2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

      ABSTRACT

      The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

      Keywords

      Abbreviations

      Abbreviations and Acronyms

      ACS
      acute coronary syndromes
      AED
      automated external defibrillator
      ALS
      advanced life support
      ARD
      absolute risk difference
      BLS
      basic life support
      BPD
      bronchopulmonary dysplasia
      CAG
      coronary angiography
      CED
      carbohydrate-electrolyte drink
      CoSTR
      International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
      COVID-19
      coronavirus disease 2019
      CPC
      Cerebral Performance Category
      CPR
      cardiopulmonary resuscitation
      DA-CPR
      dispatcher-assisted CPR
      ECMO
      extracorporeal membrane oxygenation
      ECPR
      extracorporeal cardiopulmonary resuscitation
      EIT
      education, implementation, and teams
      EMS
      emergency medical services
      EvUp
      evidence update
      GRADE
      Grading of Recommendations Assessment, Development, and Evaluation
      ICU
      intensive care unit
      ILCOR
      International Liaison Committee on Resuscitation
      MD
      mean difference
      NIV
      noninvasive ventilation
      NLS
      neonatal life support
      OHCA
      out-of-hospital cardiac arrest
      OR
      odds ratio
      PCI
      percutaneous coronary intervention
      PEEP
      positive end-expiratory pressure
      PICO
      population, intervention, comparator, outcome
      PPE
      personal protective equipment
      PPV
      positive-pressure ventilation
      PROSPERO
      International Prospective Register of Systematic Reviews
      RCT
      randomized controlled trial
      ROSC
      return of spontaneous circulation
      RR
      risk ratio
      ScopRev
      scoping review
      SysRev
      systematic review
      This is the fifth in a series of annual International Liaison Committee on Resuscitation (ILCOR) International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) summary publications that summarize the ILCOR task force analyses of published resuscitation evidence. This 2021 review includes 13 topics addressed with systematic reviews (SysRevs) by the 6 ILCOR task forces and an additional topic reviewed by the coronavirus disease 2019 (COVID-19) working group. Although only a SysRev can generate a full CoSTR and updated treatment recommendations, many other topics were reviewed via more streamlined approaches, detailed below.
      Draft CoSTRs for all topics evaluated with SysRevs were posted on a rolling basis from November 2020 through March 2021 on the ILCOR website
      • Guyatt G.
      • Oxman A.D.
      • Akl E.A.
      • Kunz R.
      • Vist G.
      • Brozek J.
      • Norris S.
      • Falck-Ytter Y.
      • Glasziou P.
      • DeBeer H.
      • et al.
      GRADE guidelines, 1: introduction–GRADE evidence profiles and summary of findings tables..
      and included the data reviewed and draft treatment recommendations, with comments accepted for at least 2 weeks after each posting date. The 9 draft CoSTR statements were viewed ≈11 000 times, and 154 comments were provided as feedback. These CoSTRs are now available online, adding to the existing CoSTR statements.
      This summary contains the final wording of the treatment recommendations and good practice statements as approved by the task forces and by the ILCOR member councils, but it differs in several respects from the online CoSTRs: The language used to describe the evidence in this summary is not restricted to standard Grading of Recommendations Assessment, Development, and Evaluation (GRADE) terminology, thereby making it more transparent to a wider audience; in some cases, only the high-priority outcomes are reported; the Justification and Evidence-to-Decision Framework Highlights sections are in some cases shortened but aim to provide insight into the rationale behind the treatment recommendations; and finally, the task forces have prioritized knowledge gaps requiring future research. Links to the published reviews and full online CoSTR are provided in the individual sections.
      The CoSTRs are based on task force analysis of the data using the GRADE approach.
      • Guyatt G.
      • Oxman A.D.
      • Akl E.A.
      • Kunz R.
      • Vist G.
      • Brozek J.
      • Norris S.
      • Falck-Ytter Y.
      • Glasziou P.
      • DeBeer H.
      • et al.
      GRADE guidelines, 1: introduction–GRADE evidence profiles and summary of findings tables..
      Each analysis has been detailed either in a SysRev conducted by a Knowledge Synthesis Unit or a systematic reviewer or as a task force–led SysRev, and always with input from ILCOR content experts. This GRADE approach rates the certainty of evidence supporting the intervention (predefined by the population, intervention, comparator, outcome [PICO] question) as high, moderate, low, or very low. Randomized controlled trials (RCTs) begin the analysis as high-certainty evidence, and observational studies begin as low-certainty evidence. Certainty of evidence can be downgraded for risk of bias, inconsistency, indirectness, imprecision, or publication bias; it can be upgraded for a large effect, a dose-response effect, or if any residual confounding would be thought to reduce the detected effect.
      In addition to the certainty of evidence, each statement includes the pertinent outcome data. The format for the data varies by what is available but ideally includes both risk ratio (RR) with 95% CI and risk difference with 95% CI. The risk difference is the absolute difference between the risks and is calculated by subtracting the risk in the control group from the risk in the intervention group. This absolute effect enables a more clinically useful assessment of the magnitude of the effect of an intervention and enables calculation of the number needed to treat (number needed to treat=1/risk difference). In cases when the data do not enable absolute effect estimates to be determined, alternative measures of effect such as odds ratios (ORs) are reported.
      Treatment recommendations are generated by the task forces after weighing the evidence and after task force discussion. The strength of a recommendation is determined by the task force and is not necessarily tied to the certainty of evidence. Although ILCOR generally has not produced any guidance when the evidence is insufficient to support a recommendation, in some cases good practice statements have been provided for topics thought to be of particular interest to the resuscitation community. Good practice statements are not recommendations but represent expert opinion in light of very limited data.
      ILCOR’s goal is to review at least 20% of all PICO questions each year so that the CoSTRs reflect current and emerging science. To facilitate this goal and acknowledging that many PICO topics will not have sufficient new evidence to warrant a SysRev, ILCOR implemented 2 additional levels of evidence review in 2020, which were also used for 2021. Scoping reviews (ScopRevs) are undertaken when there is a lack of clarity on the amount and type of evidence on a broader topic. ScopRevs are broad searches done in multiple databases with a rigor similar to that of a SysRev but do not include bias assessments or meta-analyses. The third and least rigorous form of evidence evaluation is the evidence update (EvUp), in which a PubMed search is carried out to screen for significant new data and assess whether there has been sufficient new science to warrant a new ScopRev or SysRev. Both ScopRevs and EvUps can inform a decision about whether a SysRev should be undertaken but are not used to generate a new or updated CoSTR because they do not include bias assessment, GRADE evaluation, or meta-analyses. In some instances, ScopRevs done for the 2021 review did generate good practice statements. In this document, the results of ScopRevs are included in a more concise form than in the online version, similar to the SysRevs. EvUps are tabulated by topic at the end of each task force section, with the associated documents provided in the appendix.
      The following topics are addressed in this CoSTR summary:

      Basic Life Support

      • Video-based dispatch system (new: SysRev)
      • Head-up cardiopulmonary resuscitation (CPR) (new: SysRev)
      • Bystander CPR in drowning (BLS 856: ScopRev)
      • In-water resuscitation in drowning (BLS 856: ScopRev)
      • Resuscitation on a boat after drowning (BLS 856: ScopRev)
      • Airway management in drowning (BLS 856: ScopRev)
      • Prehospital oxygen in drowning (BLS 856: ScopRev)
      • Automated external defibrillator (AED) use in drowning (BLS 856: ScopRev)
      • Mechanical ventilation in drowning (BLS 856: ScopRev)
      • Extracorporeal membrane oxygenator (ECMO) in drowning (BLS 856: ScopRev)
      • Criteria for discharge in drowning (BLS 856: ScopRev)
      • Paddle size and placement for defibrillation (new: EvUp)
      • CPR before call for help (BLS 1527: EvUp)
      • Barrier devices (BLS 342: EvUp)
      • Chest compression rate (BLS 343: EvUp)
      • Rhythm check timing (BLS 345: EvUp)
      • Timing of CPR cycles (2 minutes versus other) (BLS 346: EvUp)
      • Public-access AED programs (BLS 347: EvUp)
      • Check for circulation during basic life support (BLS) (BLS 348: EvUp)
      • Rescuer fatigue in chest compression–only CPR (BLS 349: EvUp)
      • Harm from CPR to victims not in arrest (BLS 353: EvUp)
      • Harm to rescuers from CPR (BLS 354: EvUp)
      • Hand position during compressions (BLS 357: EvUp)
      • Dispatcher instructions (BLS 359: EvUp)
      • Emergency medical services (EMS) chest compression–only CPR versus conventional CPR (BLS 360: EvUp)
      • Feedback for CPR quality (BLS 361: EvUp)
      • Compression-to-ventilation ratio (BLS 362: EvUp)
      • CPR before defibrillation (BLS 363: EvUp)
      • Chest compression depth (BLS 366: EvUp)
      • Chest wall recoil (BLS 367: EvUp)
      • Foreign body airway obstruction (BLS 368: EvUp)
      • Firm surface for CPR (BLS 370: EvUp)
      • Analysis of rhythm during chest compression (BLS 373: EvUp)
      • Alternative compression techniques (cough, precordial thump, fist pacing) (BLS 374: EvUp)
      • Tidal volumes and ventilation rates (BLS 546: EvUp)
      • Lay rescuer chest compression–only CPR versus standard CPR (BLS 547: EvUp)
      • Starting CPR (compression-airway-breathing compared with airway-breathing-compression) (BLS 661: EvUp)
      • Dispatcher recognition of cardiac arrest (BLS 740: EvUp)
      • Resuscitation care for suspected opioid-associated emergencies (BLS 811: EvUp)
      • Drowning (BLS 856: EvUp)
      • Dispatcher-assisted continuous chest compressions CPR versus conventional CPR (new: EvUp)

      Advanced Life Support

      • Early coronary angiography (CAG) after return of spontaneous circulation (ROSC) (ACS 340, 885: SysRev)
      • CPR and defibrillation in the prone patient (new: SysRev)
      • Consciousness during CPR (new: ScopRev)
      • Transition from shockable to nonshockable rhythm (ALS 444: EvUp)
      • Oxygen dose during CPR (ALS 889: EvUp)
      • Steroids during CPR (ALS 433: EvUp)
      • Confirmation of tracheal tube position (ALS 469: EvUp)
      • Automatic ventilators versus manual ventilation during CPR (ALS 490: EvUp)
      • Cardiac arrest and asthma (ALS 492: EvUp)
      • Extracorporeal CPR (ECPR) versus manual or mechanical CPR (ALS 723: EvUp)
      • Steroids after ROSC (ALS 446: EvUp)
      • Oxygen dose after ROSC (ALS 448: EvUp)
      • Neuroprognostication after ROSC (ALS 450, 458, 460, 484, 487, 713: EvUp)

      Pediatric Life Support

      The Pediatric Life Support Task Force did not complete any primary SysRevs before the deadline for publication of the 2021 CoSTR (although several reviews are in progress). The following SysRevs include children and were done in collaboration with the Pediatric Life Support Task Force members: duration of cooling with water for thermal burns as a first aid intervention (First Aid), pediatric tourniquets (First Aid), and CPR in the prone patient (ALS).

      Neonatal Life Support

      • Cord management at birth for preterm infants (NLS 787: SysRev)
      • Cord management at birth for term and late preterm infants (NLS 1551: SysRev)
      • Devices for administering positive-pressure ventilation (PPV) at birth (NLS 870: SysRev)
      • Family presence during neonatal resuscitation (NLS 1590: SysRev)

      Education, Implementation, and Teams

      • Self-directed, digitally based BLS education and training in adults and children (EIT 647: SysRev)
      • EMS practitioner’s experience or exposure (EIT 437: EvUp)
      • High-fidelity training (EIT 623: EvUp)
      • Cardiac arrest centers (EIT 624: EvUp)
      • Timing for retraining (EIT 628: EvUp)
      • Cognitive aids during resuscitation (EIT 629: EvUp)
      • Termination of resuscitation for in-hospital cardiac arrest (EIT 4002 EvUp)
      • Precourse preparation for advanced courses (EIT 637: EvUp)
      • System performance improvements (EIT 640: EvUp)
      • Community initiatives to promote BLS implementation (EIT 641: EvUp)
      • Prehospital termination of resuscitation rules (EIT 642: EvUp)
      • CPR feedback devices during training (EIT 648: EvUp)
      • BLS training in high-risk populations (EIT 649: EvUp)
      • Technology to engage first responders (EIT 878: EvUp)
      • Resuscitation team with advanced life support (ALS) course training (EIT 4000: EvUp)
      • Opioid overdose first aid education (EIT 4001: EvUp)
      • Facilitators and barriers to bystander CPR (EIT 4003: EvUp)
      • Virtual reality, augmented reality, and gamified learning (EIT 4005: EvUp)
      • In situ training (EIT 4007: EvUp)

      First Aid

      • Duration of cooling with water for thermal burns as a first aid intervention (FA 770: SysRev)
      • Exertion-related dehydration and rehydration (FA 584: SysRev)
      • Pediatric tourniquet types (FA 768: SysRev)
      • Methods of tick removal (new: SysRev Adolopment)
      • Use of cryotherapy for acute epistaxis in the first aid setting (new: ScopRev)
      • Pressure immobilization bandaging for venomous snakebites (FA 1001: EvUp)
      • Second dose of epinephrine for anaphylaxis (FA 500: EvUp)
      • Dietary sugars for treatment of hypoglycemia (FA 795: EvUp)

      COVID-19 Working Group

      • COVID-19 infection risk to rescuers from patients in cardiac arrest (new: SysRev)
      Readers are encouraged to monitor the ILCOR website
      • Guyatt G.
      • Oxman A.D.
      • Akl E.A.
      • Kunz R.
      • Vist G.
      • Brozek J.
      • Norris S.
      • Falck-Ytter Y.
      • Glasziou P.
      • DeBeer H.
      • et al.
      GRADE guidelines, 1: introduction–GRADE evidence profiles and summary of findings tables..
      to provide feedback on planned SysRevs and to provide comments when additional draft reviews are posted.

      Basic Life Support

       Video-Based Dispatch System (SysRev)

       Rationale for Review

      Because new communication technologies offer promising new avenues in emergency medical dispatch, the BLS Task Force considered it important to review any available evidence evaluating the use of video to enhance communication and improve lay-rescuer CPR in the out-of-hospital cardiac arrest (OHCA) setting. The SysRev was registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration CRD42020219112).
      The full text of this CoSTR can be found on the ILCOR website.

      Chung S, Avis S, Castren M, Considine J, Folke F, Hung K, Ikeyama T, Kudenchuk P, Lagina A, Malta-Hansen C, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Video-based dispatch system: BLS Task Force systematic review.Accessed March 4, 2021. https://costr.ilcor.org/document/video-based-dispatch-system-bls-tf-systematic-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children with presumed cardiac arrest in the out-of-hospital setting
      • Intervention: Patients/cases or EMS systems through which dispatcher-assisted CPR (DA-CPR) is offered by video and audio communication between dispatcher center and scene
      • Comparator: Patients/cases or EMS systems through which DA-CPR is offered by audio-only communication between dispatcher center and scene
      • Outcome: Any clinical outcome (survival with favorable neurological outcome, survival, ROSC, and CPR quality)
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion; unpublished studies (eg, conference abstracts, trial protocols) were excluded.
      • Time frame: All years and all languages were included as long as there was an English abstract. Literature search was updated to February 8, 2021.

       Consensus on Science

      Only 1 observational study was identified.
      • Lee S.Y.
      • Song K.J.
      • Shin S.D.
      • Hong K.J.
      • Kim T.H.
      Comparison of the effects of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation on resuscitation outcomes after out-of-hospital cardiac arrest..
      For the critical outcome of good neurological function at discharge, we identified very low–certainty evidence from 1 observational study enrolling 1720 adult OHCAs, which showed benefit from the use of video-based dispatch compared with standard audio-based dispatch (OR, 1.89 [95% CI, 1.18–3.04]; P<0.01). However, the benefit was not observed after multivariable statistical adjustment (OR, 1.28 [95% CI, 0.73–2.26]) or propensity score–matching analysis (OR, 0.91 [95% CI, 0.51–1.64]). Similarly, the group receiving video-based dispatch had higher rates of survival to discharge and ROSC compared with the group receiving standard audio-based dispatch in unadjusted analysis, but there were no significant differences between the groups after multivariable statistical adjustment and propensity score–matching analysis.
      • Lee S.Y.
      • Song K.J.
      • Shin S.D.
      • Hong K.J.
      • Kim T.H.
      Comparison of the effects of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation on resuscitation outcomes after out-of-hospital cardiac arrest..
      We also identified 13 manikin simulation studies that compared video-based with audio-based dispatch.
      • Atkinson P.R.
      • Bingham J.
      • McNicholl B.P.
      • Loane M.A.
      • Wootton R.
      Telemedicine and cardiopulmonary resuscitation: the value of video-link and telephone instruction to a mock bystander..
      • Bang J.Y.
      • Cho Y.
      • Cho G.C.
      • Lee J.
      • Kim IY.
      Can mobile videocall assist laypersons’ use of automated external defibrillators? A randomized simulation study and qualitative analysis..
      • Bolle S.R.
      • Scholl J.
      • Gilbert M.
      Can video mobile phones improve CPR quality when used for dispatcher assistance during simulated cardiac arrest?.
      • Dong X.
      • Zhang L.
      • Myklebust H.
      • Birkenes T.S.
      • Zheng Z.J.
      Effect of a real-time feedback smartphone application (TCPRLink) on the quality of telephone-assisted CPR performed by trained laypeople in China: a manikin-based randomised controlled study..
      • Ecker H.
      • Wingen S.
      • Hamacher S.
      • Lindacher F.
      • Bottiger B.W.
      • Wetsch W.A.
      Evaluation of CPR quality via smartphone with a video livestream: a study in a metropolitan area..
      • Hunt E.A.
      • Heine M.
      • Shilkofski N.S.
      • Bradshaw J.H.
      • Nelson-McMillan K.
      • Duval-Arnould J.
      • Elfenbein R.
      Exploration of the impact of a voice activated decision support system (VADSS) with video on resuscitation performance by lay rescuers during simulated cardiopulmonary arrest..
      • Lee J.S.
      • Jeon W.C.
      • Ahn J.H.
      • Cho Y.J.
      • Jung Y.S.
      • Kim G.W.
      The effect of a cellular-phone video demonstration to improve the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation as compared with audio coaching..
      • Márquez-Hernández V.V.
      • Gutiérrez-Puertas L.
      • Garrido-Molina J.M.
      • García-Viola A.
      • Granados-Gámez G.
      • Aguilera-Manrique G.
      Using a mobile phone application versus telephone assistance during cardiopulmonary resuscitation: a randomized comparative study..
      • Perry O.
      • Wacht O.
      • Jaffe E.
      • Sinuany-Stern Z.
      • Bitan Y.
      Using a filming protocol to improve video-instructed cardiopulmonary resuscitation..
      • Plata C.
      • Stolz M.
      • Warnecke T.
      • Steinhauser S.
      • Hinkelbein J.
      • Wetsch W.A.
      • Böttiger B.W.
      • Spelten O.
      Using a smartphone application (PocketCPR) to determine CPR quality in a bystander CPR scenario: a manikin trial..
      • Stipulante S.
      • Delfosse A.S.
      • Donneau A.F.
      • Hartsein G.
      • Haus S.
      • D’Orio V.
      • Ghuysen A.
      Interactive videoconferencing versus audio telephone calls for dispatcher-assisted cardiopulmonary resuscitation using the ALERT algorithm: a randomized trial..
      • Yang C.W.
      • Wang H.C.
      • Chiang W.C.
      • Chang W.T.
      • Yen Z.S.
      • Chen S.Y.
      • Ko P.C.
      • Ma M.H.
      • Chen S.C.
      • Chang S.C.
      • et al.
      Impact of adding video communication to dispatch instructions on the quality of rescue breathing in simulated cardiac arrests: a randomized controlled study..
      • Yang C.W.
      • Wang H.C.
      • Chiang W.C.
      • Hsu C.W.
      • Chang W.T.
      • Yen Z.S.
      • Ko P.C.
      • Ma M.H.
      • Chen S.C.
      • Chang S.C.
      Interactive video instruction improves the quality of dispatcher-assisted chest compression-only cardiopulmonary resuscitation in simulated cardiac arrests..
      The simulation studies showed improved CPR quality parameters such as compression rate and time to compression in the video-based dispatch group but did not show any significant differences in chest compression depth, correct compression depth, correct hand position, correct chest release, or time to defibrillation.

       Treatment Recommendations

      We suggest that the usefulness of video-based dispatch systems be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence).

       Justification and Evidence-to-Decision Framework Highlights

      The evidence-to-decision table is included in Supplemental Appendix A1.
      Only a single human observational study was identified, so the evidence informing the guideline is very uncertain. Despite limited evidence, the BLS Task Force considered it important to encourage research in this important area and therefore provided a conditional recommendation for video-based dispatch systems to be assessed in clinical trials or research initiatives.
      Several manikin simulation studies were identified comparing video-based with audio-based dispatch. Lin et al
      • Lin Y.Y.
      • Chiang W.C.
      • Hsieh M.J.
      • Sun J.T.
      • Chang Y.C.
      • Ma M.H.
      Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopulmonary resuscitation: a systematic review and meta-analysis..
      published a SysRev of simulation studies comparing the effect of video-based dispatch with the effect of audio-based dispatch on quality of DA-CPR. The review included 6 simulation studies that showed that video-based DA-CPR significantly improved the chest compression rate compared with audio-based dispatch, and a trend toward more correct hand position was also observed. However, video-based dispatch was associated with a delay in the start of bystander-initiated CPR.
      • Lin Y.Y.
      • Chiang W.C.
      • Hsieh M.J.
      • Sun J.T.
      • Chang Y.C.
      • Ma M.H.
      Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopulmonary resuscitation: a systematic review and meta-analysis..
      Although not directly informing clinical practice, these simulation studies provide important information about the aspects that need to be addressed and evaluated in future clinical studies evaluating video-based dispatch.

       Task Force Knowledge Gaps

      • RCT evidence comparing video-based dispatch with audio-based dispatch in any patient population
      • Further observational evidence evaluating the use of video communication in emergency medical dispatch
      • Whether 2 rescuers are needed to effectively process video-based DA-CPR: 1 to provide chest compressions and 1 to handle the mobile phone and assist with communication. This might lead to varying feasibility of implementing video-based dispatcher CPR according to location of arrest (crowded public place versus at home) and other variables.

       Head-Up CPR (SysRev)

       Rationale for Review

      This topic was prioritized by the BLS Task Force because of increasing interest and debate surrounding head-up CPR within the resuscitation community. Head-up CPR has been suggested as an alternative CPR method, potentially improving cerebral perfusion by facilitating venous return from the brain. The BLS Task Force was aware of the growing body of animal research addressing head-up CPR
      • Debaty G.
      • Shin S.D.
      • Metzger A.
      • Kim T.
      • Ryu H.H.
      • Rees J.
      • McKnite S.
      • Matsuura T.
      • Lick M.
      • Yannopoulos D.
      • et al.
      Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest..
      • Ryu H.H.
      • Moore J.C.
      • Yannopoulos D.
      • Lick M.
      • McKnite S.
      • Shin S.D.
      • Kim T.Y.
      • Metzger A.
      • Rees J.
      • Tsangaris A.
      • et al.
      The effect of head up cardiopulmonary resuscitation on cerebral and systemic hemodynamics..
      • Kim T.
      • Shin S.D.
      • Song K.J.
      • Park Y.J.
      • Ryu H.H.
      • Debaty G.
      • Lurie K.
      • Hong K.J.
      The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model..
      • Moore J.C.
      • Salverda B.
      • Rojas-Salvador C.
      • Lick M.
      • Debaty G.
      • Lurie K.G.
      Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest..
      • Rojas-Salvador C.
      • Moore J.C.
      • Salverda B.
      • Lick M.
      • Debaty G.
      • Lurie K.G.
      Effect of controlled sequential elevation timing of the head and thorax during cardiopulmonary resuscitation on cerebral perfusion pressures in a porcine model of cardiac arrest..
      • Park Y.J.
      • Hong K.J.
      • Shin S.D.
      • Kim T.Y.
      • Ro Y.S.
      • Song K.J.
      • Ryu H.H.
      Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model..
      and that this strategy is currently being used in some EMS systems. The evidence review was performed in collaboration with the ALS Task Force. Because there was no intent to publish this SysRev outside of the 2021 CoSTR, PROSPERO registration was not done.
      The full text of this CoSTR can be found on the ILCOR website.

      Wigginton J, Olasveengen TM, O’Neil B, Berg K, Kudenchuck P, Ristagno G, Morley PT; International Liaison Committee on Resuscitation Basic and Advanced Life Support Task Forces. Head-up CPR: BLS systematic review.Accessed March 4, 2021. https://costr.ilcor.org/document/head-up-cpr-bls-systematic-revies

       PICO, Study Design, and Time Frame

      • Population: Adults in any setting (in hospital or out of hospital) with cardiac arrest
      • Intervention: Head-up CPR
      • Comparator: Standard or compression-only CPR in the supine position
      • Outcome: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. ROSC was ranked as an important outcome.
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.
      • Time frame: All years and all languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols) were excluded. Literature search was updated to January 22, 2021.

       Consensus on Science

      Only 1 observational study was identified.
      • Pepe P.E.
      • Scheppke K.A.
      • Antevy P.M.
      • Crowe R.P.
      • Millstone D.
      • Coyle C.
      • Prusansky C.
      • Garay S.
      • Ellis R.
      • Fowler R.L.
      • et al.
      Confirming the clinical safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation involving a head-up/torso-up chest compression technique..
      For the important outcome of survival to hospital admission, we identified very low–certainty evidence from 1 observational (before-and-after) study enrolling 1835 adult OHCAs; the study showed an increased rate of ROSC at hospital arrival in patients receiving −20° head-up CPR compared with standard care (RR, 1.90 [95% CI, 1.61–2.26]; P<0.001; absolute risk reduction, 16.1% [95% CI, 20.0%–12.2%], or 161 [95% CI, 109–225] more patients per 1000 survived with the intervention more). Notably, both head-up CPR and standard resuscitation in this study were bundled with mechanical CPR and the use of an impedance threshold device. Head-up CPR, but not standard care, was also accompanied by deferred PPV for several minutes and the deployment of a pit-crew approach for more efficient placement of the mechanical CPR device. No studies were identified that compared head-up CPR alone with standard care.
      This technique has also been evaluated in animal laboratory studies (also in concert with mechanical CPR and an impedance threshold device) with mixed outcomes, but those studies were not included in this review, which focused on clinical data.
      • Debaty G.
      • Shin S.D.
      • Metzger A.
      • Kim T.
      • Ryu H.H.
      • Rees J.
      • McKnite S.
      • Matsuura T.
      • Lick M.
      • Yannopoulos D.
      • et al.
      Tilting for perfusion: head-up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest..
      • Ryu H.H.
      • Moore J.C.
      • Yannopoulos D.
      • Lick M.
      • McKnite S.
      • Shin S.D.
      • Kim T.Y.
      • Metzger A.
      • Rees J.
      • Tsangaris A.
      • et al.
      The effect of head up cardiopulmonary resuscitation on cerebral and systemic hemodynamics..
      • Kim T.
      • Shin S.D.
      • Song K.J.
      • Park Y.J.
      • Ryu H.H.
      • Debaty G.
      • Lurie K.
      • Hong K.J.
      The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model..
      • Moore J.C.
      • Salverda B.
      • Rojas-Salvador C.
      • Lick M.
      • Debaty G.
      • Lurie K.G.
      Controlled sequential elevation of the head and thorax combined with active compression decompression cardiopulmonary resuscitation and an impedance threshold device improves neurological survival in a porcine model of cardiac arrest..
      • Rojas-Salvador C.
      • Moore J.C.
      • Salverda B.
      • Lick M.
      • Debaty G.
      • Lurie K.G.
      Effect of controlled sequential elevation timing of the head and thorax during cardiopulmonary resuscitation on cerebral perfusion pressures in a porcine model of cardiac arrest..
      • Park Y.J.
      • Hong K.J.
      • Shin S.D.
      • Kim T.Y.
      • Ro Y.S.
      • Song K.J.
      • Ryu H.H.
      Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model..

       Treatment Recommendations

      We suggest against the routine use of head-up CPR during CPR (weak recommendation, very low–certainty evidence).
      We suggest that the usefulness of head-up CPR during CPR be assessed in clinical trials or research initiatives (weak recommendation, very low–certainty evidence).

       Justification and Evidence-to-Decision Framework Highlights

      The evidence-to-decision table is included in Supplemental Appendix A1.
      The limited observational evidence identified in this review suggests that head-up CPR might have the potential to improve short-term outcome from cardiac arrest, but the certainty of evidence is very low with very high risk of bias. Head-up CPR was assessed only as a bundle with mechanical CPR with active decompression and the use of an impedance threshold device, making the generalizability of the results to other systems questionable. With a before-and-after design, the study findings may have been influenced by unrelated and unreported changes in practice over time—in particular, a change in ventilation strategy and potentially more efficient deployment of the mechanical CPR that accompanied the intervention. Outcome measures were also limited to ROSC at the time of hospital arrival, without any information on longer-term survival or functional outcomes.
      Implementation of the head-up CPR bundle requires purchase of equipment (mechanical CPR and the impedance threshold device), along with education and training in the use of this equipment and the technique for deploying head-up CPR. Without a demonstrable improvement in longer-term outcomes, it is unlikely to be an acceptable strategy for key stakeholders. The BLS Task Force does not find the current evidence sufficient to recommend routine use of this strategy and encourages further research before its clinical deployment.

       Task Force Knowledge Gaps

      • Comparisons of head-up CPR alone with standard care
      • RCT evidence evaluating the effect of head-up CPR either alone or as part of a bundle of care
      • The effect of head-up CPR on longer-term outcomes such as survival and neurologically intact survival to hospital discharge or 30 days

       Bystander CPR in Drowning (BLS 856: ScopRev)

       Rationale for Review

      Drowning is the third leading cause of unintentional injury death worldwide, accounting for >360 000 deaths annually. Submersion in water leads to the rapid onset of hypoxemia. If someone who has drowned is left untreated, cardiac arrest occurs within minutes. The initiation of CPR by a bystander allows treatment to be delivered before EMS arrives, but its effects on outcomes after drowning are uncertain. The BLS Task Force, in collaboration with several experts on drowning, considered it timely to undertake a ScopRev of the literature to identify any new evidence on multiple BLS topics in the context of drowning.
      • Bierens J.
      • Abelairas-Gomez C.
      • Barcala Furelos R.
      • Beerman S.
      • Claesson A.
      • Dunne C.
      • Elsenga H.E.
      • Morgan P.
      • Mecrow T.
      • Pereira J.C.
      • et al.
      Resuscitation and emergency care in drowning: a scoping review..
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Bystander CPR in drowning (BLS #856): scoping review. Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-bystander-cpr-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Bystander CPR
      • Comparator: No bystander CPR
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization)
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Eighteen studies were identified that discussed bystander CPR as an intervention for 16 303 adults and children after drowning.
      • Al-Mofadda S.M.
      • Nassar A.
      • Al-Turki A.
      • Al-Sallounm A.A.
      Pediatric near drowning: the experience of King Khalid University Hospital..
      • Claesson A.
      • Svensson L.
      • Silfverstolpe J.
      • Herlitz J.
      Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning..
      • Ballesteros M.A.
      • Gutiérrez-Cuadra M.
      • Muñoz P.
      • Miñambres E.
      Prognostic factors and outcome after drowning in an adult population..
      • Grmec S.
      • Strnad M.
      • Podgorsek D.
      Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest..
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      • Venema A.M.
      • Groothoff J.W.
      • Bierens J.J.
      The role of bystanders during rescue and resuscitation of drowning victims..
      • Claesson A.
      • Lindqvist J.
      • Ortenwall P.
      • Herlitz J.
      Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services 1996-2010..
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      • Buick J.E.
      • Lin S.
      • Rac V.E.
      • Brooks S.C.
      • Kierzek G.
      • Morrison L.J.
      Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada..
      • Claesson A.
      • Lindqvist J.
      • Herlitz J.
      Cardiac arrest due to drowning: changes over time and factors of importance for survival..
      • Vähätalo R.
      • Lunetta P.
      • Olkkola K.T.
      • Suominen P.K.
      Drowning in children: Utstein style reporting and outcome..
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      • Al-Qurashi F.O.
      • Yousef A.A.
      • Aljoudi A.
      • Alzahrani S.M.
      • Al-Jawder N.Y.
      • Al-Ahmar A.K.
      • Al-Majed M.S.
      • Abouollo H.M.
      A review of nonfatal drowning in the pediatric-age group: a 10-year experience at a university hospital in Saudi Arabia..
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      • Cohen N.
      • Scolnik D.
      • Rimon A.
      • Balla U.
      • Glatstein M.
      Childhood drowning: review of patients presenting to the emergency departments of 2 large tertiary care pediatric hospitals near and distant from the sea coast..
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kondo Y.
      • Kukita I.
      Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning..

      Deleted in proof

      There were 2 prospective observational studies,
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      ,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      9 retrospective observational studies,
      • Claesson A.
      • Svensson L.
      • Silfverstolpe J.
      • Herlitz J.
      Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning..
      • Ballesteros M.A.
      • Gutiérrez-Cuadra M.
      • Muñoz P.
      • Miñambres E.
      Prognostic factors and outcome after drowning in an adult population..
      • Grmec S.
      • Strnad M.
      • Podgorsek D.
      Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest..
      ,
      • Buick J.E.
      • Lin S.
      • Rac V.E.
      • Brooks S.C.
      • Kierzek G.
      • Morrison L.J.
      Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada..
      ,
      • Claesson A.
      • Lindqvist J.
      • Herlitz J.
      Cardiac arrest due to drowning: changes over time and factors of importance for survival..
      ,
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      • Cohen N.
      • Scolnik D.
      • Rimon A.
      • Balla U.
      • Glatstein M.
      Childhood drowning: review of patients presenting to the emergency departments of 2 large tertiary care pediatric hospitals near and distant from the sea coast..
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kondo Y.
      • Kukita I.
      Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning..
      and 7 retrospective case reviews.
      • Al-Mofadda S.M.
      • Nassar A.
      • Al-Turki A.
      • Al-Sallounm A.A.
      Pediatric near drowning: the experience of King Khalid University Hospital..
      ,
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      • Venema A.M.
      • Groothoff J.W.
      • Bierens J.J.
      The role of bystanders during rescue and resuscitation of drowning victims..
      • Claesson A.
      • Lindqvist J.
      • Ortenwall P.
      • Herlitz J.
      Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services 1996-2010..
      ,
      • Vähätalo R.
      • Lunetta P.
      • Olkkola K.T.
      • Suominen P.K.
      Drowning in children: Utstein style reporting and outcome..
      ,
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      ,
      • Al-Qurashi F.O.
      • Yousef A.A.
      • Aljoudi A.
      • Alzahrani S.M.
      • Al-Jawder N.Y.
      • Al-Ahmar A.K.
      • Al-Majed M.S.
      • Abouollo H.M.
      A review of nonfatal drowning in the pediatric-age group: a 10-year experience at a university hospital in Saudi Arabia..
      All studies reported survival status after OHCA caused by drowning, and 13 reported neurological outcomes.
      • Al-Mofadda S.M.
      • Nassar A.
      • Al-Turki A.
      • Al-Sallounm A.A.
      Pediatric near drowning: the experience of King Khalid University Hospital..
      ,
      • Ballesteros M.A.
      • Gutiérrez-Cuadra M.
      • Muñoz P.
      • Miñambres E.
      Prognostic factors and outcome after drowning in an adult population..
      • Grmec S.
      • Strnad M.
      • Podgorsek D.
      Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest..
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      ,
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      ,
      • Vähätalo R.
      • Lunetta P.
      • Olkkola K.T.
      • Suominen P.K.
      Drowning in children: Utstein style reporting and outcome..
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      • Al-Qurashi F.O.
      • Yousef A.A.
      • Aljoudi A.
      • Alzahrani S.M.
      • Al-Jawder N.Y.
      • Al-Ahmar A.K.
      • Al-Majed M.S.
      • Abouollo H.M.
      A review of nonfatal drowning in the pediatric-age group: a 10-year experience at a university hospital in Saudi Arabia..
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      • Cohen N.
      • Scolnik D.
      • Rimon A.
      • Balla U.
      • Glatstein M.
      Childhood drowning: review of patients presenting to the emergency departments of 2 large tertiary care pediatric hospitals near and distant from the sea coast..
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      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 J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      ,
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      One study documented improved neurologically favorable survival (RR, 2.19; P=0.0076), 1-month survival (RR, 1.55; P=0.0150), and prehospital ROSC (RR, 1.30; P=0.0296).
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      The second study also documented an association between bystander CPR and neurologically favorable survival (adjusted OR, 3.02; P<0.001).
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      Four other studies found significant associations with bystander CPR and survival.
      • Grmec S.
      • Strnad M.
      • Podgorsek D.
      Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest..
      ,
      • Claesson A.
      • Lindqvist J.
      • Herlitz J.
      Cardiac arrest due to drowning: changes over time and factors of importance for survival..
      ,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      ,
      • Cohen N.
      • Scolnik D.
      • Rimon A.
      • Balla U.
      • Glatstein M.
      Childhood drowning: review of patients presenting to the emergency departments of 2 large tertiary care pediatric hospitals near and distant from the sea coast..
      Five studies found a positive trend toward survival,
      • Al-Mofadda S.M.
      • Nassar A.
      • Al-Turki A.
      • Al-Sallounm A.A.
      Pediatric near drowning: the experience of King Khalid University Hospital..
      ,
      • Venema A.M.
      • Groothoff J.W.
      • Bierens J.J.
      The role of bystanders during rescue and resuscitation of drowning victims..
      ,
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      ,
      • Vähätalo R.
      • Lunetta P.
      • Olkkola K.T.
      • Suominen P.K.
      Drowning in children: Utstein style reporting and outcome..
      ,
      • Al-Qurashi F.O.
      • Yousef A.A.
      • Aljoudi A.
      • Alzahrani S.M.
      • Al-Jawder N.Y.
      • Al-Ahmar A.K.
      • Al-Majed M.S.
      • Abouollo H.M.
      A review of nonfatal drowning in the pediatric-age group: a 10-year experience at a university hospital in Saudi Arabia..
      and 3 found no association between bystander CPR and good outcomes.
      • Al-Mofadda S.M.
      • Nassar A.
      • Al-Turki A.
      • Al-Sallounm A.A.
      Pediatric near drowning: the experience of King Khalid University Hospital..
      ,
      • Claesson A.
      • Svensson L.
      • Silfverstolpe J.
      • Herlitz J.
      Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning..
      ,
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      ,
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      One of those studies did find a significant association between survival and the time from witnessing arrest to BLS initiation (P<0.001).
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      Several studies compared the effect on survival of conventional CPR by bystanders with the effect on survival of compression-only CPR by bystanders.
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      ,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      ,
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kondo Y.
      • Kukita I.
      Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning..
      One study documented a highly positive association with bystander ventilation and survival (OR, 6.742; P=0.002),
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      and another documented a trend favoring conventional CPR for both survival (adjusted OR, 1.87 [95% CI, 0.83–4.20]) and neurologically favorable outcome (adjusted OR, 2.35 [95% CI, 0.52–10.62]).
      • Nitta M.
      • Kitamura T.
      • Iwami T.
      • Nadkarni V.M.
      • Berg R.A.
      • Topjian A.A.
      • Okamoto Y.
      • Nishiyama C.
      • Nishiuchi T.
      • Hayashi Y.
      • et al.
      Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project..
      Another study documented similar outcomes for conventional CPR and compression-only CPR: Both were better than no CPR.
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kondo Y.
      • Kukita I.
      Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning..
      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, adjusted OR, 1.54 [95% CI, 1.01–2.36]; P=0.046) and neurological outcomes in children (adjusted OR, 2.68 [95% CI, 1.10–6.77]; P=0.03).
      • Tobin J.M.
      • Ramos W.D.
      • Greenshields J.
      • Dickinson S.
      • Rossano J.W.
      • Wernicki P.G.
      • Markenson D.
      • Vellano K.
      • McNally B.
      • CARES Surveillance Group
      Outcome of conventional bystander cardiopulmonary resuscitation in cardiac arrest following drowning..

       Task Force Insights

      The evidence identified suggests that bystander CPR for drowning is feasible and appears effective. The apparent superiority of conventional CPR, which includes ventilation, has biological plausibility because cardiac arrest attributable to drowning is caused primarily by hypoxemia. The findings of this review are consistent with the 2020 ILCOR recommendation that chest compressions be performed for all patients in cardiac arrest.
      • Olasveengen T.M.
      • Mancini M.E.
      • Perkins G.D.
      • Avis S.
      • Brooks S.
      • Castrén M.
      • Chung S.P.
      • Considine J.
      • Couper K.
      • Escalante R.
      • Adult Basic Life Support Collaborators
      • et al.
      Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..
      ILCOR suggests that those who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest.
      • Olasveengen T.M.
      • Mancini M.E.
      • Perkins G.D.
      • Avis S.
      • Brooks S.
      • Castrén M.
      • Chung S.P.
      • Considine J.
      • Couper K.
      • Escalante R.
      • Adult Basic Life Support Collaborators
      • et al.
      Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..
      Rescue breaths are likely to be particularly important in patients who sustain a cardiac arrest attributable to hypoxemia after drowning. The evidence base identified in this ScopRev suggests that a SysRev on this topic should be considered.

       Treatment Recommendations

      There was no previous treatment recommendation on bystander CPR in drowning, and a SysRev will be pursued by the BLS Task Force.
      In the meantime, we highlight our 2020 recommendation and suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest (weak recommendation, very low–certainty evidence).

       In-Water Resuscitation in Drowning (BLS 856: ScopRev)

       Rationale for Review

      The 2005 ILCOR treatment recommendation stated 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 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, part 2: adult basic life support..
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. In water resuscitation in drowning (BLS #856): scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-in-water-resuscitation-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Starting resuscitation while the person is still in the water
      • Comparator: Delaying resuscitation until the person is rescued from the water
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), CPR quality, physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Five studies evaluating in-water resuscitation were identified. 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 D.
      • Soares M.
      In-water resuscitation: is it worthwhile?.
      The other 4 studies were manikin studies conducted in swimming pools
      • Perkins G.D.
      In-water resuscitation: a pilot evaluation..
      ,
      • Winkler B.E.
      • Eff A.M.
      • Ehrmann U.
      • Eff S.
      • Koch A.
      • Kaehler W.
      • Georgieff M.
      • Muth C.M.
      Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study..
      and open water.
      • Lungwitz Y.P.
      • Nussbaum B.L.
      • Paulat K.
      • Muth C.M.
      • Kranke P.
      • Winkler B.E.
      A novel rescue-tube device for in-water resuscitation..
      ,
      • Winkler B.E.
      • Eff A.M.
      • Eff S.
      • Ehrmann U.
      • Koch A.
      • Kähler W.
      • Muth C.M.
      Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation: a randomized cross-over trial..
      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 D.
      • Soares M.
      In-water resuscitation: is it worthwhile?.
      The in-water resuscitation protocol recommended performing up to 1 minute of ventilation 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% versus 37.0%; P<0.001). The rate of survival at hospital discharge was higher in the in-water resuscitation group (87.5% versus 25%; P<0.005), as was favorable neurological outcome (52.6% versus 7.4%; P<0.001).
      • Szpilman D.
      • Soares M.
      In-water resuscitation: is it worthwhile?.
      All other studies were crossover trials that evaluated the capacity of lifeguards
      • Perkins G.D.
      In-water resuscitation: a pilot evaluation..
      • Winkler B.E.
      • Eff A.M.
      • Ehrmann U.
      • Eff S.
      • Koch A.
      • Kaehler W.
      • Georgieff M.
      • Muth C.M.
      Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study..
      • Lungwitz Y.P.
      • Nussbaum B.L.
      • Paulat K.
      • Muth C.M.
      • Kranke P.
      • Winkler B.E.
      A novel rescue-tube device for in-water resuscitation..
      • Winkler B.E.
      • Eff A.M.
      • Eff S.
      • Ehrmann U.
      • Koch A.
      • Kähler W.
      • Muth C.M.
      Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation: a randomized cross-over trial..
      and laypeople
      • Winkler B.E.
      • Eff A.M.
      • Ehrmann U.
      • Eff S.
      • Koch A.
      • Kaehler W.
      • Georgieff M.
      • Muth C.M.
      Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study..
      to perform in-water resuscitation while simulating a water rescue with a manikin. In-water resuscitation was technically difficult and physically demanding, particularly in open water. Some trained lifeguards
      • Lungwitz Y.P.
      • Nussbaum B.L.
      • Paulat K.
      • Muth C.M.
      • Kranke P.
      • Winkler B.E.
      A novel rescue-tube device for in-water resuscitation..
      and laypeople
      • Winkler B.E.
      • Eff A.M.
      • Ehrmann U.
      • Eff S.
      • Koch A.
      • Kaehler W.
      • Georgieff M.
      • Muth C.M.
      Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study..
      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 B.E.
      • Eff A.M.
      • Ehrmann U.
      • Eff S.
      • Koch A.
      • Kaehler W.
      • Georgieff M.
      • Muth C.M.
      Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study..
      • Lungwitz Y.P.
      • Nussbaum B.L.
      • Paulat K.
      • Muth C.M.
      • Kranke P.
      • Winkler B.E.
      A novel rescue-tube device for in-water resuscitation..
      • Winkler B.E.
      • Eff A.M.
      • Eff S.
      • Ehrmann U.
      • Koch A.
      • Kähler W.
      • Muth C.M.
      Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation: a randomized cross-over trial..
      The use of ventilation adjuncts by well-trained lifeguards might facilitate in-water resuscitation.
      • Lungwitz Y.P.
      • Nussbaum B.L.
      • Paulat K.
      • Muth C.M.
      • Kranke P.
      • Winkler B.E.
      A novel rescue-tube device for in-water resuscitation..
      ,
      • Winkler B.E.
      • Eff A.M.
      • Eff S.
      • Ehrmann U.
      • Koch A.
      • Kähler W.
      • Muth C.M.
      Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation: a randomized cross-over trial..

       Task Force Insights

      From the available evidence, in suitable water conditions, in-water resuscitation by highly trained rescue teams with water rescue equipment seems feasible.
      The evidence base identified in this ScopRev suggests that a SysRev on this topic should be considered.

       Treatment Recommendations

      The 2005 treatment recommendation is unchanged: 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 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, part 2: adult basic life support..

       Resuscitation on a Boat After Drowning (BLS 856: ScopRev)

       Rationale for Review

      Starting resuscitation on a rescue boat is one approach to enable early initiation of resuscitation. However, the feasibility and effectiveness of CPR on a boat have not previously been explored.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Resuscitation on a boat following drowning (BLS #856): scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-resuscitation-a-boat-following-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Delivering resuscitation on a boat
      • Comparator: Delaying resuscitation until on dry land
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), CPR quality, physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Six studies evaluating resuscitation on a boat were identified. Two were clinical studies undertaken in the Netherlands
      • 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..
      and Hawaii,
      • Kingdon D.
      • Stapleton E.
      • Stahl E.
      Successful resuscitation: novel partnership between paramedics and U.S. Coast Guard..
      and 4 were manikin studies.
      • 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..
      • 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..
      • Tipton M.
      • David G.
      • Eglin C.
      • Golden F.
      Basic life support on small boats at sea..
      • de Vries W.
      • Bierens J.J.
      • Maas M.W.
      Moderate sea states do not influence the application of an AED in rigid inflatable boats..
      A case series from the Royal Dutch Lifeboat Institution reported 37 patients who had received resuscitation from lifeboat crews.
      • 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..
      Among these, 24 cases included resuscitation on a lifeboat or another ship. There were only 3 survivors, none of whom received resuscitation on a boat. An AED was used on 12 patients (7 drowned, 4 not drowned, 1 unknown), and 3 shocks were delivered. CPR quality was reported as suboptimal (high compression frequency and long pauses in chest compressions). In the other case series, 6 resuscitations were attempted on a boat or lifeboat; there was only 1 survivor after 1 month who received BLS, ALS, and tracheal intubation on board.
      • Kingdon D.
      • Stapleton E.
      • Stahl E.
      Successful resuscitation: novel partnership between paramedics and U.S. Coast Guard..
      Three simulation crossover studies evaluated the capacity of lifeguards
      • 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..
      ,
      • Tipton M.
      • David G.
      • Eglin C.
      • Golden F.
      Basic life support on small boats at sea..
      and fishermen
      • 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..
      to perform CPR on inflatable rescue boats or traditional fishing boats. These studies showed that resuscitation on a boat was feasible; however, the quality of the resuscitation was affected by boat speed
      • 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..
      ,
      • 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..
      and sea conditions.
      • Tipton M.
      • David G.
      • Eglin C.
      • Golden F.
      Basic life support on small boats at sea..
      CPR was physically demanding.
      • 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..
      • 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..
      • Tipton M.
      • David G.
      • Eglin C.
      • Golden F.
      Basic life support on small boats at sea..
      The motion-induced interruptions and early fatigue affected mainly ventilation.
      • Tipton M.
      • David G.
      • Eglin C.
      • Golden F.
      Basic life support on small boats at sea..
      A further simulation study showed that AED use on rigid inflatable rescue boats on calm water was feasible.
      • de Vries W.
      • Bierens J.J.
      • Maas M.W.
      Moderate sea states do not influence the application of an AED in rigid inflatable boats..

       Task Force Insights

      From the available evidence, resuscitation on a boat seems feasible if safety conditions, number of crew, and deck space allow, but those who are providing resuscitation need to focus on high-quality CPR and be alert to the development of fatigue.
      The evidence base identified in this ScopRev suggests that a SysRev on this topic should be considered.

       Treatment Recommendations

      There was no previous treatment recommendation on resuscitation on a boat after drowning; a SysRev will be pursued by the BLS Task Force.
      In the meantime, we highlight our 2020 recommendation and suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adults patients in cardiac arrest (weak recommendation, very low–certainty evidence).

       Airway Management in Drowning (BLS 856: ScopRev)

       Rationale for Review

      Airway management in drowning is pivotal to effective resuscitation, but the optimal strategy is unclear.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Airway management in drowning (BLS #856): scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-airway-management-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Advanced airway management
      • Comparator: No advanced airway management
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), CPR quality, physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      No studies specifically examining the effect of any particular airway management strategy over another in the management of a submerged casualty were identified. Five observational studies indirectly examined airway management strategies in 699 adults and children after drowning events.
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      ,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      ,
      • Garner A.A.
      • Barker C.L.
      • Weatherall A.D.
      Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service..
      • Salas Ballestin A.
      • de Carlos Vicente J.C.
      • Frontera Juan G.
      • Sharluyan Petrosyan A.
      • Reina Ferragut C.M.
      • Gonzalez Calvar A.
      • Clavero Rubio M.D.C.
      • Fernandez de la Ballina A.
      Prognostic factors of children admitted to a pediatric intensive care unit after an episode of drowning..
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      One study reported outcomes in adults and children,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      whereas the other 4 studies reported only pediatric cases.
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      ,
      • Garner A.A.
      • Barker C.L.
      • Weatherall A.D.
      Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service..
      • Salas Ballestin A.
      • de Carlos Vicente J.C.
      • Frontera Juan G.
      • Sharluyan Petrosyan A.
      • Reina Ferragut C.M.
      • Gonzalez Calvar A.
      • Clavero Rubio M.D.C.
      • Fernandez de la Ballina A.
      Prognostic factors of children admitted to a pediatric intensive care unit after an episode of drowning..
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      Some studies reported only those who sustained cardiac arrest attributable to drowning.
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      ,
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      All studies reported survival—specifically, survival with good neurological outcome,
      • Garner A.A.
      • Barker C.L.
      • Weatherall A.D.
      Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service..
      survival to hospital admission,
      • Hubert H.
      • Escutnaire J.
      • Michelet P.
      • Babykina E.
      • El Khoury C.
      • Tazarourte K.
      • Vilhelm C.
      • El Hiki L.
      • Guinhouya B.
      • Gueugniaud P.Y.
      • GR-RéAC
      Can we identify termination of resuscitation criteria in cardiac arrest due to drowning: results from the French national out-of-hospital cardiac arrest registry..
      and good outcome versus bad outcome (death or neurological sequelae).
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      In all studies, tracheal intubation was an indication of the severity of the injury, with the most severely injured being intubated during cardiac arrest or facilitated with anesthesia, without comprehensive adjustment for confounders. Two studies showed that tracheal intubation was associated with worse outcome (OR for good outcome, 0.25 [95% CI, 0.08–0.83]
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      ; OR, 0.04 [95% CI, 0.01–0.2]).
      • Joanknecht L.
      • Argent A.C.
      • van Dijk M.
      • van As A.B.
      Childhood drowning in South Africa: local data should inform prevention strategies..
      One study showed that mobile medical team ventilation was associated with better outcomes (44% versus 17% survival to admission).
      • Garner A.A.
      • Barker C.L.
      • Weatherall A.D.
      Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service..

       Task Force Insights

      The studies reviewed show that tracheal intubation is a feasible intervention after a water submersion incident. The association between tracheal intubation and poor outcomes is almost certainly confounded by the fact that tracheal intubation is limited to more severe drowning.
      The limited evidence base identified in the ScopRev suggests little benefit from a full SysRev to evaluate advanced airway management compared with no advanced airway management after drowning. In the absence of data supporting an alternative strategy, there is no reason to deviate from the ALS Task Force recommendations for airway management.
      • Berg K.M.
      • Soar J.
      • Andersen L.W.
      • Böttiger B.W.
      • Cacciola S.
      • Callaway C.W.
      • Couper K.
      • Cronberg T.
      • D’Arrigo S.
      • Deakin C.D.
      • on behalf of the Adult Advanced Life Support Collaborators
      • et al.
      Adult advanced life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..

       Treatment Recommendations

      There was no previous treatment recommendation on advanced airway management after drowning. The lack of evidence in the drowning setting supports the use of standard ALS Task Force recommendations for airway management.
      • Berg K.M.
      • Soar J.
      • Andersen L.W.
      • Böttiger B.W.
      • Cacciola S.
      • Callaway C.W.
      • Couper K.
      • Cronberg T.
      • D’Arrigo S.
      • Deakin C.D.
      • on behalf of the Adult Advanced Life Support Collaborators
      • et al.
      Adult advanced life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..

       Prehospital Oxygen in Drowning (BLS 856: ScopRev)

       Rationale for Review

      The use of prehospital oxygen has the potential to reverse hypoxemia and may improve outcomes. However, providing access to oxygen therapy has substantial resource implications to cover the costs of equipment and training. Without access to pulse oximetry or arterial blood gas analysis, identifying patients who may benefit from oxygen therapy can be difficult.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala Furelos R, Beerman S, Claesson A, Dunn C, Elsenga H, Gomez CA, Morgan P, Bierens J, Barcala-Furelos R, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Pre-hospital oxygen in drowning (BLS #856): task force scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-pre-hospital-oxygen-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Prehospital oxygen administration
      • Comparator: No prehospital oxygen administration
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Indirect evidence from 4 observational studies found associations among hypoxemia, oxygen administration, and worse outcomes. One study documented a higher rate of hospital admission in patients with an initial oxygen saturation measured by pulse oximetry (Spo2) no higher than 95% on arrival in the emergency department (92% versus 52%; adjusted OR, 6.8 [95% CI, 1.07–43.8]).
      • Cantu R.M.
      • Pruitt C.M.
      • Samuy N.
      • Wu C.L.
      Predictors of emergency department discharge following pediatric drowning..
      Hospital admission rates were also higher (91% versus 34%) among 71 children with an initial Spo2<92% at the scene or on arrival in the emergency department in univariate but not multivariate analysis.
      • Cohen N.
      • Capua T.
      • Lahat S.
      • Glatstein M.
      • Sadot E.
      • Rimon A.
      Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning..
      In contrast, another study did not find an association between Pao2/fraction of inspired oxygen (Fio2) ratio and the duration of hospital stay among 43 adults and children.
      • Gregorakos L.
      • Markou N.
      • Psalida V.
      • Kanakaki M.
      • Alexopoulou A.
      • Sotiriou E.
      • Damianos A.
      • Myrianthefs P.
      Near-drowning: clinical course of lung injury in adults..
      In an observational study involving 31 adults, lower blood oxygen saturations (87% versus 76%; P=0.007) and Pao2/Fio2 ratios (255 versus 133; P=0.004) were associated with reduced survival with favorable neurological outcome.
      • Jung C.Y.
      • Cha S.I.
      • Jang S.S.
      • Lee S.Y.
      • Lee J.H.
      • Son J.W.
      • Park J.Y.
      • Jung T.H.
      • Kim C.H.
      Clinical feature of submersion injury in adults [in Korean]..

       Task Force Insights

      The review found no direct evidence to guide the prehospital use of oxygen therapy in drowning. Yet, the primary cause of death from drowning is insufficient oxygen delivery to the heart and brain, and prompt restoration of oxygen delivery is of paramount importance. The indirect evidence identified in this review suggests frequent need for supplemental oxygen in patients who have drowned. Work in other domains of resuscitation science has identified adverse outcomes associated with both sustained hypoxia and hyperoxia. Pulse oximetry can be unreliable, particularly after cold-water immersion,
      • Montenij L.J.
      • de Vries W.
      • Schwarte L.
      • Bierens J.J.
      Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: a preliminary study..
      but when feasible can enable continuous titration of Fio2 after restoration of spontaneous circulation.

       Treatment Recommendations

      There was no previous treatment recommendation on prehospital use of oxygen therapy in drowning. The lack of evidence for a different approach to prehospital oxygen therapy in the drowning setting supports the use of standard ALS Task Force recommendations to avoid hypoxemia and hyperoxia by using 100% inspired oxygen until arterial oxygen saturation or the partial pressure of arterial oxygen can be measured, after which oxygen can be titrated to maintain an arterial oxygen saturation in the normal range.
      • Berg K.M.
      • Soar J.
      • Andersen L.W.
      • Böttiger B.W.
      • Cacciola S.
      • Callaway C.W.
      • Couper K.
      • Cronberg T.
      • D’Arrigo S.
      • Deakin C.D.
      • on behalf of the Adult Advanced Life Support Collaborators
      • et al.
      Adult advanced life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..

       AED Use in Drowning (BLS 856: ScopRev)

       Rationale for Review

      Although the most common cause of cardiac arrest associated with drowning is hypoxemia, in some cases, a primary cardiac arrythmia may be the precipitating event. The use of an AED in such cases may be lifesaving, but this needs to be balanced against the risk of harm from interruptions to CPR for patients with nonshockable rhythms. Although ILCOR recommends the use of AEDs, their role in the setting of resuscitation from drowning is not clearly defined.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Automated external defibrillator use in drowning AED use (BLS #856): scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-automated-external-defibrillator-use-in-drowning-aed-use-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: AED use
      • Comparator: No AED use
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), CPR quality, physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      There were no interventional, observational, or case series showing direct evidence on the outcome from on-site AED use in OHCA attributable to drowning before the arrival of EMS. Indirect evidence of AED use was found from 15 observational studies. Four studies involving 1044 patients showed a range of AED use in cases of suspected drowning before the arrival of EMS of 5% to 32%.
      • Buick J.E.
      • Lin S.
      • Rac V.E.
      • Brooks S.C.
      • Kierzek G.
      • Morrison L.J.
      Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada..
      ,
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      ,
      • 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..
      ,
      • El-Assaad I.
      • Al-Kindi S.G.
      • McNally B.
      • Vellano K.
      • Worley S.
      • Tang A.S.
      • Aziz P.F.
      • CARES Surveillance Group
      Automated external defibrillator application before EMS arrival in pediatric cardiac arrests..
      In 12 studies involving 14 920 patients, a shockable rhythm in OHCA attributable to drowning was uncommon, with a reported range of ventricular fibrillation/ventricular tachycardia between 2% and 14%.
      • Claesson A.
      • Svensson L.
      • Silfverstolpe J.
      • Herlitz J.
      Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning..
      ,
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      ,
      • Claesson A.
      • Lindqvist J.
      • Ortenwall P.
      • Herlitz J.
      Characteristics of lifesaving from drowning as reported by the Swedish Fire and Rescue Services 1996-2010..
      ,
      • Buick J.E.
      • Lin S.
      • Rac V.E.
      • Brooks S.C.
      • Kierzek G.
      • Morrison L.J.
      Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada..
      • Claesson A.
      • Lindqvist J.
      • Herlitz J.
      Cardiac arrest due to drowning: changes over time and factors of importance for survival..
      • Vähätalo R.
      • Lunetta P.
      • Olkkola K.T.
      • Suominen P.K.
      Drowning in children: Utstein style reporting and outcome..
      ,
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      ,
      • Fukuda T.
      • Ohashi-Fukuda N.
      • Hayashida K.
      • Kukita I.
      Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013–2016..
      ,
      • 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..
      ,
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      ,
      • El-Assaad I.
      • Al-Kindi S.G.
      • McNally B.
      • Vellano K.
      • Worley S.
      • Tang A.S.
      • Aziz P.F.
      • CARES Surveillance Group
      Automated external defibrillator application before EMS arrival in pediatric cardiac arrests..
      ,
      • Dyson K.
      • Morgans A.
      • Bray J.
      • Matthews B.
      • Smith K.
      Drowning related out-of-hospital cardiac arrests: characteristics and outcomes..
      Among 7 observational studies involving 1846 patients in cardiac arrest after drowning, a shockable rhythm was not associated with better survival.
      • Claesson A.
      • Svensson L.
      • Silfverstolpe J.
      • Herlitz J.
      Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning..
      ,
      • Youn C.S.
      • Choi S.P.
      • Yim H.W.
      • Park K.N.
      Out-of-hospital cardiac arrest due to drowning: an Utstein style report of 10 years of experience from St. Mary’s Hospital..
      ,
      • Tobin J.M.
      • Ramos W.D.
      • Pu Y.
      • Wernicki P.G.
      • Quan L.
      • Rossano J.W.
      Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning..
      ,
      • 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..
      ,
      • Kieboom J.K.
      • Verkade H.J.
      • Burgerhof J.G.
      • Bierens J.J.
      • Rheenen P.F.
      • Kneyber M.C.
      • Albers M.J.
      Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study..
      ,
      • El-Assaad I.
      • Al-Kindi S.G.
      • McNally B.
      • Vellano K.
      • Worley S.
      • Tang A.S.
      • Aziz P.F.
      • CARES Surveillance Group
      Automated external defibrillator application before EMS arrival in pediatric cardiac arrests..
      ,
      • Dyson K.
      • Morgans A.
      • Bray J.
      • Matthews B.
      • Smith K.
      Drowning related out-of-hospital cardiac arrests: characteristics and outcomes..
      In 1 study with 776 drowning survivors, only 0.4% were defibrillated at the emergency department.
      • Reynolds J.C.
      • Michiels E.A.
      • Nasiri M.
      • Reeves M.J.
      • Quan L.
      Observed long-term mortality after 18,000 person-years among survivors in a large regional drowning registry..
      In 1 study involving 529 patients in a multivariable analysis, although a shockable rhythm did not improve survival to hospital admission, there was an association between shockable rhythm and increased 30-day survival (OR, 4.12 [95% CI, 1.13–13.71]).
      • Claesson A.
      • Lindqvist J.
      • Herlitz J.
      Cardiac arrest due to drowning: changes over time and factors of importance for survival..
      In 1 simulation study testing 6 AEDs on 3 different boats in moderate sea conditions, use of AEDs seemed feasible.
      • de Vries W.
      • Bierens J.J.
      • Maas M.W.
      Moderate sea states do not influence the application of an AED in rigid inflatable boats..
      In 1 simulation study with 616 lifeguards, mean time from arrival to defibrillation was 62 seconds (SD, 20 seconds).
      • Iserbyt P.
      • Schouppe G.
      • Charlier N.
      A multiple linear regression analysis of factors affecting the simulated basic life support (BLS) performance with automated external defibrillator (AED) in Flemish lifeguards..
      In 1 study, a case of inappropriate shock delivered to a patient in asystole with artifacts on the ECG resulting from movements was described, with no obvious consequences.
      • 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..
      No adverse events were reported in the studies identified in this review.

       Task Force Insights

      Studies reviewed showed that using AEDs in cardiac arrest in the drowning setting appears to be feasible and safe, although the chances of a shockable rhythm may be lower (2%–14%) than for a primary cardiac cause. The current ILCOR treatment recommendation suggests a short period of CPR until the defibrillator is ready for analysis or until defibrillation in unmonitored cardiac arrest. This may be particularly important in situations in which the cardiac arrest was caused by drowning.
      • Olasveengen T.M.
      • Mancini M.E.
      • Perkins G.D.
      • Avis S.
      • Brooks S.
      • Castrén M.
      • Chung S.P.
      • Considine J.
      • Couper K.
      • Escalante R.
      • Adult Basic Life Support Collaborators
      • et al.
      Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations..

       Treatment Recommendations

      There was no previous treatment recommendation on AED use after drowning; a SysRev will be pursued by the BLS Task Force.
      In the meantime, we highlight our 2020 recommendation suggesting that delivery of a shock with an AED during BLS is safe.

       Mechanical Ventilation in Drowning (BLS 856: ScopRev)

       Rationale for Review

      Patients with severe lung injury after submersion may require support from a mechanical ventilator, but the optimal ventilation strategy is unclear.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Mechanical ventilation in drowning (BLS #856): task force scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-mechanical-ventilation-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: Mechanical ventilation
      • Comparator: No mechanical ventilation
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Four studies were identified that examined the use of ventilation strategies in 93 adults or children after drowning.
      • Caglar A.
      • Er A.
      • Ozden O.
      • Karaarslan U.
      • Akgul F.
      • Koroglu T.F.
      • Duman M.
      Efficacy of early noninvasive ventilation in three cases of nonfatal drowning with pulmonary oedema in the paediatric emergency department..
      • Onarheim H.
      • Vik V.
      Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old..
      • Ruggeri P.
      • Calcaterra S.
      • Bottari A.
      • Girbino G.
      • Fodale V.
      Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient..
      • Michelet P.
      • Bouzana F.
      • Charmensat O.
      • Tiger F.
      • Durand-Gasselin J.
      • Hraiech S.
      • Jaber S.
      • Dellamonica J.
      • Ichai C.
      Acute respiratory failure after drowning: a retrospective multicenter survey..
      The studies included 1 retrospective observational study with 88 patients,
      • Michelet P.
      • Bouzana F.
      • Charmensat O.
      • Tiger F.
      • Durand-Gasselin J.
      • Hraiech S.
      • Jaber S.
      • Dellamonica J.
      • Ichai C.
      Acute respiratory failure after drowning: a retrospective multicenter survey..
      1 case series comprising 3 children,
      • Caglar A.
      • Er A.
      • Ozden O.
      • Karaarslan U.
      • Akgul F.
      • Koroglu T.F.
      • Duman M.
      Efficacy of early noninvasive ventilation in three cases of nonfatal drowning with pulmonary oedema in the paediatric emergency department..
      and 2 case reports.
      • Onarheim H.
      • Vik V.
      Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old..
      ,
      • Ruggeri P.
      • Calcaterra S.
      • Bottari A.
      • Girbino G.
      • Fodale V.
      Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient..
      All articles reported survival status at hospital discharge. Two articles reported neurological outcome (Glasgow Coma Scale) and severity of oxygen impairment.
      • Onarheim H.
      • Vik V.
      Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old..
      ,
      • Michelet P.
      • Bouzana F.
      • Charmensat O.
      • Tiger F.
      • Durand-Gasselin J.
      • Hraiech S.
      • Jaber S.
      • Dellamonica J.
      • Ichai C.
      Acute respiratory failure after drowning: a retrospective multicenter survey..
      Three studies reported the feasibility of noninvasive ventilation (NIV) use in patients with respiratory failure after drowning.
      • Caglar A.
      • Er A.
      • Ozden O.
      • Karaarslan U.
      • Akgul F.
      • Koroglu T.F.
      • Duman M.
      Efficacy of early noninvasive ventilation in three cases of nonfatal drowning with pulmonary oedema in the paediatric emergency department..
      ,
      • Onarheim H.
      • Vik V.
      Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old..
      ,
      • Michelet P.
      • Bouzana F.
      • Charmensat O.
      • Tiger F.
      • Durand-Gasselin J.
      • Hraiech S.
      • Jaber S.
      • Dellamonica J.
      • Ichai C.
      Acute respiratory failure after drowning: a retrospective multicenter survey..
      In a multicenter, retrospective observational study across 7 French intensive care units (ICUs), 48 adults received NIV (both continuous positive airway pressure and bilevel positive airway pressure; average positive end-expiratory pressure [PEEP], 8±2 cm H2O) to treat moderate to severe lung injury (mean Pao2/Fio2 ratio, 156 mm Hg).
      • Michelet P.
      • Bouzana F.
      • Charmensat O.
      • Tiger F.
      • Durand-Gasselin J.
      • Hraiech S.
      • Jaber S.
      • Dellamonica J.
      • Ichai C.
      Acute respiratory failure after drowning: a retrospective multicenter survey..
      Compared with patients treated with invasive mechanical ventilation, those receiving NIV had a better initial neurological and hemodynamic status. NIV was successful in 92% (44 of 48), with an average duration of ventilation of 1.4 days. Both mechanical ventilation and NIV were associated with rapid improvement of oxygenation (within 6 hours) and short ICU length of stay. Two further articles reported successful use of NIV to treat drowning-related acute lung injury in hemodynamically stable adults
      • Onarheim H.
      • Vik V.
      Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old..
      ,
      • Ruggeri P.
      • Calcaterra S.
      • Bottari A.
      • Girbino G.
      • Fodale V.
      Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient..
      and children.
      • Caglar A.
      • Er A.
      • Ozden O.
      • Karaarslan U.
      • Akgul F.
      • Koroglu T.F.
      • Duman M.
      Efficacy of early noninvasive ventilation in three cases of nonfatal drowning with pulmonary oedema in the paediatric emergency department..

       Task Force Insights

      NIV appears feasible as a treatment for moderate to severe lung injury caused by drowning. The published experience involves mostly patients with higher Glasgow Coma Scale scores who were hemodynamically stable. Patients appear to respond within 12 to 24 hours. The indications for the optimal time to transition to invasive ventilation if NIV is unsuccessful require further research.

       Treatment Recommendations

      There was no previous treatment recommendation on mechanical ventilation after drowning. The lack of evidence in the drowning setting supports the use of standard general recommendations for the management of acute respiratory distress syndrome.
      • Griffiths M.J.D.
      • McAuley D.F.
      • Perkins G.D.
      • Barrett N.
      • Blackwood B.
      • Boyle A.
      • Chee N.
      • Connolly B.
      • Dark P.
      • Finney S.
      • et al.
      Guidelines on the management of acute respiratory distress syndrome..

       ECMO in Drowning (BLS 856: ScopRev)

       Rationale for Review

      ECMO and ECPR have been used in the treatment of severe drowning with refractory hypoxia or cardiac arrest.
      The full text of this ScopRev can be found on the ILCOR website.

      Bierens J, Barcala-Furelos R, Beerman S, Claesson A, Dunne C, Elsenga H, Abelairas-Gomez C, Morgan P, Mecrow T, Pereira JCC, et al; International Liaison Committee on Resuscitation Basic Life Support Task Force. Criteria for discharge in drowning (BLS #856): scoping review.Accessed March 4, 2021. https://costr.ilcor.org/document/bls-856-criteria-for-discharge-in-drowning-tf-scoping-review

       PICO, Study Design, and Time Frame

      • Population: Adults and children who are submerged in water
      • Intervention: ECMO
      • Comparator: No ECMO
      • Outcome: Any clinical outcome (eg, survival, survival with a favorable neurological outcome, hospitalization), CPR quality, physiological end points
      • Study design: RCTs and nonrandomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Manikin studies were included only if no human studies were available.
      • Time frame: From 2000 onward. All languages were included as long as there was an English abstract; unpublished studies (eg, conference abstracts, trial protocols), narrative reviews, and animal studies were excluded. Literature search was updated to October 2019.

       Summary of Evidence

      Thirteen studies were identified that examined the use of extracorporeal support in 658 adults and children after drowning.

      Bauman BD, Louiselle A, Nygaard RM, Vakayil V, Acton R, Hess D, Saltzman D, Kreykes N, Fischer G, Louie J, et al.Treatment of hypothermic cardiac arrest in the pediatric drowning victim, a case report, and systematic review [published online January 29, 2019].Pediatr Emerg Care.doi: 10.1097/PEC.0000000000001735. https://journals.lww.com/pec-online/Abstract/9000/Treatment_of_Hypothermic_Cardiac_Arrest_in_the.98239.aspx

      • Burke C.R.
      • Chan T.
      • Brogan T.V.
      • Lequier L.
      • Thiagarajan R.R.
      • Rycus P.T.
      • McMullan D.M.
      Extracorporeal life support for victims of drowning..
      • Champigneulle B.
      • Bellenfant-Zegdi F.
      • Follin A.
      • Lebard C.
      • Guinvarch A.
      • Thomas F.
      • Pirracchio R.
      • Journois D.
      Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience..
      • Coskun K.O.
      • Popov A.F.
      • Schmitto J.D.
      • Hinz J.
      • Kriebel T.
      • Schoendube F.A.
      • Ruschewski W.
      • Tirilomis T.
      Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients..
      • Dunne B.
      • Christou E.
      • Duff O.
      • Merry C.
      Extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest: a systematic review of the literature..
      • Eich C.
      • Bräuer A.
      • Timmermann A.
      • Schwarz S.K.
      • Russo S.G.
      • Neubert K.
      • Graf B.M.
      • Aleksic I.
      Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein style for drowning.”.
      • Hilmo J.
      • Naesheim T.
      • Gilbert M.
      “Nobody is dead until warm and dead”: prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas: a retrospective study from northern Norway..
      • Kim K.I.
      • Lee W.Y.
      • Kim H.S.
      • Jeong J.H.
      • Ko H.H.
      Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure..
      • Ruttmann E.
      • Weissenbacher A.
      • Ulmer H.
      • Müller L.
      • Höfer D.
      • Kilo J.
      • Rabl W.
      • Schwarz B.
      • Laufer G.
      • Antretter H.
      • et al.
      Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest..
      • Skarda D.
      • Barnhart D.
      • Scaife E.
      • Molitor M.
      • Meyers R.
      • Rollins M.
      Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation?.
      • Svendsen ØS
      • Grong K.
      • Andersen K.S.
      • Husby P.
      Outcome after rewarming from accidental hypothermia by use of extracorporeal circulation..
      • Wanscher M.
      • Agersnap L.
      • Ravn J.
      • Yndgaard S.
      • Nielsen J.F.
      • Danielsen E.R.
      • Hassager C.
      • Romner B.
      • Thomsen C.
      • Barnung S.
      • et al.
      Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident..
      • Weuster M.
      • Haneya A.
      • Panholzer B.
      • Klüter T.
      • van der Brelie M.
      • van Laak U.
      • Cremer J.
      • Haake N.
      The use of extracorporeal membrane oxygenation systems in severe accidental hypothermia after drowning: a centre experience..
      The studies included 2 retrospective observational studies
      • Burke C.R.
      • Chan T.
      • Brogan T.V.
      • Lequier L.
      • Thiagarajan R.R.
      • Rycus P.T.
      • McMullan D.M.
      Extracorporeal life support for victims of drowning..
      ,
      • Champigneulle B.
      • Bellenfant-Zegdi F.
      • Follin A.
      • Lebard C.
      • Guinvarch A.
      • Thomas F.
      • Pirracchio R.
      • Journois D.
      Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience..
      and 11 case series.

      Bauman BD, Louiselle A, Nygaard RM, Vakayil V, Acton R, Hess D, Saltzman D, Kreykes N, Fischer G, Louie J, et al.Treatment of hypothermic cardiac arrest in the pediatric drowning victim, a case report, and systematic review [published online January 29, 2019].Pediatr Emerg Care.doi: 10.1097/PEC.0000000000001735. https://journals.lww.com/pec-online/Abstract/9000/Treatment_of_Hypothermic_Cardiac_Arrest_in_the.98239.aspx

      ,
      • Coskun K.O.
      • Popov A.F.
      • Schmitto J.D.
      • Hinz J.
      • Kriebel T.
      • Schoendube F.A.
      • Ruschewski W.
      • Tirilomis T.
      Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients..
      • Dunne B.
      • Christou E.
      • Duff O.
      • Merry C.
      Extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest: a systematic review of the literature..
      • Eich C.
      • Bräuer A.
      • Timmermann A.
      • Schwarz S.K.
      • Russo S.G.
      • Neubert K.
      • Graf B.M.
      • Aleksic I.
      Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein style for drowning.”.
      • Hilmo J.
      • Naesheim T.
      • Gilbert M.
      “Nobody is dead until warm and dead”: prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas: a retrospective study from northern Norway..
      • Kim K.I.
      • Lee W.Y.
      • Kim H.S.
      • Jeong J.H.
      • Ko H.H.
      Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure..
      • Ruttmann E.
      • Weissenbacher A.
      • Ulmer H.
      • Müller L.
      • Höfer D.
      • Kilo J.
      • Rabl W.
      • Schwarz B.
      • Laufer G.
      • Antretter H.
      • et al.
      Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest..
      • Skarda D.
      • Barnhart D.
      • Scaife E.
      • Molitor M.
      • Meyers R.
      • Rollins M.
      Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation?.
      • Svendsen ØS
      • Grong K.
      • Andersen K.S.
      • Husby P.
      Outcome after rewarming from accidental hypothermia by use of extracorporeal circulation..
      • Wanscher M.
      • Agersnap L.
      • Ravn J.
      • Yndgaard S.
      • Nielsen J.F.
      • Danielsen E.R.
      • Hassager C.
      • Romner B.
      • Thomsen C.
      • Barnung S.
      • et al.
      Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident..
      • Weuster M.
      • Haneya A.
      • Panholzer B.
      • Klüter T.
      • van der Brelie M.
      • van Laak U.
      • Cremer J.
      • Haake N.
      The use of extracorporeal membrane oxygenation systems in severe accidental hypothermia after drowning: a centre experience..
      Some articles reported overlapping data: 1 study
      • Dunne B.
      • Christou E.
      • Duff O.
      • Merry C.
      Extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest: a systematic review of the literature..
      reported cases from 3 other case series,
      • Coskun K.O.
      • Popov A.F.
      • Schmitto J.D.
      • Hinz J.
      • Kriebel T.
      • Schoendube F.A.
      • Ruschewski W.
      • Tirilomis T.
      Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients..
      ,
      • Eich C.
      • Bräuer A.
      • Timmermann A.
      • Schwarz S.K.
      • Russo S.G.
      • Neubert K.
      • Graf B.M.
      • Aleksic I.
      Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein style for drowning.”.
      ,
      • Wanscher M.
      • Agersnap L.
      • Ravn J.
      • Yndgaard S.
      • Nielsen J.F.
      • Danielsen E.R.
      • Hassager C.
      • Romner B.
      • Thomsen C.
      • Barnung S.
      • et al.
      Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident..
      whereas 2 studies appear to report the same cases.
      • Coskun K.O.
      • Popov A.F.
      • Schmitto J.D.
      • Hinz J.
      • Kriebel T.
      • Schoendube F.A.
      • Ruschewski W.
      • Tirilomis T.
      Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients..
      ,
      • Eich C.
      • Bräuer A.
      • Timmermann A.
      • Schwarz S.K.
      • Russo S.G.
      • Neubert K.
      • Graf B.M.
      • Aleksic I.
      Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein style for drowning.”.
      All 13 articles reported survival status, and 9 reported neurological outcomes.

      Bauman BD, Louiselle A, Nygaard RM, Vakayil V, Acton R, Hess D, Saltzman D, Kreykes N, Fischer G, Louie J, et al.Treatment of hypothermic cardiac arrest in the pediatric drowning victim, a case report, and systematic review [published online January 29, 2019].Pediatr Emerg Care.doi: 10.1097/PEC.0000000000001735. https://journals.lww.com/pec-online/Abstract/9000/Treatment_of_Hypothermic_Cardiac_Arrest_in_the.98239.aspx

      ,
      • Champigneulle B.
      • Bellenfant-Zegdi F.
      • Follin A.
      • Lebard C.
      • Guinvarch A.
      • Thomas F.
      • Pirracchio R.
      • Journois D.
      Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience..
      • Coskun K.O.
      • Popov A.F.
      • Schmitto J.D.
      • Hinz J.
      • Kriebel T.
      • Schoendube F.A.
      • Ruschewski W.
      • Tirilomis T.
      Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients..
      • Dunne B.
      • Christou E.
      • Duff O.
      • Merry C.
      Extracorporeal-assisted rewarming in the management of accidental deep hypothermic cardiac arrest: a systematic review of the literature..
      • Eich C.
      • Bräuer A.
      • Timmermann A.
      • Schwarz S.K.
      • Russo S.G.
      • Neubert K.
      • Graf B.M.
      • Aleksic I.
      Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Utstein style for drowning.”.
      ,
      • Kim K.I.
      • Lee W.Y.
      • Kim H.S.
      • Jeong J.H.
      • Ko H.H.
      Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure..
      ,
      • Skarda D.
      • Barnhart D.
      • Scaife E.
      • Molitor M.
      • Meyers R.
      • Rollins M.
      Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: is meaningful survival a reasonable expectation?.
      • Svendsen ØS
      • Grong K.
      • Andersen K.S.
      • Husby P.
      Outcome after rewarming from accidental hypothermia by use of extracorporeal circulation..
      • Wanscher M.
      • Agersnap L.
      • Ravn J.
      • Yndgaard S.
      • Nielsen J.F.
      • Danielsen E.R.
      • Hassager C.
      • Romner B.
      • Thomsen C.
      • Barnung S.
      • et al.
      Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident..
      • Weuster M.
      • Haneya A.
      • Panholzer B.
      • Klüter T.
      • van der Brelie M.
      • van Laak U.
      • Cremer J.
      • Haake N.
      The use of extracorporeal membrane oxygenation systems in severe accidental hypothermia after drowning: a centre experience..
      Outcome measures reported for neurological outcome were the Glasgow Coma Scale
      • Wanscher M.
      • Agersnap L.
      • Ravn J.
      • Yndgaard S.
      • Nielsen J.F.
      • Danielsen E.R.
      • Hassager C.
      • Romner B.
      • Thomsen C.
      • Barnung S.
      • et al.
      Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident..
      ,
      • Weuster M.
      • Haneya A.
      • Panholzer B.
      • Klüter T.
      • van der Brelie M.
      • van Laak U.
      • Cremer J.
      • Haake N.
      The use of extracorporeal membrane oxygenation systems in severe accidental hypothermia after drowning: a centre experience..
      or the Cerebral Performance Category (CPC)
      • Champigneulle B.
      • Bellenfant-Zegdi F.
      • Follin A.
      • Lebard C.
      • Guinvarch A.
      • Thomas F.
      • Pirracchio R.
      • Journois D.
      Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience..