In-water resuscitation - What are the highlights and pitfalls?

TitleIn-water resuscitation - What are the highlights and pitfalls?
Publication TypeConference Paper
Year of Publication2007
AuthorsDr Szpilman, MD, D, Handley, AJ
Conference NameWorld Conference on Drowning Prevention
Date Published09/2007
PublisherInternational Life Saving Federation
Conference LocationPorto, Portugal
Other Numbers03-21

Whenever an apparently non-breathing victim is found in the water, the rescuer is confronted with a difficult choice. Should the rescuer attempt resuscitation procedures in the water or first bring the victim to shore, and then attempt resuscitation? This question was one of those looked at by the 2005 International Consensus on Cardiopulmonary (CPR) and Emergency Cardiovascular Care (ECC) Science and Treatment Recommendations (CoSTR) organized by the International Liaison Committee on Resuscitation (ILCOR). The purpose of this presentation is to present the CoSTR evidence-based worksheet on in-water resuscitation (IWR). (1).

Material & Methods: Until 2005, there was no reliable information about in-water resuscitation supported by evidence-based medicine. The CoSTR process reviewed the available evidence and assigned a “class of recommendation” and “level of evidence (LOE)” to IWR.

Results: These recommendations are for cases where the submersion time is unknown or is known to be less than 15 minutes (LOE 4). Whenever a non-breathing victim is found in the water, the rescuer should bring the victim's face out of water and extend the neck to open the airway (Class IIa – LOE 4). In either shallow or deep water, if two or more rescuers are present, or a single rescuer is equipped with a floatation device, the victim should then be checked check for breathing. In the absence of spontaneous breathing, rescue breathing should be carried out for approximately one minute. If breathing IS restored, the victim’s airway should be kept open during recovery to dry land.  Only a brief stop should be made to monitor breathing and restart rescue breathing if necessary. If breathing IS NOT restored or there is no circulation, the rescuer should recover the victim to shore without further attempts at rescue breathing (2) (LOE 4). Rescuers should not check victim’s pulse or start compressions while in the water. Cardiac compression in the water has been shown to be ineffective and pulse checks are both unreliable and slow the rescue process; even if CPR is necessary, this may place the victim in further danger of aspiration of water and needlessly tire the rescuer (LOE 5). After successful resuscitation the victim should be kept under observation for 5 to 10 minutes in case breathing stops (LOE 5). Even trained lifeguards cannot always accomplish IWR technique effectively, especially in deep water (LOE 4).

Discussion: The process of evidence-based medicine recommendations adopted by ILCOR for the 2005 CoSTR process allows national resuscitation councils to draw up their own guidelines according to their individual needs. The IWR worksheet was used differently by the European Resuscitation Council (ERC), the American Heart Association (AHA) and other organizations when producing practical guidelines. Lifeguards should be well trained in IWR.  The decision whether to start IWR or to recover the victim as quickly as possible to the shore is a matter of judgment, which should take into account daily beach conditions, and distance from shore, as well as lifeguard fitness, experience, skill and self-confidence. (2). An algorithm has been produced summarizing IWR (algorithm 1).

Learning Outcomes
  1. Why the new recommendation?
  2. When to do it?
  3. How to do it?
  4. What are the benefits and the pitfalls?
  1. Szpilman D  Worksheet to 2005 Guidelines - American Heart Association (AHA) & International Liaisson Comittee for Resuscitation (ILCOR), Budapest, September 2004.
  2. Szpilman D. & Soares M., In-water resuscitation— is it worthwhile?  Resuscitation  63/1 pp. 25-31 October 2004.
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