable rhythm may be lower (2-14%) than for a primary cardiac cause. The current ILCOR treatment recommendation suggest a short period of CPR until the defibrillator is ready for analysis and/or defibrillation in unmonitored cardiac arrest. This may be particularly important where the cardiac arrest was caused by drowning. [ILCOR CoSTR 2020 BLS]
Knowledge Gaps
Current knowledge gaps include but are not limited to:
Prospective observational studies and randomised trials examining the effectiveness of AED programmes in areas where people are at risk of drowning.
Optimal timing for AED deployment for cardiac arrest associated with drowning.
- How to reduce risks and optimise successful defibrillation in and around water.
Studies in low resource settings were lacking.
References
References listed alphabetically by first author last name in this citation format
Buick, J. E., et al. (2014). "Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada." CJEM Canadian Journal of Emergency Medical Care 16(4): 314.
Claesson, A., et al. (2014). "Cardiac arrest due to drowning--changes over time and factors of importance for survival." Resuscitation 85(5): 644.
Claesson, A., et al. (2012). "Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services 1996-2010." Resuscitation 83(9): 1072.
Claesson, A., et al. (2008). "Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning." Resuscitation 76(3): 381.
de Vries, W., et al. (2006). "Moderate sea states do not influence the application of an AED in rigid inflatable boats." Resuscitation 70(2): 247.
Dyson, K., et al. (2013). "Drowning related out-of-hospital cardiac arrests: characteristics and outcomes." Resuscitation 84(8): 1114.
El-Assaad, I., et al. (2018). "Automated External Defibrillator Application Before EMS Arrival in Pediatric Cardiac Arrests." Pediatrics 142(4): 10.
Fukuda, T., et al. (2019). "Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013-2016." Resuscitation 141: 111.
Iserbyt, P., et al. (2015). "A multiple linear regression analysis of factors affecting the simulated Basic Life Support (BLS) performance with Automated External Defibrillator (AED) in Flemish lifeguards." Resuscitation 89: 70.
Kieboom, J. K., et al. (2015). "Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study." BMJ 350: h418.
Reynolds, J. C., et al. (2017). "Observed long-term mortality after 18,000 person-years among survivors in a large regional drowning registry." Resuscitation 110: 18.
Seesink, J., et al. (2019). "Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews." Resuscitation 142: 104.
Tobin, J. M., et al. (2017). "Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning." Resuscitation 115: 39.
Vahatalo, R., et al. (2014). "Drowning in children: Utstein style reporting and outcome." Acta Anaesthesiologica Scandinavica 58(5): 604.
World Health Organization (2020) Drowning.
Youn, C. S., et al. (2009). "Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's Hospital." Resuscitation 80(7): 778.