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).
Bystander CPR 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 Steve Beerman and Cody Dunn 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.
Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.
Usman M, Fitzpatrick-Lewis D, Kenny M, Parminder R, Atkins DL, Soar J, Nolan J, Ristagno G, Sherifali D Effectiveness of antiarrhythmic drugs for shockable cardiac arrest: A systematic review Resuscitation 132:November 2018 63-72 PMID:30179691 DOI:10.1016/j.resuscitation.2018.08.025
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: bystander CPR
Comparators: no bystander CPR
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.
Inclusion and Exclusion criteria
- Adult and paediatric patients
- Submersion in water (drowning, near drowning)
- Describe delivery of bystander CPR
- Studies report clinical outcomes e.g. survival, survival with a favourable neurological outcome, hospitilisation
- Other outcomes: CPR quality, physiology
- 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.
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] Submersion in water leads to the rapid onset of hypoxia. Left untreated cardiac arrest occurs within minutes. The initiation of CPR by bystander allows treatment to be delivered before emergency services arrive but its effects on outcomes following drowning are uncertain. 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, 71 studies were identified for full text review. Of these, 18 studies were identified that discussed bystander CPR as an intervention for 16,303 adults and children following drowning.[Al-Mofadda, 2001, 300; Claesson, 2008, 381; Ballesteros, 2009, 935; Grmec, 2009, 7; Youn, 2009, 778; Venema, 2010, 434; Claesson, 2012, 1072; Nitta, 2013, 1568; Buick, 2014, 314; Claesson, 2014, 644; Vahatalo, 2014, 604; Joanknecht, 2015, 123; Hubert, 2016, 924; Al-Qurashi, 2017, 17; Tobin, 2017, 39; Cohen, 2018, 05; Fukuda, 2019, 22; Fukuda, 2019, 111]
There were 2 prospective observational studies,[Nitta, 2013, 1568; Hubert, 2016, 924] 9 retrospective observational studies,[Claesson, 2008, 381; Ballesteros, 2009, 935; Grmec, 2009, 7; Buick, 2014, 314; Claesson, 2014, 644; Tobin, 2017, 39; Cohen, 2018, 05; Fukuda, 2019, 22; Fukuda, 2019, 111] and 7 retrospective case reviews.[Al-Mofadda, 2001, 300; Youn, 2009, 778; Venema, 2010, 434; Claesson, 2012, 1072; Vahatalo, 2014, 604; Joanknecht, 2015, 123; Al-Qurashi, 2017, 17] The studies provided global data from high income settings with 9 from Europe, [Claesson, 2008, 381; Ballesteros, 2009, 935; Grmec, 2009, 7; Venema, 2010, 434; Claesson, 2012, 1072; Claesson, 2014, 644; Vahatalo, 2014, 604; Joanknecht, 2015, 123; Hubert, 2016, 924] 2 from North America[Buick, 2014, 314; Tobin, 2017, 39] and Korea.[Youn, 2009, 778] 2 Japanese studies assessed different variables from the same data set. [Fukada 2019,111; Fukada 2019,166].
All studies reported survival status following OHCA due to drowning and 13 reported neurological outcomes.[Al-Mofadda, 2001, 300; Ballesteros, 2009, 935; Grmec, 2009, 7; Youn, 2009, 778; Nitta, 2013, 1568; Vahatalo, 2014, 604; Joanknecht, 2015, 123; Hubert, 2016, 924; Al-Qurashi, 2017, 17; Tobin, 2017, 39; Cohen, 2018, 05; Fukuda, 2019, 22; Fukuda, 2019, 111]
Only 2 cohort studies were designed to directly assess the impact of bystander CPR and both found statistically significant associations between bystander CPR and improved outcomes.[Tobin, 2017, 39; Fukuda, 2019, 111] Fukada et al reported improved neurologically favourable survival (RR 2.19, p=0.0076), one-month survival (RR 1.55, p=0.0150) and prehospital ROSC (RR 1.30, p=0.0296).[Fukuda, 2019, 111] . Tobin et al similarly supported it as an intervention associated with neurologically favourable survival (aOR=3.02, p<0.001).[Tobin, 2017, 39]
Four other studies found significant associations with bystander CPR and survival.[Grmec, 2009, 7; Claesson, 2014, 644; Hubert, 2016, 924; Cohen, 2018, 05] Five studies found a positive trend towards survival.[Al-Mofadda, 2001, 300; Venema, 2010, 434; Nitta, 2013, 1568; Vahatalo, 2014, 604; Al-Qurashi, 2017, 17] and 3 found no association between bystander CPR and good outcomes.[Al-Mofadda, 2001, 300; Claesson, 2008, 381; Youn, 2009, 778; Joanknecht, 2015, 123] One of those studies did find a significant association between survival and the time from witnessing to BLS initiation (p<0.001).[Youn, 2009, 778]
Several studies examined the effect of conventional CPR versus compression-only CPR by bystanders on survival.[Nitta, 2013, 1568; Hubert, 2016, 924; Fukuda, 2019, 22] Hubert et al found a highly positive association with bystander ventilation and survival (OR 6.742, p=0.002) [Hubert, 2016, 924] and Nitta et al trended towards favouring conventional CPR for both survival (aOR=1.87;95%CI 0.83-4.20) and neurologically favourable outcome (aOR=2.35;95%CI 0.52-10.62).[Nitta, 2013, 1568] Fukada et al found similar outcomes for conventional and compression only CPR – both were better than no CPR.[Fukuda, 2019, 22] A more recent study, published after the literature search was conducted, reported that compared with compression only CPR, conventional CPR improved survival to discharge (all patients, aOR = 1.54; 95% CI, 1.01-2.36; P = 0.046) and neurological outcomes in children (aOR = 2.68; 95% CI, 1.10-6.77; P = 0.03).[Tobin, 2020, 1]
3. Narrative Reporting of the task force discussions
The evidence base identified in this scoping review, suggests that a systematic review on this topic should be considered.
The evidence identified suggests that bystander CPR in drowning is feasible and appears effective. The apparent superiority of conventional CPR which includes ventilation, has biological plausibility as cardiac arrest caused by drowning is primarily due to hypoxia. The findings of this review are consistent with the ILCOR CoSTR which recommends that chest compressions be performed for all patients in cardiac arrest. ILCOR suggests that those who are trained, able and willing to give rescue breaths as well as chest compressions do so for all adult patients in cardiac arrest.[CoSTR 2020]. This is likely to be particularly important in patients who sustain a cardiac arrest due to hypoxia following drowning.
Current knowledge gaps include but are not limited to:
Prospective observational studies and / or randomised trials evaluating the effectiveness of compression only versus compression and ventilation for resuscitation from drowning.
Prospective observational studies and / or randomised trials evaluating ventilations first versus chest compression first strategy for resuscitation from drowning.
Studies in low resource settings were lacking.
Al-Mofadda, S. M., et al. (2001). "Pediatric near drowning: the experience of King Khalid University Hospital." Annals of Saudi Medicine 21(5-6): 300.
Al-Qurashi, F. O., et al. (2017). "A Review of Nonfatal Drowning in the Pediatric-Age Group: A 10-Year Experience at a University Hospital in Saudi Arabia." Pediatric Emergency Care 17: 17.
Ballesteros, M. A., et al. (2009). "Prognostic factors and outcome after drowning in an adult population." Acta Anaesthesiologica Scandinavica 53(7): 935.
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.
Cohen, N., et al. (2018). "Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast." Pediatric Emergency Care 05: 05.
Fukuda, T., et al. (2019). "Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning." Resuscitation 22: 22.
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.
Grmec, S., et al. (2009). "Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest." International Journal of Emergency Medicine 2(1): 7.
Hubert, H., et al. (2016). "Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry." Journal of Evaluation in Clinical Practice 22(6): 924.
Joanknecht, L., et al. (2015). "Childhood drowning in South Africa: local data should inform prevention strategies." Pediatric Surgery International 31(2): 123.
Nitta, M., et al. (2013). "Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project." Resuscitation 84(11): 1568.
Tobin, J. M., et al. (2020). "Outcome of Conventional Bystander Cardiopulmonary Resuscitation in Cardiac Arrest Following Drowning." Prehosp Disaster Med: 1.
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.
Venema, A. M., et al. (2010). "The role of bystanders during rescue and resuscitation of drowning victims." Resuscitation 81(4): 434.
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.