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: None
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).
Criteria for discharge in 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 Justin Sempsrott and Andrew Schmidt 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.
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: In adults and children who are submerged in water
Intervention: criteria for discharge after submersion
Comparators: criteria for discharge after submersion
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 criteria for discharge after submersion
- 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 leads to a spectrum of presentations from no / mild symptoms through to severe hypoxia and / or cardiac arrest. Patients with milder symptoms may not require hospitalisation. Some have suggested discharge criteria which can be used to guide the decision about whether to admit or discharge from the scene and / or emergency department. 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
Five studies were identified for final data abstraction[Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cantu, 2018, 446; Cohen, 2019, 1379] all of which were retrospective observational studies, including one with both derivation and validation arms.[Shenoi, 2017, 1491] Four studies were performed in the US[Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cantu, 2018, 446] and one was performed in Israel.[Cohen, 2019, 1379] In total, 834 patients were analyzed, all of which were under the age of 18.
All studies correlated objective clinical findings to determine factors which could predict safe discharge early in the clinical phase. These factors include pulmonary examination (744 patients),[Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cohen, 2019, 1379] , room air oxygen saturation (834 patients), [Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cantu, 2018, 446; Cohen, 2019, 1379] pulse rate (673 patients), [Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619] blood pressure (673 patients), [Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619] mental status (744 patients), [Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cohen, 2019, 1379] need for airway support (535 patients),[Shenoi, 2017, 1491; Cantu, 2018, 446] and dyspnea (744 patients). [Causey, 2000, 9; Shenoi, 2017, 1491; Brennan, 2018, 1619; Cohen, 2019, 1379] Three studies evaluated specific safe discharge times, specifically 6 hours[Causey, 2000, 9; Cohen, 2019, 1379] and 8 hours, [Shenoi, 2017, 1491] with the remaining studies solely comparing discharged patients to admitted patients. Additional objective factors that were analyzed were chest radiography (341 patients)[Brennan, 2018, 1619; Cantu, 2018, 446; Cohen, 2019, 1379] and arterial blood gas results (161 patients).[Cantu, 2018, 446; Cohen, 2019, 1379]
Pooled together, these studies found that for drowning patients under the age of 18, presenting to the emergency department with normal mentation, an observation period of at least 6 hours appears to be sufficient to allow for any clinical deterioration to be revealed. Patients who remain with normal mentation, no need for supplemental oxygen, and normal age-adjusted vital signs can be considered for discharge at this time.
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.
This small body of evidence demonstrated associations between clinical and physiological factors and likelihood of hospital admission after a submersion incident. None of the studies identifies prospectively tested a clinical decision rule to identify patients who can be safely discharged. Future studies should consider creating and validating clinical decision rules.