Saturday, February 24, 2018

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions

Title: The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions
Authors: Shenoi RP, Allahabadi S, Rubalcava DM, Camp EA
Journal: Academic Emergency Medicine, December 2017

This is the 3rd paper in a few months concerning improving prognostication of pediatric drowning patients in the emergency department (ED). The aim of this is to better understand who can be safely discharged and who needs to be admitted. This group of authors did some very nice work to derive and validate a clinical score to be used in the ED. They based the derivation on previous work by Dr David Szpilman, found which factors correlated best with "safe discharge" within 8 hours, and then re-applied this criteria to earlier data to validate the score.

This paper has a lot of advanced study design and statistics, but here is the bottom line:

Design

  • Derivation
    • Retrospective review of pediatric drowning cases 2010-2015
    • Evaluated predictor variables based on previous literature
    • Correlated to outcome of safe discharge at 8 hours post-submersion
      • Absence of respiratory distress/need for O2
      • Normal mentation (GCS 14-15)
      • Normal lung exam
      • Normal vital signs
  • Validation
    • Retrospective review of pediatric drowning cases 2008-2009
    • Applied factors found in validation to these cases
      • Correlated with "safe discharge" and outcome, found by reviewing medical records and fatality records
Results
  • Risk score derivation
    • Based on 278 patients
    • Predictors chosen for score
      • Normal ED mentation
      • Normal ED respiratory rate
      • Absence of ED dyspnea
      • Absence of need for airway support
      • Absence of ED hypotension
  • Risk score validation
    • Based on 80 patients
    • 1 point for each criteria named above
      • Discriminative ability peaked at 75% with score ≥ 3.5
      • Score of ≥ 4 in ED suggests a safe discharge at 8 hours
  • Outcome analysis
    • Based on medical records of all derivation and validation patients
      • No patients who were judged to be safe for discharge at 8 hours__
      • 2 patients returned to ED in derivation group, both at 4 days, one with pneumonia and one with fever
      • No return visits by those in validation group
      • No deaths in those children deemed safe for discharge 
Discussion

These authors derived and validation a clinical score to assist in determining pediatric patients who are safe for discharged after 8 hours of ED observation. The following factors predict safe discharge:

  • Normal ED mentation
  • Normal ED respiratory rate
  • Absence of ED dyspnea
  • Absence of need for airway support
  • Absence of ED hypotension
Presence of 4 or more of the above predicts safe discharge. While there are some inherent weaknesses to the design and the single-center nature restricts its generalizability, this study will hopefully set a foundation for further validation throughout other health systems.

Reference

Sunday, February 4, 2018

Predictors of safe discharge for pediatric drowning patients in the emergency department

Title: Predictors of safe discharge for pediatric drowning patients in the emergency department
Authors: Courtney E. Brennan, Travis K.F. Hong, Vincent J. Wang
Journal: The American Journal of Emergency Medicine, Jan 2018

This is the second article on this topic within the past 6 months. This is great to see as the evidence concerning this important topic is scant.

Study Aim


"determine if pediatric drowning patients who are well-appearing with normal age-adjusted vital signs and pulse oximetry at presentation to the emergency department can be safely discharged without admission or a prolonged observation period."

Methods
  • Retrospective chart review of all pediatric patients with discharge diagnosis of drowning, near drowning, or submersion injury, 1995-2014
  • Excluded patients transferred in, with significant comorbids, distracting injuries, or GCS < 14
Results
  • 180 patient included
    • Mean age 2.94 years
    • 64% males
    • Majority of drownings in pools
    • Submersion time known 66%, all less than 5 minutes
  • Findings
    • No correlation between age, submersion time, apneic time, resus time, and disposition
    • 34% had normal age-adjusted initial vital signs and pulse oximetry on arrival
      • One of these patients had clinical decline and had grunting respirations within 1 hour of presentation.
    • 52% of patients in the study admitted to the hospital
      • 8 of these patients had clinical decline
        • All experienced decline within 1 hour of presentation
        • None of these patients required more than supplement oxygen
        • All returned to baseline before discharge
        • 2 of these patients had normal vital signs on presentation
          • Both developed grunting within 1 hour
        • Abnormal vital signs on presentation not associated with decline
        • Those with decline more likely to have abnormal pulse ox on arrival
    • 48% discharged from emergency department
      • 2 had return visits within 3 days, both discharged from department same day
Bottom Line

While small in nature, this study adds much needed evidence to an important and not well-studied topic. The most important result of this study is that it helps confirm what we have found in similar studies: patients presenting to the emergency department following drowning who are initially stable and mentating well tend to do well, and if they decline they do so within first 4-8 hours.


Reference