In-water resuscitation during a surf rescue: Time lost or breaths gained? A pilot study.

BACKGROUND: A technique called in-water resuscitation (IWR) was devised on a surfboard to ventilate persons who seemingly did not breathe upon a water rescue. Despite IWR still raises uncertainties regarding its applicability, this technique is recommended by the International Liaison Committee for Resuscitation (ILCOR). Thus, this study aimed to evaluate the feasibility of IWR with a rescue board before and during towing and, to compare rescue times and rescue-associated fatigue levels between rescues with rescue breath attempts and without (SR). METHODS: A randomized crossover pilot test was conducted: 1) IWR test with pocket mask and, 2) Conventional SR test. IWR tests were conducted using a Laerdal ResusciAnne manikin (Stavanger, Norway). Three groups of variables were recorded: a) rescue time (in s), b) effective ventilations during rescue, and c) rating of perceived effort (RPE). RESULTS: Focusing on the rescue time, the performance SR was significantly faster than IWR rescue which took 61 s longer to complete the rescue (Z = -2.805; p = 0.005). No significant differences were found between techniques for the RPE (T = -1.890; p = 0.095). In the IWR analysis, lifeguards performed an average of 27 ± 12 rescue breaths. CONCLUSION: The application of IWR on a rescue board is feasible both at the time of rescue and during towing. It shortens the reoxygenation time but delays the arrival time to shore. Both IWR and SR result in similar levels of perceived fatigue.

Assessment of over-the-head resuscitation method in an inflatable rescue boat sailing at full speed. A non-inferiority pilot study.

INTRODUCTION: Drowning is a public health problem. Interrupting the drowning process as soon as possible and starting cardiopulmonary resuscitation (CPR) can improve survival rates. Inflatable rescue boats (IRBs) are widely used worldwide to rescue drowning victims. Performing CPR in special circumstances requires adjusting the position based on the environment and space available. The aim of this study was to assess the quality of over-the-head resuscitation performed by rescuers aboard an IRB in comparison to standard CPR. METHODS: A quasi-experimental, quantitative, cross-sectional pilot study was conducted. Ten professional rescuers performed 1 min of simulated CPR on a QCPR Resuscy Anne manikin (Laerdal, Norway) sailing at 20 knots using two different techniques: 1) standard CPR (S-CPR) and 2) over-the-head CPR (OTH-CPR). Data were recorded through the APP QCPR Training (Laerdal, Norway). RESULTS: The quality of CPR was similar between S-CPR (61%) and OTH-CPR (66%), with no statistically significant differences (p = 0.585). Both the percentage of compressions and the percentage of correct ventilations did not show significant differences (p > 0.05) between the techniques. CONCLUSION: The rescuers can perform CPR maneuvers with acceptable quality in the IRB. The OTH-CPR technique did not show inferiority compared to S-CPR, making it a viable alternative when boat space or rescue conditions do not allow the conventional technique to be performed.

"Dispatcher, Can You Help Me? A Woman Is Giving Birth". A Pilot Study of Remote Video Assistance with Smart Glasses.

Smart glasses (SG) could be a breakthrough in emergency situations, so the aim of this work was to assess the potential benefits of teleassistance with smart glasses (SG) from a midwife to a lifeguard in a simulated, unplanned, out-of-hospital birth (OHB). Thirty-eight lifeguards were randomized into SG and control (CG) groups. All participants were required to act in a simulated imminent childbirth with a maternal−fetal simulator (PROMPT Flex, Laerdal, Norway). The CG acted autonomously, while the SG group was video-assisted by a midwife through SG (Vuzix Blade, New York, NY, USA). The video assistance was based on the OHB protocol, speaking and receiving images on the SG. The performance time, compliance with the protocol steps, and perceived performance with the SG were evaluated. The midwife's video assistance with SG allowed 35% of the SG participants to perform the complete OHB protocol. No CG participant was able to perform it (p = 0.005). All OHB protocol variables were significantly better in the SG group than in the CG (p < 0.05). Telemedicine through video assistance with SG is feasible so that a lifeguard with no knowledge of childbirth care can act according to the recommendations in a simulated, unplanned, uncomplicated OHB. Communication with the midwife by speaking and sending images to the SG is perceived as an important benefit to the performance.

HbLFG1, a Rubber Tree (Hevea brasiliensis) Lifeguard Protein, Can Facilitate Powdery Mildew Infection by Suppressing Plant Immunity.

Powdery mildew causes substantial losses in crop and economic plant yields worldwide. Although powdery mildew infection of rubber trees (Hevea brasiliensis), caused by the biotrophic fungus Erysiphe quercicola, severely threatens natural rubber production, little is known about the mechanism by which E. quercicola adapts to H. brasiliensis to invade the host plant. In barley and Arabidopsis thaliana, lifeguard (LFG) proteins, which have topological similarity to BAX INHIBITOR-1, are involved in host plant susceptibility to powdery mildew infection. In this study, we characterized an H. brasiliensis LFG protein (HbLFG1) with a focus on its function in regulating defense against powdery mildew. HbLFG1 gene expression was found to be upregulated during E. quercicola infection. HbLFG1 showed conserved functions in cell death inhibition and membrane localization. Expression of HbLFG1 in Nicotiana benthamiana leaves and A. thaliana Col-0 was demonstrated to significantly suppress callose deposition induced by conserved pathogen-associated molecular patterns chitin and flg22. Furthermore, we found that overexpression of HbLFG1 in H. brasiliensis mesophyll protoplasts significantly suppressed the chitin-induced burst of reactive oxygen species. Although A. thaliana Col-0 and E. quercicola displayed an incompatible interaction, Col-0 transformants overexpressing HbLFG1 were shown to be susceptible to E. quercicola. Collectively, the findings of this study provide evidence that HbLFG1 acts as a negative regulator of plant immunity that facilitates E. quercicola infection in H. brasiliensis.

Does a short intervention with vibration foam roller recover lifeguards better after a water rescue? A pilot study.

PURPOSE: The aim of this study was to analyze the effects of a recovery program based on foam roller with and without vibration on blood lactate clearance and perceived fatigue after a water rescue. METHODS: A quasi-experimental crossover design was carried out to compare passive (PR) recovery and a short protocol of foam roller (FR) and vibration foam roller (VFR) recovery after a 100 m water rescue in 7 volunteer lifeguards. Blood lactate and perceived exertion were measured before and after the rescue, and also after the 5-min recovery intervention. RESULTS: Blood lactate levels decrease significantly with foam roller (p = 0.013; effect size = 0.97) and vibration foam roller recovery (p < 0.001; effect size = 1.62). Passive recovery did not show significant differences clearing out blood lactate. Fatigue perceived decrease significantly with all the recovery methods, but foam roller has higher effects on the global fatigue and VFR on the legs. CONCLUSION: FR and VFR clear out more blood lactate and decrease fatigue more than PR, with the subsequently increase of the physical conditioning to perform another effort.

Plastic blanket drowning kit: A protection barrier to immediate resuscitation at the beach in the Covid-19 era. A pilot study.

OBJECTIVE: Introducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and HEPA filter, which could offer significant time-saving advantages to reduce COVID-19 risk transmission in the first few minutes of CPR after water rescue, avoiding the negative impact of delayed ventilation. METHOD: A pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and HEPA filter adapted on a pre-set plastic-blanket. The first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (PPE) and then covering the victim with an assembled plastic blanket. The second step consisted of 10 min of cardiopulmonary resuscitation (CPR) with PPE and plastic blanket, following the technical recommendations for ventilation during COVID-19. RESULTS: Ten rescuers took part in the pilot study. The average time to wear PPE and place the pre-assembly kit on the victim was 82 s [IC 58-105]. After 10 min the quality of the resuscitation (QCPR) was 91% [87-94]. Quality chest compressions (CC) were 22% better than ventilations (V). Most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple. CONCLUSIONS: Resuscitation techniques in COVID-19 era at the beach have added complexities for the correct use of PPE. Plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission.

New insights into the phylogeny of the TMBIM superfamily across the tree of life: Comparative genomics and synteny networks reveal independent evolution of the BI and LFG families in plants.

The Transmembrane BAX Inhibitor Motif containing (TMBIM) superfamily, divided into BAX Inhibitor (BI) and Lifeguard (LFG) families, comprises a group of cytoprotective cell death regulators conserved in prokaryotes and eukaryotes. However, no research has focused on the evolution of this superfamily in plants. We identified 685 TMBIM proteins in 171 organisms from Archaea, Bacteria, and Eukarya, and provided a phylogenetic overview of the whole TMBIM superfamily. Then, we used orthology and synteny network analyses to further investigate the evolution and expansion of the BI and LFG families in 48 plants from diverse taxa. Plant BI family forms a single monophyletic group; however, monocot BI sequences transposed to another genomic context during evolution. Plant LFG family, which expanded trough whole genome and tandem duplications, is subdivided in LFG I, LFG IIA, and LFG IIB major phylogenetic groups, and retains synteny in angiosperms. Moreover, two orthologous groups (OGs) are shared between bryophytes and seed plants. Other several lineage-specific OGs are present in plants. This work clarifies the phylogenetic classification of the TMBIM superfamily across the three domains of life. Furthermore, it sheds new light on the evolution of the BI and LFG families in plants providing a benchmark for future research.

The ocean lifeguard drowning prevention paradigm: how and where do lifeguards intervene in the drowning process?

Drowning is a global health problem that can be addressed with multiple strategies including utilisation of lifeguards in recreational swim areas. However, few studies have described lifeguard prevention activities. We conducted a retrospective analysis using lifeguard activity data collected in real time with a Computer-Aided-Dispatch (CAD) system to characterise the nature of lifeguard primary and secondary drowning prevention at a popular ocean beach in California. Preventative actions constituted the majority (232 065/423 071; 54.8%) of lifeguard activities, while rescues represented 1.9%. Most preventative actions and rescues occurred during summer months, weekends and afternoons. Statistically significant geographical clusters of preventative actions were identified all over the beach, while rescue clusters were primarily restricted to two sites. Using the most reliable and valid collection system to date, these data show spatial and temporal patterns for ocean lifeguard provision of primary prevention as well as secondary drowning prevention (rescue).

Do wave heights and water levels increase ocean lifeguard rescues?

OBJECTIVE: To investigate the association of wave height and tidal water level changes with the frequency of ocean lifeguard rescues. METHODS: All ocean lifeguard rescues recorded by Newport Beach Lifeguards in 2015 and 2016 were linked by time and location to weather and ocean variables contained in other historical databases. We performed separate multivariable analyses using mixed effects negative binomial regression to evaluate the total effects of wave height, mean water level (primarily set by tidal elevation), and rising vs. falling water level, on the frequency of ocean rescue in the study location, controlling for confounding variables. RESULTS: Newport Beach Lifeguards made 8046 rescues during the study period. In all areas of the beach, rescue frequency increased as waves got larger (IRR: 3.25; 95%CI: 2.91-3.79) but then decreased in large surf (IRR: 0.52; 95%CI: 0.37-0.73). In two sections of beach, lifeguards made more rescues during lower water levels, but in the third section of beach, made more rescues during higher water levels. Rescue frequency increased in two sections of beach with rising water levels, but did not in the other section. CONCLUSIONS: Wave height, water level, and water level direction were associated with rescue frequency, but the environmental factors included in the analysis did not fully account for most variation in rescue frequency. Other factors need to be evaluated to identify major determinants of rescue frequency.

Examination of a pilot intervention program to change parent supervision behaviour at Australian public swimming pools.

ISSUE ADDRESSED: Drowning is one of the leading causes of unintentional death in children worldwide. There is limited evidence about the effectiveness of programs targeting child drowning prevention at public swimming pools. We examined the effectiveness of a public education program (Keep Watch @ Public Pools) for improving child supervision levels by parents at public swimming pools. METHODS: The program was evaluated via an observational study of parent supervision behaviour with children aged 0-14 years. Measures included domains of attention, proximity and preparedness. A rating scale from 0 = least effective to 4 = most effective was used, based upon the supervision domains. Seven public swimming pools in Melbourne, Victoria, Australia were randomised to either intervention or control pool. The intervention occurred over six weeks, and observations were taken over a one-week period both pre- and postintervention. Observations of a total of 10 186 children and 6930 parents/carers were recorded and analysed. RESULTS: A significant improvement in attention, proximity and preparedness was observed in parents of children aged 6-10 years at intervention pools. However, similar results were not observed in parents of children aged 0-5 years and 11-14 years. CONCLUSIONS: Supervision behaviour of parents can be modified, and the implications of these results for the community through to practice and policy are discussed. SO WHAT?: Targeted public education programs provide an effective way of improving parental supervision of children at public swimming pools. Such education programs should be widely implemented throughout public swimming pools, as one part of a comprehensive approach to drowning prevention.

How can lifeguards recover better? A cross-over study comparing resting, running, and foam rolling.

PURPOSE: The aim of this study is to compare the effectiveness of active recovery in form of running or foam rolling on clearing blood lactate compared to remain sitting after a water rescue. METHOD: A quasi experimental cross-over design was used to test the effectiveness of two active recovery methods: foam rolling (FR) and running (RR), compared with passive recovery (PR) on the blood lactate clearance after performing a water rescue. Twelve lifeguards from Marín (Pontevedra) completed the study. The participants performed a 100-meter water rescue and a 25-minute recovery protocol. RESULTS: The post recovery lactate levels were significantly lower for foam rolling (4.4±1.5mmol/l, P=0.005, d=0.94) and running (4.9±2.3mmol/l, P=0.027, d=1.21) compared with resting (7.2±2.5mmol/l); there was no significant difference between foam rolling and running (P=1.000). CONCLUSIONS: We found that surf lifesavers clear out blood lactate more efficient when performing an active recovery protocol. Foam rolling is an effective method of increasing the rate of blood lactate clearance. These two recovery methods are also adequate for surf lifeguards as they do not interfere with the surveillance aspect of their job.

Can surf-lifeguards perform a quality cardiopulmonary resuscitation sailing on a lifeboat? A quasi-experimental study.

PURPOSE: Drowning is a high-priority public health problem around the world. The European Resuscitation Council Guidelines for Resuscitation 2015 put special emphasis on special environments like open waters. Stopping the drowning process as soon as possible and starting an early cardiopulmonary resuscitation (CPR) improve survival. Inflatable rescue boats (IRBs) are used around the world in the water rescue of drowning victims. Our objective was to test the quality of CPR performed by surf-lifeguards while sailing on an IRB. METHODS: A quasi-experimental simulation trial was conducted in Tenerife (Canary Islands-Spain) on September 2015. Ten surf-lifeguards were asked to perform a 2 min CPR on manikins in four different scenarios: (1) onshore, (2) on adrift boat, (3) on a boat sailing at 5 knots and (4) on a boat sailing at 10 knots. CPR was performed individually and was measured by means of CPRmeter (Laerdal, Norway) located on the standard manikin. Repeated measures analysis of variance was used in order to analyse the differences between scenarios. RESULTS: The composite of all CPR variables was over 84% in all conditions, but it was lower when CPR was performed on board: onshore (96.49±3.58%) versus adrift (91.80±3.56, p=0.04), sailing at 5 knots (88.65±5.54, p=0.03) and sailing at 10 knots (84.74±5.56, p=0.001). CONCLUSION: Surf-lifeguards are able to deliver good-quality CPR even on a moving IRB, but their performance is lower than onshore. This fact should be considered in real cases to balance the risk and benefits of CPR on board.

Prehospital Emergency Medicine at the Beach: What Is the Effect of Fins and Rescue Tubes in Lifesaving and Cardiopulmonary Resuscitation After Rescue?

OBJECTIVE: To analyze the influence of fins and rescue tube use in a water rescue, assessed by time and distance to salvage position, physiological parameters, and cardiopulmonary resuscitation (CPR). METHODS: Twenty professional lifeguards (10 men, 10 women) conducted 3 tests: a baseline test of 5 minutes of CPR and 2 water rescues, 1 without rescue equipment (NRE), and the other with fins and rescue tube (FRT). They also had to perform 5 minutes of CPR after each rescue. Time and distance of the rescues, physiological parameters (blood lactate concentration and heart rate), and quality of CPR were analyzed. RESULTS: CPR quality worsened by 26 to 28% (P < .001) after rescue. However, there were no differences using FRT. The use of rescue equipment reduced the time (FRT: 216±57 seconds; NRE: 319±127 seconds; P < .001) and distance covered (FRT: 265±52 m; NRE: 326±41 m; P < .001). No differences were found in lactate levels between FRT and NRE just after the rescues, but there were some after 5 minutes of subsequent CPR (FRT: 10.7±2.2 mmol/L; NRE: 12.6±1.8 mmol/L; P < .001). Comparing women with men, we found significant differences in lactate concentrations only in FRT (women: 9.6±1.4 mmol/L; men: 8.1±1.2 mmol/L; P = .031). CONCLUSIONS: The use of fins and rescue tube provides a comprehensive benefit in an aquatic emergency. However, FRT did not have any effect on the quality of the postrescue CPR.

Fas apoptosis inhibitory molecules: more than death-receptor antagonists in the nervous system.

The importance of death receptor (DR) signaling in embryonic development and physiological homeostasis is well established, as is the existence of several molecules that modulate DRs function, among them Fas Apoptotis Inhibitory Molecules. Although FAIM1, FAIM2, and FAIM3 inhibit Fas-induced cell death, they are not structurally related, nor do they share expression patterns. Moreover, they inhibit apoptosis through completely different mechanisms. FAIM1 and FAIM2 protect neurons from DR-induced apoptosis and are involved in neurite outgrowth and neuronal plasticity. FAIM1 inhibits Fas ligand- and tumor necrosis factor alpha-induced apoptosis by direct interaction with Fas receptor and through the stabilization of levels of X-linked inhibitor of apoptosis protein, a potent anti-apoptotic protein that inhibits caspases. Low FAIM1 levels are found in Alzheimer's disease, thus sensitizing neurons to tumor necrosis factor alpha and prompting neuronal loss. FAIM2 protects from Fas by direct interaction with Fas receptor, as well as by modulating calcium release at the endoplasmic reticulum through interaction with Bcl-xL. Several studies prove the role of FAIM2 in diseases of the nervous system, such as ischemia, bacterial meningitis, and neuroblastoma. The less characterized member of the FAIM family is FAIM3, which is expressed in tissues of the digestive and urinary tracts, bone marrow and testes, and restricted to the cerebellum in the nervous system. FAIM3 protects against DR-induced apoptosis by inducing the expression of other DR-antagonists such as CFLAR or through the interaction with the DR-adaptor protein Fas-associated via death domain. FAIM3 null mouse models reveal this protein as an important mediator of inflammatory autoimmune responses such as those triggered in autoimmune encephalomyelitis. Given the differences between FAIMs and the variety of processes in which they are involved, here we sought to provide a concise review about these molecules and their roles in the physiology and pathology of the nervous system. Even though they share name and inhibit Fas-induced cell death, Fas apoptotic inhibitory molecules (FAIMs) are not structurally related and inhibit apoptosis through completely different mechanisms. In this review, we describe FAIM1, FAIM2, and FAIM3 functions in the nervous system, and their implication in diverse pathologies such as neurodegenerative disease, cancer, or autoimmune diseases.

Mice lacking Faim2 show increased cell death in the MPTP mouse model of Parkinson disease.

The death receptor Fas/CD95 mediates apoptotic cell death in response to external stimuli. In neurons, Fas-induced apoptosis is prevented by Fas-apoptotic inhibitory molecule 2 (Faim2). Mice lacking Faim2 showed increased neurodegeneration in animal models of stroke and bacterial meningitis. We therefore tested the relevance of Faim2 in a classical animal model of Parkinson disease and determined the toxicity of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in Faim2-deficient mice. Without MPTP treatment, there was no difference in the dopaminergic system between Faim2-deficient mice and control mice. MPTP was applied i.p. in doses of 30 mg per kg on five consecutive days. Fourteen days after the last MPTP injection, the number of dopaminergic neurons in the lateral substantia nigra, assayed by stereological counting, was reduced by 39% in control mice and 53% in Faim2-deficient mice. The density of dopaminergic fibers in the dorsal striatum was reduced by 36% in control mice and 69% in Faim2-deficient mice, in the ventral striatum 44% in control mice and 76% in Faim2-deficient mice. Fiber density recovered at 90 days after MPTP with similar density in both groups. Striatal catecholamine levels were reduced by 81-84% in both groups and recovered at 90 days. Faim2 expression was documented in mouse midbrain using quantitative reverse transcription-PCR (qRT-PCR) and found decreased after MPTP administration. Taken together, our findings demonstrate increased degeneration of dopaminergic neurons with Faim2 deficiency, indicating that Fas-induced apoptosis contributes to cell death in the MPTP mouse model. Along with the decreased expression of Faim2 after MPTP, this finding indicates that boosting Faim2 function might represent a therapeutic strategy for Parkinson disease.

Impact of lifeguard oxygen therapy on the resuscitation of drowning victims: Results from an Utstein Style for Drowning Study.

INTRODUCTION: No published evidence was identified regarding the use of oxygen in the treatment of drowning in two recent systematic reviews. The aim of our study was to investigate the impact of on scene, pre-Emergency Medical Services (EMS) oxygen therapy by lifeguards in the resuscitation of drowning victims. METHOD: We conducted a retrospective case match analysis of drowning patients presenting to the EDs of Sunshine Coast Hospital and Health Service. Patients were matched for age, sex and severity of drowning injury. The primary outcome was in-hospital mortality. Secondary outcomes included positive pressure ventilation (PPV) by EMS and the ED, as well as admission to the Intensive Care Unit. RESULTS: There were 108 patients in each group. Median (IQR) age was 22 (15-43) in the oxygen group and 23 (15-44) years in the non-oxygen group. There were 45 females in the oxygen group and 41 females in the non-oxygen group. Sixteen patients had suffered cardiac arrest and three patients respiratory arrest in each group. There were five deaths in each group. Initial oxygen saturation on arrival of EMS was identical in both groups 89.2% (±19.9) in the oxygen group versus 89.3% (±21.1) (P = 0.294) in the non-oxygen group. The oxygen group required PPV more frequently with EMS (19 vs 11, P < 0.01) and in the ED (19 vs 15, P < 0.01). CONCLUSION: On scene treatment with oxygen by lifeguards did not improve oxygenation or outcomes in drowning patients.

Gaps in Education: A Cross-Sectional Survey Study of Knowledge of Advanced Lifesaving Interventions among Canadian Lifeguards.

Objective: The aim of this study was to assess lifeguards' knowledge retention of airway management, oxygen administration, and ventilation interventions following certification and employer-provided training. Methods: This cross-sectional study was conducted using an online survey administered between February and May 2024. A total of 1322 responses from Canadian lifeguards certified in airway management and oxygen administration were deemed eligible for analysis. The survey included 15 knowledge assessment questions, with data analyzed based on lifeguard experience and the date of last certification or in-service training. Results: The mean knowledge assessment score was 10.4 ± 2.2 (69.3 ± 14.6%), with the highest scores in the airway management category and the lowest in the oxygen administration category. Lifeguard experience significantly increased knowledge retention, whereas recertification showed no significant impact, and employer-provided training significantly decreased knowledge retention. Conclusions: The findings underscore the importance of lifeguarding experience in knowledge retention among lifeguards. Optional airway management and oxygen administration recertification, coupled with inconsistent in-service training, have created significant gaps in lifeguard education. This study identifies the need for regular, competency-based training delivered by qualified facilitators. Addressing these gaps is crucial for enhancing the effectiveness of lifeguards in emergency response and ensuring high-quality care for drowning victims.

Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study.

BACKGROUND: Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed. METHODS: An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75-85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. RESULTS: Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90-95%). The integral flowchart received strong consensus (93%). CONCLUSIONS: This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

Oxylator and SCUBA dive regulators: useful utilities for in-water resuscitation.

INTRODUCTION: In water resuscitation has been reported to enhance the outcome of drowning victims. Mouth-to-mouth ventilation during swimming is challenging. Therefore, the efficacy of ventilation utilities was evaluated. METHODS: Ventilation was assessed with the Oxylator ventilator, as well as the consecutive self-contained underwater breathing apparatus (SCUBA) regulators using an anaesthetic test lung: Poseidon Cyklon 5000, Poseidon XStream, Apeks TX 100, Spiro Arctic, Scubapro Air2 and Buddy AutoAir. RESULTS: Oxylator, Apeks TX 100, Arctic and Buddy AutoAir delivered reliable peak pressures and tidal volumes. In contrast, the ventilation parameters remarkably depended on duration and depth of pressing the purge button in Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2. Critical peak pressures occurred during ventilation with all these three regulators. DISCUSSION: The use of Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2 regulators is consequently not recommended for in-water ventilation. With the limitation that the devices were tested with a test lung and not in a human field study, Apeks TX 100, Spiro Arctic and Buddy AutoAir might be used for emergency ventilation and probably ease in-water resuscitation for the dive buddy of the victim. Professional rescue divers could be equipped with the Oxylator and an oxygen tank to achieve an early onset of efficient in-water ventilation in drowning victims.