Implementation of PAD programs for drowning: BLS

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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

Lagina AT, Claesson A, Bierens J, Olasveengen T, Bray J, Morley PT, Perkins GD on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force.

Public access to defibrillation following drowning Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, <<INSERT DATE>>. Available from:

Methodological Preamble and Link to Published Systematic Review

Unlike most adult cardiac arrests that arise primarily due to a cardiac cause, drowning leading to cardiac arrest is primarily caused by hypoxia. Therefore, whether a different approach to the provision of public access defibrillation is required in the specific circumstances associated with drowning is uncertain.

This review was initiated following a request from the ILCOR BLS Task Force as part of a series of reviews relating to drowning.

The continuous evidence evaluation process for this Consensus on Science with Treatment Recommendations (CoSTR) started with a scoping review of the literature [Bierens 2021 205]. After completing the scoping review, the decision was to progress to a systematic review. The systematic review was registered with PROSPERO CRD42021259983. The PICO question was developed by drowning experts and approved by the ILCOR BLS Task Force. The search strategy was created and run by Samantha Johnson. The search strategy results were reviewed, and the development of this CoSTR was conducted by Anthony Lagina and Andreas Claesson in collaboration with Joost Bierens and Gavin Perkins. Finally, the CoSTR was reviewed and agreed upon by Basic Life Support and Paediatric Task Forces.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published


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

Population: Adults and children in cardiac arrest following drowning

Intervention: Public Access to Defibrillation Programme

Comparators: Absence of PAD programme

Outcomes: Survival to hospital discharge/30 days with good neurological outcome, Survival to hospital discharge/30 days, eeturn of spontaneous circulation (ROSC) were ranked as critical outcomes.

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.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to September 2021.

PROSPERO Registration CRD42021259983

Consensus on Science

Medline, PreMedline, Embase, and Cochrane libraries CDSR were searched during September 2021, resulting in 195 publications available for review. Outputs from the search were loaded into Rayyan software. An initial screen of titles and abstracts identified 26 papers retrieved for full-text review.

Following the review of full texts, no studies were identified that directly addressed the research question.

Treatment Recommendations

ILCOR already recommends implementing PAD programs for all patients with OHCA (strong recommendation, low-certainty evidence) (Olasveengen 2020, S41).

We suggest PAD programs are considered in aquatic environments where there is a high risk of cardiac arrest (e.g. areas with high population density, frequent utilization, other forms of exercise, long distances or response times to nearest AED) (Good Practice Statement).

Justification and Evidence to Decision Framework Highlights

Drowning is the third leading cause of unintentional injury-related deaths around the world. Furthermore, morbidity after initially successful resuscitation is high, with many survivors experiencing unfavourable neurological outcomes. Therefore, developing evidence-based treatment recommendations to aid those attempting to resuscitate people following drowning is a high priority.

While no direct evidence relating to the use of PAD programmes during resuscitation from drowning, the review group and Task Force noted:

  • Drowning often occurs in high-use public areas where AED placement can be utilized by both drowning and non-drowning victims of cardiac arrest.
  • Although only a minority of patients sustaining OHCA due to drowning present with a shockable rhythm, using an AED in such instances seems beneficial.
  • No adverse events were reported in the studies identified in this review.
  • AED use in the aquatic environment is feasible
  • Seeskink et al. reported the deployment of 67 AEDs across lifeboats within a sea-rescue organization (Royal Dutch Lifeboat Institution (KNMR)) between July 2011 and December 2017. During this period, 37 cases of resuscitation were attempted by lifeboat crews during mostly adverse water conditions(n=29). The AEDs were deployed­­ in 12 OHCA cases (8 drowning cases and 4 non-drowning cases), amongst whom one patient was shocked. Return of spontaneous circulation was achieved in a single case. There were no long-term survivors.
  • In one study from a waterpark in Germany by Trappe et al., 8 AEDs were installed alongside BLS training for 20 lifeguards to provide AED retrieval in suspected OHCA within 60 seconds all over the park. Over three years, the park had 2.05 million visitors; however, no OHCAs occurred on land or water during the study period. Setting up a PAD program in a water park seems feasible.
  • Data from an observational study from Canada by Buick et al. showed a non-significant trend that drowning OHCAs more frequently had a public access AED attached (5/95 ,5.3%) compared to OHCA due to a presumed cardiac etiology (289/13,544 ,2.1%; p= 0.054). Although limited by very few cases in the drowning cohort and lack of comparison data, bystanders seem to use PAD systems similarly for Drowning OHCA and OHCA due to a presumed cardiac etiology.
  • The current general acceptance of PAD programmes in areas of high public use to be beneficial during resuscitation and would also be beneficial for resuscitation in aquatic environments. Aquatic environments where implementation of a PAD programme is practical and could be made available. The group considered it unlikely that the addition of PAD programmes during resuscitation would have a significant adverse effect on drowning victims. Although the most common initially recorded rhythm in cardiac arrest following drowning is asystole, VT and VF are present in a small percentage of victims.
  • PAD programmes are expensive in terms of equipment and maintenance required for effective delivery. Therefore, the application of PAD in aquatic environments should be based on the availability of resources, incidence and cause of cardiac arrest, and activation and response of other AED providers.

Knowledge Gaps

There are currently no interventional studies to evaluate PAD vs. no PAD in OHCA due to drowning OHCA specifically.

It is unclear to what extent traditional PAD programs coverage extends to include the drowning population.

The cost-effectiveness of implementing PAD directed specifically toward drowning victims is yet to be explored.


Buick JE, Lin S, Rac VE, Brooks SC, Kierzek G, Morrison LJ. Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada. CJEM. 2014 Jul;16(4):314-21.

Seesink J, Nieuwenburg SAV, van der Linden T, Bierens JJLM. Circumstances, outcome and quality of cardiopulmonary resuscitation by lifeboat crews. Resuscitation. 2019 Sep;142:104-110.

Trappe HJ, Nesslinger M, Schrage OM, Wissuwa H, Becker HJ. Frühdefibrillation im LAGO-die Therme- Ergebnisse und Erfahrungen [First responder defibrillation in the LAGO-die Therme--results and experiences]. Herzschrittmacherther Elektrophysiol. 2005 Jun;16(2):103-11.

Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, Chung SP, Considine J, Couper K, Escalante R, Hatanaka T, Hung KKC, Kudenchuk P, Lim SH, Nishiyama C, Ristagno G, Semeraro F, Smith CM, Smyth MA, Vaillancourt C, Nolan JP, Hazinski MF, Morley PT; on behalf of the Adult Basic Life Support Collaborators. Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S41–S91.


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