A systematic review of interventions for resuscitation following drowning.

Objectives: The International Liaison Committee on Resuscitation, in collaboration with drowning researchers from around the world, aimed to review the evidence addressing seven key resuscitation interventions: 1) immediate versus delayed resuscitation; (2) compression first versus ventilation first strategy; (3) compression-only CPR versus standard CPR (compressions and ventilations); (4) ventilation with and without equipment; (5) oxygen administration prior to hospital arrival; (6) automated external defibrillation first versus cardiopulmonary resuscitation first strategy; (7) public access defibrillation programmes. Methods: The review included studies relating to adults and children who had sustained a cardiac arrest following drowning with control groups and reported patient outcomes. Searches were run from database inception through to April 2023. The following databases were searched Ovid MEDLINE, Pre-Medline, Embase, Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The findings are reported as a narrative synthesis. Results: Three studies were included for two of the seven interventions (2,451 patients). No randomised controlled trials were identified. A retrospective observational study reported in-water resuscitation with rescue breaths improved patient outcomes compared to delayed resuscitation on land (n = 46 patients, very low certainty of evidence). The two observational studies (n = 2,405 patients), comparing compression-only with standard resuscitation, reported no difference for most outcomes. A statistically higher rate of survival to hospital discharge was reported for the standard resuscitation group in one of these studies (29.7% versus 18.1%, adjusted odds ratio 1.54 (95% confidence interval 1.01-2.36) (very low certainty of evidence). Conclusion: The key finding of this systematic review is the paucity of evidence, with control groups, to inform treatment guidelines for resuscitation in drowning.

Resuscitation of Drowned Persons During the COVID-19 Pandemic: A Consensus Statement.

Importance: Resuscitation is a niche example of how the COVID-19 pandemic has affected society in the long term. Those trained in cardiopulmonary resuscitation (CPR) face the dilemma that attempting to save a life may result in their own harm. This is most of all a problem for drowning, where hypoxia is the cause of cardiac arrest and ventilation is the essential first step in reversing the situation. Objective: To develop recommendations for water rescue organizations in providing their rescuers with safe drowning resuscitation procedures during the COVID-19 pandemic. Evidence Review: Two consecutive modified Delphi procedures involving 56 participants from 17 countries with expertise in drowning prevention research, resuscitation, and programming were performed from March 28, 2020, to March 29, 2021. In parallel, PubMed and Google Scholar were searched to identify new emerging evidence relevant to each core element, acknowledge previous studies relevant in the new context, and identify knowledge gaps. Findings: Seven core elements, each with their own specific recommendations, were identified in the initial consensus procedure and were grouped into 4 categories: (1) prevention and mitigation of the risks of becoming infected, (2) resuscitation of drowned persons during the COVID-19 pandemic, (3) organizational responsibilities, and (4) organizations unable to meet the recommended guidelines. The common measures of infection risk mitigation, personal protective equipment, and vaccination are the base of the recommendations. Measures to increase drowning prevention efforts reduce the root cause of the dilemma. Additional infection risk mitigation measures include screening all people entering aquatic facilities, defining criteria for futile resuscitation, and avoiding contact with drowned persons by rescuers with a high-risk profile. Ventilation techniques must balance required skill level, oxygen delivery, infection risk, and costs of equipment and training. Bag-mask ventilation with a high-efficiency particulate air filter by 2 trained rescuers is advised. Major implications for the methods, facilities, and environment of CPR training have been identified, including nonpractical skills to avoid being infected or to infect others. Most of all, the organization is responsible for informing their members about the impact of the COVID-19 pandemic and taking measures that maximize rescuer safety. Research is urgently needed to better understand, develop, and implement strategies to reduce infection transmission during drowning resuscitation. Conclusions and Relevance: This consensus document provides an overview of recommendations for water rescue organizations to improve the safety of their rescuers during the COVID-19 pandemic and balances the competing interests between a potentially lifesaving intervention and risk to the rescuer. The consensus-based recommendations can also serve as an example for other volunteer organizations and altruistic laypeople who may provide resuscitation.

Willingness to administer mouth-to-mouth ventilation in a first response program in rural Bangladesh.

BACKGROUND: Timely mouth-to-mouth ventilation is critical to resuscitate drowning victims. While drowning is frequent, there are no lay persons trained in cardio-pulmonary resuscitation (CPR) in rural Bangladesh. As part of a feasibility study to create a first response system in a conservative Islamic village environment, a pilot was undertaken to examine willingness to provide mouth-to-mouth ventilation for drowning resuscitation. METHODS: A questionnaire was administered to 721 participants at the beginning of a village-based CPR training course. Trainees were asked regarding willingness to administer mouth-to-mouth ventilation on a variety of hypothetical victims. Responses were tabulated according to the age, sex and relationship of the trainee to the postulated victim. RESULTS: Willingness to deliver mouth-to-mouth ventilation was influenced by sex of a potential recipient and relationship to the trainee. Adolescent participants were significantly more willing to perform mouth-to-mouth ventilation on someone of the same sex. Willingness increased for both sexes when the postulated victim was an immediate family member. Willingness was lower with extended family members and lowest with strangers. Adult trainees were more likely to perform mouth-to-mouth ventilation than adolescent trainees in any scenario. CONCLUSION: Adults express more willingness to resuscitate a broader range of drowning victims than adolescents. However in rural Bangladesh, adolescents are more likely to be in close proximity to a drowning in progress. Further efforts are needed to increase willingness of adolescents to provide resuscitation to drowning victims. However, despite potential cultural limitations, trained responders appear to be willing to give mouth-to-mouth ventilation to various recipients. Final determination will require evidence on response outcomes which is being collected.

Does teaching children to swim increase exposure to water or risk-taking when in the water? Emerging evidence from Bangladesh.

BACKGROUND: SwimSafe, a basic swimming and safe rescue curriculum, has been taught to large numbers of children in Bangladesh. Teaching swimming potentially increases risk if it increases water exposure or high-risk practices in water. This study compares water exposure and risk practices for SwimSafe graduates (SS) with children who learned swimming naturally. METHODS: Interviewers obtained detailed water exposure histories for the preceding 48 h from 3936 SS aged 6-14 and 3952 age-matched and sex-matched children who had learned swimming naturally. Frequencies of water exposure and water entries for swimming or playing were compared. RESULTS: There were 9741 entries into water among the 7046 participants in the 48 h prior to interview. About one-third (31.2%) had no water entries, one-tenth (10.5%) entered once, half (49.2%) entered twice and a tenth (9.1%) entered three or more times. Proportions of children in each group were similar. About 99.5% of both groups only entered the water for bathing. For those entering to swim or play, the mean number of entries was similar (SS 1.63, natural swimmer (NS) 1.36, p=0.40). Swimming or playing alone in the water was rare (1 SS, 0 NS). CONCLUSIONS: Most water exposure for children is for bathing. Less than 1% swam or played in the water during the 48 h recall period (0.6% SS, 0.4% NS). Learning swimming in SwimSafe did not increase water exposure nor did it increase water entry for playing or swimming compared with children who learned to swim naturally.

Children reporting rescuing other children drowning in rural Bangladesh: a descriptive study.

BACKGROUND: SwimSafe, a basic swimming and safer rescue curriculum, has been taught to large numbers of Bangladeshi children since 2006. This study examines the frequency and characteristics of rescues reported by children who graduated from SwimSafe and compares them with age-matched and sex-matched children who did not participate in SwimSafe. METHODS: Interviews were conducted during the swimming season in Raiganj, Bangladesh. Data were collected from 3890 SwimSafe graduates aged 6-14. Two age-matched and sex-matched controls were selected; one who had learned to swim naturally, the other who had not learned to swim. RESULTS: 188 rescues were reported by the three groups. The 12-14-year age groups reported the highest monthly rate of rescues (SwimSafe 10.5/100 000 (95% CI 3.4 to 24.5), natural swimmers 8.5/100 000 (95% CI 2.2 to 21.2)) and annual rate of rescue reported (SwimSafe 25.4/100 000 (95% CI 13.2 to 43.9), natural swimmers 35.4/100 000 (20.8 to 56.2)). Reported rescue numbers among both swimming groups was similar. Mean victim age was 4.1 years and 92.5% were under 7 years. All victims were younger than their rescuer (mean 5.9 years less). Most rescues (73.7%) took place in ponds or ditches with most (86.6%) within 10 m of the bank. Most victims had entered the water to bathe (53.8%). A large majority of reported rescues (90.9%) were conducted with the rescuer in the water, half requiring the rescuer to swim. CONCLUSIONS: Children report frequent drowning rescues of younger children in rural Bangladesh. Most reported are contact rescues with the rescuer in the water. Formal training for in-water rescue techniques may be needed to reduce the risk to the child rescuer.

Feasibility of a first responder programme in rural Bangladesh.

OBJECTIVES: To develop and implement a first responder training programme, assess the feasibility of training lay persons with low literacy in rural Bangladesh and determine the acceptability of the programme in the community. METHODS: A first responder training programme including cardiopulmonary resuscitation (CPR) was developed covering 20 villages in a rural sub-district in north-central Bangladesh. 2398 participants received training and 2120 graduated over a 14-month period. Responders were a mix of adolescents, community volunteers and community elders. The programme was evaluated through post-training assessment of knowledge and skills of participants and performance evaluation of trainers. A focus group discussion was used to assess the response of community leaders to usefulness and community acceptance of the programme. RESULTS: Materials developed for training include a low-literacy training manual, posters and a training video. Almost 90 per cent (88.4) of participants qualified in post training assessment. Adolescents and community volunteers had higher pass rates than community elders. In all, CPR skills showed a significant decline over 9 months of assessment, while first aid knowledge appeared stable over the same period. Community leaders considered the programme useful for the community and expressed their support for the programme. CONCLUSION: Developing a first responder training programme that includes CPR in a rural Bangladesh community is feasible if participants have secondary school attainment. Adolescents and young adults are suitable candidates. Evaluation is ongoing to see whether the programme graduates were able to reduce morbidity and mortality through effective first response efforts.