In Water Resuscitation in Drowning (BLS #856): Scoping Review

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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).

In-water resuscitation 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:

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.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: In adults and children who are submerged in water

Intervention: Commencing resuscitation whilst the persons is still in the water

Comparators: Delaying resuscitation until rescued from the water.

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


Inclusion and Exclusion criteria

Inclusion criteria:

  • Adult and paediatric patients
  • Submersion in water (drowning, near drowning)
  • Describe initiating resuscitation in the water
  • 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] Submersion in water leads to the rapid onset of hypoxia. Left untreated cardiac arrest occurs within minutes. Early initiation of resuscitation is likely to lead to the best outcomes. The 2005 ILCOR Consensus on Science and Treatment Recommendations advocated that in-water expired-air resuscitation may be considered by trained rescuers, preferably with a flotation device, but chest compressions should not be attempted in the water.[2005, 187] 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, eight studies were identified for full text review. Of these, five studies evaluated in-water resuscitation. A single retrospective observational study reported the outcomes of adults and children who were rescued unconscious and not-breathing from the ocean in Brazil.[Szpilman, 2004, 25] The other four studies were manikin studies conducted in swimming pools [Perkins, 2005, 321; Winkler, 2013, 409] and open water.[Winkler, 2013, 1137; Lungwitz, 2015, 379]

The clinical study reported survival status and neurological outcome of 19 patients who received in-water resuscitation compared with 27 patients who did not.[Szpilman, 2004, 25] The in-water resuscitation protocol recommended performing up to 1 min of ventilations before attempting to bring the unconscious and not-breathing patient to the shore. For patients in deep water, in-water resuscitation required the availability of rescue flotation equipment or at least 2 rescuers. In the prehospital setting initial survival was significantly higher in the in-water resuscitation group (94.7% vs 37.0%, P<0.001). The rate of survival at hospital discharge was higher in the in-water resuscitation group (87.5% vs 25%, P<0.005) as was favourable neurological outcome (52.6% vs 7.4%, P<0.001).[Szpilman, 2004, 25]

All other studies were crossover trials which evaluated the capacity of lifeguards[Perkins, 2005, 321; Winkler, 2013, 1137; Winkler, 2013, 409; Lungwitz, 2015, 379] and laypeople[Winkler, 2013, 409] to perform in-water resuscitation while simulating a manikin water rescue. In-water resuscitation was technically difficult and physically demanding, particularly in open water. Some trained lifeguards [Lungwitz, 2015, 379] and laypeople[Winkler, 2013, 409] were unable to complete the rescue. In-water resuscitation increased rescue time and the number of submersions and aspiration of water by the manikin.[Winkler, 2013, 1137; Winkler, 2013, 409; Lungwitz, 2015, 379] The use of ventilation adjuncts by well-trained lifeguards might facilitate in-water resuscitation.[Winkler, 2013, 1137; Lungwitz, 2015, 379]

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..

From the available evidence, in suitable water conditions, in-water resuscitation by highly trained rescue teams with water rescue equipment seems feasible.

Knowledge Gaps

Current knowledge gaps include but are not limited to:

Prospective observational studies reporting clinical outcomes of different in-water resuscitation strategies.

Feasibility and effectiveness of in-water resuscitation in shallow water.

Optimal configuration of rescue teams and use of rescue aids.

Studies in low resource settings were lacking.


(2005). "2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 2: Adult basic life support." Resuscitation 67(2-3): 187.

Lungwitz, Y. P., et al. (2015). "A novel rescue-tube device for in-water resuscitation." Aerospace Medicine & Human Performance 86(4): 379.

Perkins, G. D. (2005). "In-water resuscitation: a pilot evaluation." Resuscitation 65(3): 321.

Szpilman, D. and M. Soares (2004). "In-water resuscitation--is it worthwhile?" Resuscitation 63(1): 25.

Winkler, B. E., et al. (2013). "Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation--a randomized cross-over trial." Resuscitation 84(8): 1137.

Winkler, B. E., et al. (2013). "Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study." Prehospital Emergency Care 17(3): 409.

World Health Organization (2020) Drowning.


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