The pediatric submersion score predicts children at low risk for injury following submersions

Abstract

Introduction

Pediatric submersion victims often require admission. We wanted to identify a cohort of children at low risk for submersion-related injury who can be safely discharged from the emergency department (ED) after a period of observation.

Methods

This was a single-center retrospective derivation/validation cross-sectional study of children (0-18 years) who presented post-submersion to a tertiary-care, children's hospital ED from 2008-2015. We reviewed demographics, comorbidities, prehospital and ED course. Primary outcome was safe discharge at 8 hours' post-submersion: Normal mentation and vital signs. To identify potential scoring factors, any p-value ≤0.25 was included in binary logistic regression; p-values <0.05 were included in the final score. In the validation dataset, we generated a one-point scoring system for each normal ED item. Receiver operating characteristic curves with area under the curve (AUC) were generated to test sensitivity and specificity.

Results

The derivation dataset consisted of 356 patients and validation dataset of 89 patients. Five factors generated a safe discharge score at 8 hours: normal ED mentation, normal ED respiratory rate, absence of ED dyspnea, absence of need for airway support (Bag-valve-mask ventilation, intubation and CPAP), absence of ED systolic hypotension (Max. score: 5; Range 0-5). Only the 80 patients with values for all five factors were included in the sensitivity/specificity analysis. This resulted in an AUC = 0.81 (95% CI: 0.71–0.91; p-value<0.001). Based on the sensitivity/specificity analysis, the discriminative ability peaks at 75% with a score ≥3.5. A score of 4 or higher in the ED would suggest a safe discharge at 8 hours [Sensitivity: 88.2% (95% CI: 72.5% - 96.7%); Specificity is 62.9% (95% CI: 44.9% - 78.5%); Positive Predictive Value: 69.8% (95% CI: 53.9% - 82.8%); Negative Predictive Value: 84.6% (95% CI: 65.1% - 95.6%)].

Conclusions

A risk score can identify children at low risk for submersion-related injury who can be safely discharged from the ED after observation.

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