Chest-compression-only after drowning: a call for more research

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Editorial
Chest-compression-only
after
drowning:
a
call
for
more
research
Every
now
and
again
a
publication
appears
that
challenges
long-held
beliefs:
that
by
Fukunda
et
al.
from
Japan,
published
in
the
current
issue
of
Resuscitation,
is
surely
one
such.
1
The
authors’
conclusion,
from
a
large
observational
study
of
cases
of
drowning,
is
that
there
was
no
difference
in
the
one-month
neurologically-favourable
survival
between
those
victims
who
received
bystander-initiated
conventional
CPR
and
those
who
received
compression-only
CPR.
Since
the
initial
Advisory
Statements
from
the
International
Liaison
Committee
on
Resuscitation
(ILCOR),
2
drowning
has
been
considered
a
“special
circumstance”
requiring
some
variation
from
standard
adult
CPR.
Because
drowning
produces
an
asphyxial
rather
than
a
primary
cardiac
arrest,
emphasis
has
been
put
on
the
need
for
early
ventilation.
Whilst
the
subsequent
guidelines
for
adult
basic
life
support
(BLS)
continued
to
advise
starting
resuscitation
with
rescue
breaths,
only
minor
differences
were
needed
for
drowning
victims,
such
as
giving
5
initial
breaths
and
performing
resuscitation
for
about
1
min
before
going
for
help.
It
also
meant
that
the
same
algorithm
could
be
used
for
drowning
as
for
paediatric
BLS.
34
From
2005
onwards,
however,
the
standard
adult
BLS
algorithm
changed
to
30
initial
chest
compressions
followed
by
2
rescue
breaths,
5
reflecting
the
recognition
that
most
cardiac
arrests
are
due
to
a
cardiac
cause
and
chest
compressions
are
of
primary
importance.
In
parallel
with
this
came
publications
suggesting
that
chest
compres-
sions
alone
were
at
least
as
effective
as
combined
compression
and
ventilation
in
most
cases
of
adult
cardiac
arrest.
69
This
created
a
problem
for
those
responsible
for
advising
on
resuscitation
following
drowning,
as
compression-first
was
not
consistent
with
the
need
urgently
to
ventilate
a
hypoxic
victim.
Several
publications
appeared,
emphasising
this
need
and
calling
for
more
recognition
of
drowning
as
requiring
specific
attention
and
management.
1012
The
latest
(2015)
European
Resuscitation
Council
guidelines
still
recommend
combined
compression
and
ventilation
for
all
cases
of
cardiac
arrest,
13
but
recognise
that
the
far
simpler
chest-
compression-only
is
an
effective
alternative
for
dispatcher-
directed
(telephone)
CPR.
Dispatchers
are
advised
to
offer
compression-only
CPR
for
untrained
rescuers
in
all
cases
of
cardiac
arrest
except
children,
when
instruction
on
rescue
breaths
should
be
given
as
well.
Surprisingly,
drowning
is
not
included
as
a
similar
exception,
implying
that
dispatchers
should
offer
compres-
sion-only
CPR.
The
guidelines
do
contain
a
much-expanded
section
on
water
rescue
and
drowning,
including
a
unique
treatment
algorithm,
but
this
is
specifically
for
rescuers
with
a
duty
to
respond.
14
But
what
about
the
bystander
without
such
a
duty?
Fukunda
et
al.
suggest
that
it
is,
in
fact,
reasonable,
for
dispatchers
to
offer
compression-only
CPR.
In
spite
of
the
fact
there
has
not
been
any
previous
randomised
clinical
trial,
or
even
observational
study
of
conventional
versus
compression-only
CPR
following
drowning,
1
experts
in
the
field
have
argued
that
there
is,
a
priori,
a
case
for
combined
ventilation
and
compression
based
on
the
fact
that
drowning
is
an
asphyxial
event.
1012
A
Devil’s
Advocate*,
15
however,
could
argue
that
there
is
a
good
case
for
considering
the
results
of
this
new
study
as
a
call
for
further
research,
because:
-
dispatcher-
and
mass-teaching
of
compression-only
CPR
has
been
shown
to
improve
overall
results
from
out-of-hospital
bystander
resuscitation.
16
Might
this
not
also
be
the
case
for
drowning
itself?
-
by
no
means
every
victim
of
cardiac
arrest
in
the
water
has
suffered
primary
drowning.
17
-
at
least
in
developed
countries,
cardiac
causes
of
cardiac
arrest
are
much
more
common
than
drowning:
the
principle
of
‘the
greatest
good
for
the
greatest
number’
should,
therefore,
apply.
18
-
even
if
standard
CPR
(with
ventilation)
is
the
management
of
choice
for
drowning
victims,
surely
it
is
better
for
the
untrained
rescuer
to
be
instructed
to
do
something
simple
than
to
be
unable
to
do
anything?
Fukunda
et
al.,
quite
rightly,
admit
that
there
are
weaknesses
in
their
study,
mainly
related
to
a
lack
of
data
on
specific
features
of
drowning,
such
as
water
temperature,
submersion
duration,
and
body
of
water.
These
data
are
not
included
in
reports
according
to
Utstein
reporting
of
out-of-hospital
cardiac
arrest
19
although
they
are
in
the
Utstein-style
reporting
for
drowning.
20
In
addition,
both
reporting
styles
only
ask
whether
or
not
bystander
CPR
included
rescue
breathing
as
subset
or
supplementary
information.
Future
retrospective
researchers
will
have
no
choice
but
to
use
what
data
exist,
but
prospective
studies
should
be
designed
to
avoid
these
deficiencies.
We
are
about
a
year
away
from
a
5-yearly
review
of
the
resuscitation
guidelines,
and
already
working
groups
are
reviewing
current
literature.
This
paper
will
undoubtedly
be
of
interest.
How
might
it
change
the
management
of
drowning?
Probably
very
little,
particularly
for
rescuers
with
a
duty
of
care.
It
does
seem
a
little
strange
that
guidelines
for
R
E
S
U
S
C
I
T
A
T
I
O
N
1
4
5
(
2
0
1
9
)
1
9
4
1
9
5
Available
online
at
www.sciencedirect.com
Resuscitation
jou
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epag
e:
ww
w.els
evier.c
o
m/lo
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ate/res
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sc
itat
ion

dispatcher-directed
CPR
after
drowning
are
currently
compression-only;
it
is
even
possible
that
this
was
an
oversight.
The
results
of
the
present
study,
however,
suggest
that
the
advice
may,
in
fact,
be
correct.
The
appropriate
working
group
should
take
Fukunda
and
colleagues’
research
into
consideration
when
reviewing
the
section.
We
have
been
set
a
challenge!
In
this
day
of
evidence-based
medicine,
we
need
to
be
open
to
all
ideas
that
could
possibly
result
in
a
significant
change
in
our
practice
of
resuscitation
medicine.
Who
will
be
first
to
try
and
replicate
these
database
results?
*Devil’s
Advocate
is
someone
who
takes
a
position
they
do
not
necessarily
agree
with
for
the
sake
of
debate
or
to
explore
the
thought
further.
Conflict
of
interest
statement
The
author
holds
honorary
(unpaid)
roles
in
the
European
Resuscita-
tion
Council,
Resuscitation
Council
(UK)
and
Royal
Life
Saving
Society
UK.
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©
2019
The
Author.
Published
by
Elsevier
B.V.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
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