Immediate Resuscitation in water or delaying on land in Drowning: BLS TF SR

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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 applicable

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 applicable

CoSTR Citation

Barcala-Furelos R, Schmidt A, Webber J. Perkins G, Bierens J, Bray J on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force.

Immediate resuscitation in-water or delaying until on land strategies for drowning Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2022 September 10th. Available from:

Methodological Preamble (and Link to Published Systematic Review if applicable)

There is a gap in the scientific literature regarding the benefit of commencing immediate resuscitation on drowning patients in water before arrival on land [Bierens, 2021, 205].

The last ILCOR treatment recommendation was published in 2005: “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” [International Liaison Committee on Resuscitation, 2005, 187).

This continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of the literature (Perkins et al. 2021 PROSPERO CRD42021259983) conducted by Roberto Barcala-Furelos, Andrew Schmidt, Jonathon Webber, Joost Bierens and Gavin Perkins with involvement of clinical content experts.



Adults and children in cardiac arrest1 following drowning2


Immediate resuscitation in-water3


Delaying resuscitation until on land4


Critical 9: Survival to discharge / 30 days or later

Critical 8: Survival with favourable neurological outcome to discharge / 30 days or later

Critical 7: Return of spontaneous circulation (ROSC)

Study Design

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

Unpublished studies (e.g., conference abstracts, trial protocols), manikin studies, narrative reviews and animal studies were excluded

All years and all languages are included as long as there is an English abstract


Database inception to current time.

1A broad definition of cardiac arrest will be used, including those who are unconscious and not breathing normally or those requiring resuscitation interventions.

2 Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.

3 The definition of immediate resuscitation includes in-water resuscitation (the provision of ventilations only to a non-breathing casualty while still in the water) and on-boat resuscitation (the provision of ventilations only or ventilations and chest compressions in a boat, e.g., lifeboat, inflatable rescue boat, fishing boats etc. before returning to land).

4 The definition of land is a firm, stable surface out of the water (e.g., wharf, pontoon, beach) with sufficient space for rescuers to safely perform CPR.

PROSPERO Registration CRD42021259983

Consensus on Science

A search of Medline, Pre-Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials identified 261 references. After the de-duplication of references, 164 papers were selected. After a review of titles and abstracts, ten papers were shortlisted for full-text review. One study was identified on in-water resuscitation that addressed the PICOST question.

Szpilman and Soares (2005, 25) led a retrospective analysis of non-breathing drowning victims rescued by lifeguards in Brazil between January 1995 and December 2000. An in-water resuscitation algorithm guided trained lifeguards to commence in-water ventilation in unconscious, non-breathing patients if sufficient lifeguards/equipment was available to do this effectively. The outcomes of patients receiving in-water resuscitation compared to those who did not were compared in univariate and multivariate analyses, both of which supported the use of in-water resuscitation. Due to its observational nature, this landmark study was limited by a critical risk of bias due to confounding, serious risk of selection bias, and moderate risk of bias in the selection of the reported results.

In summary, the study showed:

For the critical outcome of survival with favourable neurological outcome, 10/19 (53%) of those receiving in-water resuscitation compared to 2/27 (7%) of those who did not receive in-water resuscitation experienced a good outcome (relative risk 7.1 [95% CI 1.8 to 28.8]). The study was assessed as providing very low certainty evidence (downgraded due to very serious risk of bias and serious risk of imprecision).

For the critical outcome of survival to hospital discharge, 16/19 (53%) of those receiving in-water resuscitation compared to 4/27 (17%) of those who did not receive in-water resuscitation experienced a good outcome (relative risk 5.7 [95% CI 2.3 to 14.3]). The study was assessed as providing very low certainty evidence (downgraded due to very serious risk of bias and serious risk of imprecision.

The critical outcome of return of spontaneous circulation (ROSC) is extrapolated from the data provided in relation to pre-hospital survival status. Those who survived to reach hospital alive were considered to have achieved ROSC. Almost all, 18/19 (95%), of those who received in-water resuscitation compared to 10/27 (37%) who did not receive in-water resuscitation achieved ROSC (relative risk 2.6 [95% CI 1.5 to 4.2]). The study was assessed as providing very low certainty evidence (downgraded due to very serious risk of bias and serious risk of imprecision.

No human studies of on-boat resuscitation were found that met the inclusion criteria.

Treatment Recommendations

  • We suggest in-water resuscitation (ventilations only) may be considered in situations where a trained rescuer determines that the rescuer safety, equipment available and distance to shore warrant its use (Weak recommendation, very low certainty evidence).
  • We suggest on-boat resuscitation (ventilations only or standard CPR) may be considered in situations where there is sufficient space for rescuers to safely perform resuscitation. (Good practice statement)
  • At any point during the rescue attempt, if the rescuer/rescuers feels that the application of immediate resuscitation is too difficult or affecting personal safety, then the rescuer(s) may opt to forgo its application. (Good practice statement)

Justification and Evidence to Decision Framework Highlights

Drowning is the third leading cause of unintentional injury-related deaths worldwide. Morbidity after initially successful resuscitation is high, with many survivors experiencing unfavourable neurological outcomes due to brain hypoxia. Developing evidence-based treatment recommendations to aid those attempting to resuscitate people following drowning is, therefore, a priority.

Hypoxaemia is the leading cause of cardiac arrest in drowning [Szpilman 2021, 1473]. Experimental and clinical data support the importance of early reversal of hypoxia as a critical intervention for improving outcomes [Szpilman 2004, 25; Szpilman 2021, 1473, Bierens 2021, 205]. The logical extension of these data is to initiate resuscitation as soon as practicable instead of delaying it. The scientific evidence shows two ways to provide immediate resuscitation; either in the water (in water-resuscitation) or just after removal from the water in a boat (on-boat resuscitation).

In-water and On-boat resuscitation

In-water resuscitation

The writing group noted that it is feasible for lifeguards to perform in-water resuscitation in both shallow and deep water [Szpilman 2004, 25; Perkins 2005, 321; Lungwitz 2015, 379; Winkler 2013, 409].

However, undertaking in-water resuscitation effectively requires training, sufficient rescuers and/or equipment to assist with flotation. The evidence supporting the intervention was assessed as very low certainty, with a critical risk from confounding, which might in part explain the large treatment effect observed. Nevertheless, the evidence identified suggested the intervention to be beneficial for all the critical outcomes.

The writing group highlighted that there is also a risk in situations such as adverse weather conditions, lack of equipment, insufficient numbers of rescuers or those without adequate training that in-water resuscitation may lead to:

  • Unintentional submersion of the patient, leading to further aspiration of water [Winkler 2013, 409; Lungwitz 2015, 379; Winkler 2013, 1137]
  • A delay in getting the patient to land thus delaying other resuscitation interventions such as chest compressions, defibrillation, and advanced life support [Perkins 2005, 321; Winkler 2013, 409; Lungwitz 2015, 379; Winkler 2013, 1137]
  • The person or people performing the rescue may become fatigued, placing themselves at risk [Lungwitz 2015, 379; Winkler 2013, 409].

The treatment recommendation in support of in-water resuscitation is conditional and highlights that if at any point during the rescue attempt the rescuer feels that the application of the technique is too difficult or is affecting personal safety, then the rescuer should prioritize retrieving the patient to land. Chest compressions are ineffective in water and should never be attempted.

On-boat resuscitation

Although no clinical data have been reported to support the recommendation for resuscitation on a boat, the ILCOR scoping review on resuscitation from drowning demonstrated that it was feasible for trained rescuers to initiate resuscitation on boats in motion [Bierens 2021, 205; Seesink 2019, 104; Fungueiriño-Suárez 2018, 1; Tipton 2007, 332; Venema 2021, 1; Barcala-Furelos 2017, 370; Barcala-Furelos 2021, 163]. It seems reasonable, therefore, to consider resuscitation on boats when environmental conditions and the experience of the rescuers allow it.

Knowledge Gaps

More studies are needed to determine the effect of in-water and on-boat resuscitation before returning to land on survival and favourable neurological outcomes. This variable should be included in drowning incident analysis models.

There is no ETD table as no evidence was identified.


Barcala-Furelos, R., Abelairas-Gómez, C., Alonso-Calvete, A., Cano-Noguera, F., Carballo-Fazanes, A., Martínez-Isasi, S., & Rodríguez-Núñez, A. Safe On-Boat Resuscitation by Lifeguards in COVID-19 Era: A Pilot Study Comparing Three Sets of Personal Protective Equipment. Prehospital and Disaster Medicine. 2021;36: 163–169.

Barcala-Furelos, R., Abelairas-Gomez, C., Palacios-Aguilar, J., Rey, E., Costas-Veiga, J., Lopez-Garcia, S., & Rodriguez-Nunez, A. Can surf-lifeguards perform a quality cardiopulmonary resuscitation sailing on a lifeboat? A quasi-experimental study. Emergency Medicine Journal: EMJ. 2017;34:370–375.

Bierens, J., Abelairas-Gomez, C., Barcala Furelos, R., Beerman, S., Claesson, A., Dunne, C., Elsenga, H. E., Morgan, P., Mecrow, T., Pereira, J. C., Scapigliati, A., Seesink, J., Schmidt, A., Sempsrott, J., Szpilman, D., Warner, D. S., Webber, J., Johnson, S., Olasveengen, T., … Perkins, G. D. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021;162: 205–217.

Fungueiriño-Suárez, R., Barcala-Furelos, R., González-Fermoso, M., Martínez-Isasi, S., Fernández-Méndez, F., González-Salvado, V., Navarro-Patón, R., & Rodríguez-Núñez, A. Coastal Fishermen as Lifesavers While Sailing at High Speed: A Crossover Study. BioMed Research International. 2018:2747046.

International Liaison Committee on Resuscitation. Part 2: Adult basic life support. Resuscitation. 2005 67: 187–201.

Perkins, G. D. In-water resuscitation: A pilot evaluation. Resuscitation. 2005;65:321–324.

Seesink, J., Nieuwenburg, S. A. V., van der Linden, T., & Bierens, J. J. L. M. Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews. Resuscitation. 2019;142: 104–110.

Szpilman, D., & Morgan, P. J. Management for the Drowning Patient. Chest. 2021;159:1473–1483.

Szpilman, D., & Soares, M. (2004). In-water resuscitation—Is it worthwhile? Resuscitation, 63(1), 25–31.

Tipton, M., David, G., Eglin, C., & Golden, F. (2007). Basic life support on small boats at sea. Resuscitation, 75(2), 332–337.

Venema, A. M., Sahinovic, M. M., Ramaker, A. J. D. W. R., van de Riet, Y. N., Absalom, A. R., & Wietasch, J. K. G. (2021). Performance of Basic Life Support by Lifeboat Crewmembers While Wearing a Survival Suit and Life Vest: A Randomized Controlled Trial. Frontiers in Public Health, 9, 666553.

Winkler, B. E., Eff, A. M., Ehrmann, U., Eff, S., Koch, A., Kaehler, W., Georgieff, M., & Muth, C.-M. (2013). Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: A crossover manikin study. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 17(3), 409–415.

Winkler, B. E., Eff, A. M., Eff, S., Ehrmann, U., Koch, A., Kähler, W., & Muth, C.-M. (2013). Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation—A randomized cross-over trial. Resuscitation, 84(8), 1137–1142.


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