Por David Szpilman

Final recommendations of the World Congress on Drowning <www.drowning.nl>
Amsterdam 26 - 28 June 2002

Trabalhos Brasileiros apresentados - Clique aqui !!!

The World Congress on Drowning is an initiative of
de Maatschappij tot Redding van Drenkelingen
Established in Amsterdam in 1767

As a result of an interactive process that was initiated in 1998 by nine task forces, including some 80 experts, and finalized during plenary sessions, expert meetings and research meetings in 2002 at the World Congress on Drowning, recommendations were made in the field of drowning prevention, rescue and treatment. This was the first time that many of these subjects were addressed in a global forum.
The congress was attended by more than 500 persons. Although not every participant was directly involved in the development of each recommendation, these recommendations can be considered to be the most authoritative recommendations on the issue of drowning prevention, rescue and treatment at this moment. 
Many of the foremost authorities have been involved in the preparations during the four years prior to the congress and have been actively involved during the congress. The draft version of the 13 final recommendations was presented at the plenary closing ceremony of the congress. That preliminary version of the recommendations was distributed by e-mail and adapted as a result of the comments received. An additional series of detailed recommendations in the areas of rescue and diving (breath hold, scuba and hose diving) were agreed upon within the nominated task forces. 
This final version of the recommendations was then agreed upon by the members of the scientific steering group and the chairs of the nine task forces (epidemiology, prevention, rescue, resuscitation, hospital treatment, brain and spinal protection, immersion hypothermia, diving and drowning and water-related disasters).

All recommendations, together with the preparatory documents as consensus papers, reports of expert and research meetings, will be published in 2003 in the Handbook on Drowning.

A list of names of the members of the scientific steering group, task forces and attendees of the World Congress on Drowning is included.

1. A new, more appropriate, world-wide uniform definition of drowning must be adopted
A uniform definition of drowning is important for purposes of registration, diagnosis and research. 
The following definition was accepted: "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid."
All organisations involved in epidemiological research and vital statistical data collection as well as rescue organisations and the medical community should consider and preferably accept this new definition as a basis for useful communication and include it in their glossary. Further consultation of drowning experts is needed to uniformly classify morbidity and mortality due to drowning.

2. There is a great need of adequate and reliable international registrations of drowning incidents
International and national registration procedures of the number of drowning victims, immersion hypothermia victims, rescues, and hospital data are needed to better appreciate the world-wide burden of drowning. Also clinical data, for example on resuscitations and rewarming techniques, are needed to improve treatment.
International organisations, such as The World Health Organisation (WHO), the International Red Cross and Red Crescent organisations (IRCRC), the International Life Saving Federation (ILS), the International Life Boat Institute (ILF) and Diver's Alert Network (DAN), as well as national organisations, institutions and medical research consortiums are advised to set up and coordinate data-collection.

3. More data must be collected and knowledge gained about drowning in low-income countries and societies
According to repeated WHO reports, over 80% of all drownings occur in low-income countries or in low-income groups in high income countries. Nevertheless only few epidemiological data about these risk groups are available. The WHO, IRCRC, ILS, ILF and the European Consumer Safety Institute (ECOSA) are encouraged to expand the research on drowning risk factors in these low-income groups because this is expected to have a major impact in reducing the risk of drowning.

4. Preventive strategies and collaboration are needed
The vast majority of drownings can be prevented and prevention (rather than rescue or resuscitation) is the most important method by which to reduce the number of drownings. The circumstances and events in drowning differ across many different situations and in different countries world wide. Considerable differences exist in the locations of drowning and among different cultures. Therefore, all agencies concerned with drowning prevention - legislative bodies, consumer groups, research institutions, local authorities and designers, manufacturers and retailers - must collaborate to set up national and local prevention initiatives. These will depend on good intelligence and insightful research, and must include environmental design and equipment designs as a first route, in conjunction with education, training programs and policies which address specific groups at risk, such as children. The programs must be evaluated and the results of the evaluations must be published.

5. All individuals, and particularly police officers and fire fighters, must learn to swim
Knowing how to swim is a major skill to prevent drowning for individuals at risk. International organisations such as WHO, IRCF and ILS, and their national branches must emphasize the importance of swimming lessons and drowning survival skills at all levels for as many persons as possible. The relationships between swimming lessons, swimming ability and drowning in children needs to be studied. In addition, certain public officials who frequently come in close contact with persons at risk for drowning, such as police officers and fire fighters, must be able to swim for their own safety and for the safety of the public.

6. Rescue techniques must be investigated
Most of the current rescue techniques have evolved by trial and error, with little scientific investigation. Rescue organisations such as the ILS, ILF, IRCRC but also the International Maritime Organization (IMO) must be encouraged to evaluate the self-rescue and rescue techniques in their training programs in accordance with current scientific data on the effectiveness and efficiency. Based on the data, the best rescue techniques must be selected for education and training programs.

7. Basic resuscitation skills must be learned by all volunteer and professional rescuers as well as lay persons who frequent aquatic areas or supervise others in water environment
The instant institution of optimal first aid and resuscitation techniques is the most important factor to survive after drowning has occurred. Resuscitation organisations, such as organisations, in particular those related to International Liaison Committee on Resuscitation (ILCOR), as well as professional rescue organisations and other groups who frequent aquatic areas, must promote training programs in first aid and Basic Life Support for anyone who frequently visits or is assigned to work in the aquatic or other water environment.

8. Uniform glossary of definitions and a uniform reporting of drowning resuscitation must be developed and used
To increase the understanding of the dying process and the resuscitation potential in drowning, a uniform reporting system must be developed and used for the registration of resuscitation of drowning.
International resuscitation organisations, such as ILCOR-related organisations and medical groups, must establish a uniform reporting system, facilitate its use, be involved in the analysis of the data and support of recommendations based on the studies.

9. Hospital treatment of the severe drowning victim must be concentrated
The optimal treatment of drowning victims includes dealing with specific severe complications such as the Acute Respiratory Distress Syndrome, pneumonia, hypoxic brain damage, hypothermia and cervical spine injuries. Due to the limited exposure and experience of most physicians with drowning victims, these victims should ideally be treated in specialised intensive care centres for optimal treatment and promotion of clinical research.

10. Treatment of the patient with brain injury resulting from cardiopulmonary arrest attributable to drowning must be based on scientific evidence. Due to the absence of interventional outcome studies in human drowning victims, current therapeutic strategies must be extrapolated from studies of humans or animals having similar forms of acute brain injury
The following recommendations for care of drowning victims who remain unresponsive due to anoxic encephalopathy are made on the basis of best available scientific evidence. The highest priority is restoration of spontaneous circulation. Subsequent to this, continuous monitoring of core and/or brain (tympanic) temperature is mandatory in the emergency department and intensive care unit (and in the prehospital setting to the extent possible). Drowning victims with restoration of adequate spontaneous circulation who remain comatose should not be actively rewarmed to temperature values >32-34oC. If core temperature exceeds 34 oC, hypothermia (32-34oC) should be achieved as soon as possible and sustained for 12-24 hours. Hyperthermia should be prevented at all times in the acute recovery period. There is insufficient evidence to support the use of any neuro-resuscitative pharmacologic therapy. Seizures should be appropriately treated. Blood glucose concentration should be frequently monitored and normoglycemic values maintained. Although there is insufficient evidence to support a specific target PaCO2 or oxygen saturation during and after resuscitation, hypoxemia should be avoided. Hypotension should also be avoided. Research is needed to evaluate specific efficacy of neuroresuscitative therapies in drowning victims.

11. Wearing of appropriate and insulating life jackets must be promoted 
Without floating aids, a subject generally drowns within minutes due to swimming failure in cold water. Therefore, the development of insulating and safe garments for aquatic activities is needed. Life jackets should always be worn when immersion can occur to prevent submersion in an early stage. When only non-insulating floating aids can be used, the victim should consider whether swimming ashore is achievable. 

12. The balance between safety and profitability of recreational diving must remain critically observed
It was agreed that self-regulation within the world-wide recreational diving industry continues to be the practical route for further improvement but that there is a need to counter the perception that there is a conflict between commercial interest and safety.

13. Safety of diving fishermen needs more attention
Subsistence fishermen, who are predominantly found in the poor countries around the world, use equipment that is minimal and their training, regulations and medical support appear to be zero.
To improve diving-fishermen safety and reduce drowning there is a need to collect data on accidents and drowning among representative samples of diving fishermen around the world.
This should be followed up with international non-governmental organisations, other charities and appropriate UN development initiatives so that existing academic societies, training organisations and others could deliver suitable medical and diving advice and training for fishermen compatible with the limits of available local resources.

Several more specific recommendations have been proposed and need the full support of related organisations 
These recommendations refer to the further development of existing research projects such as:
· Global uniformity of beach signs and safety flags 
· Risk assessment of beach hazards
· Determination of optimal visual scanning techniques
· Construction of the most adequate rescue boats, including alternatives such as jet boats, hovercrafts, with minimum risk of injuries for the drivers

Other recommendations were made to improve practical aspects related to:
· Legal aspects of drowning incidents
· Evacuation planning of large passenger ships
· Uniformity in training programs for lifeguards
· Fund raising for aquatic safety activities

All recommendations, together with the preparatory documents as consensus papers, reports of expert and research meetings, will be published in the Handbook on Drowning. The Handbook will be available in 2003. 

A large number of additional recommendations were elaborated before and during the World Congress on Drowning by the members of the task forces rescue and diving (breath hold, scuba and hose diving). These detailed recommendations are included in the appendices.

All recommendations need full support from governments, organisations, institutions and individuals to enable reduction of the last remaining field of neglected injuries. Each year some 500,000 persons world-wide are still dying from drowning. This is too much.

National Steering Group World Congress on Drowning
Ed van Beeck
Henk Beerstecher
Rob Brons
Rob de Bruin
Hein Daanen
Hans Knape
Wim Rogmans
Bert Thijs
Rob van Hulst
Joost Bierens

Task-force chairpersons
Christine Branche
B. Chris Brewster
David Elliott
Paul Pepe
Jean-Louis Vincent
Beat Walpoth
David Warner
John Wilson

Task-force members
Peter Barss
Elisabeth Bennet
Robert Berg
Marileen Biekart
Alfred Bove
Ruth Brenner
Jean Carlet
Daniel Danzl
Michel Ducharme
Glen Egstrom
Adam Fischer
Dick Fundter
Luciano Gattinoni
Corsmas Goemans
Des Gorman
Tom Griffiths
Antony Handley
Martine Hoofwijk
Adriaan Hopperus Buma
Jim Howe
Paul Husby
Ahamed Idris
Udo Illievich
Cor Kalkman
Laurence Katz
Gabriel Kinney
Patrick Kochanek
Olive Kobusingye
John Langley
Gerard Laanen
Ian Mackie (†)
Peter Mair
Jorge Mancebo
Andrej Michalsen
Peter Morley
Anja Nachtegaal
Bengt Nellgard
Martin Nemiroff
Bevely Norris
John Pearn
Eleni Petridou
Sjaak Poortvliet
Linda Quan
Slim Ray 
Peter Safar
Ian Scott
Andrew Short
Antony Simcock 
Rob Slomp
Gordon Smith 
David Szpilman
Takefumi Sakabe
Maida Taylor
Michael Tipton
Peter Tikuisis
Hidde Toet
Hans van Vught
Jürg Wendling
Volker Wenzel
Peter Wernicki
Sip Wiebenga
Klaus Wilkens
Mike Woodruffe
Rick Wright
Max Harry Weil
Jörg Wendling
Jane Wigginton
Klaus Wilkens
Durk Zandstra

The Maatschappij tot Redding van Drenkelingen was established in 1767 to promote awareness of drowning in the Netherlands. The organisation has initiated the World Congress project in 1998 to facilitate involved experts, institutions and organisations to further develop insight in methods to reduce drowning and improve the outcome after drowning. The activities merged together during an interdisciplinary, international and interactive convention in Amsterdam in June 2002.

An important result of the World Congress on Drowning, that was attended by more than 500 experts from all over the world, was the establishment of recommendations. The recommendations were prepared by task-forces in the preceding years and extensively discussed by experts during the congress.
Implementation of each recommendation is expected to contribute to a reduction of the annual number of drowning (some 500,000 drowning deaths each year worldwide) and to the improvement of treatment. 

On behalf of all participating experts of the World Congress on Drowning, we would like to inform you about these recommendations. We would advocate to study all the recommendations, select those of importance for your organisation and include the implementation of the relevant recommendations in your action plans for the coming three years. It is beyond the capacities of our national organisation to take care of the implementations worldwide. 

The Maatschappij tot Redding van Drenkelingen will contact experts and other organisations involved again at the end of 2005 to be informed on the progress and difficulties in the implementation. At that time, the Maatschappij tot Redding van Drenkelingen would like to know if the initiative has created new activities and concerted actions in your organisation. Based on this evaluation, a new initiative may be taken to give all involved experts, institutions and organisations the opportunity and facilities to meet each other again.

Please do not hesitate to contact the Maatschappij tot Redding van Drenkelingen when you have any questions, remarks or suggestions.

J.C. van Dorp
Chairman Maatschappij tot Redding van Drenkelingen

Prof.Dr. JTA Knape
Chairman Scientific Steering Group

Prof.Dr. JJLM Bierens
Project coordinator World Congress on Drowning