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Predictors of death and neurologic impairment in pediatric submersion injuries. The Pediatric Risk of Mortality Score
G B Zuckerman1, P M Gregory, S M Santos-Damiani
1Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ, USA. zuckerga@umdnj.edu
Insights
The Pediatric Risk of Mortality Score (PRISM score) effectively predicted outcomes for pediatric emergency department (ED) patients after submersion incidents. However, it was less accurate for pediatric intensive care unit (PICU) patients.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Emergency medicine
Background:
- Submersion incidents pose significant risks for pediatric patients, leading to potential death or severe neurologic impairment.
- Accurate prognostication is crucial for guiding treatment and resource allocation in pediatric intensive care.
Purpose of the Study:
- To evaluate the Pediatric Risk of Mortality Score (PRISM score) for predicting neurological outcomes in pediatric patients following submersion incidents.
- To determine the score's efficacy in distinguishing between survival with intact neurological function and death or severe impairment in emergency department (ED) and pediatric intensive care unit (PICU) settings.
Main Methods:
- Retrospective chart review of pediatric patients (1 day to 18 years) admitted to a regional tertiary care ED and PICU between 1986 and 1995.
- Calculation of PRISM scores and probability of outcome upon patient arrival to the ED or PICU.
- Comparison of predicted outcomes with actual patient outcomes (neurologically intact survival, severe impairment, or death) assessed by the Pediatric Cerebral Performance Category Scale.
Main Results:
- In the ED, PRISM scores < 25 or probability of outcome < 50% accurately predicted neurologically intact survival (P < .001).
- Conversely, PRISM scores ≥ 25 or probability of outcome ≥ 50% accurately predicted death or severe impairment in ED patients (P < .001).
- In the PICU, PRISM scores ≤ 5 or probability of outcome < 4% predicted intact survival (P < .05), while scores > 20 or probability > 50% predicted death/impairment (P < .05). Prediction was unreliable for intermediate PRISM scores (6-20) in the PICU.
Conclusions:
- The PRISM score accurately predicted neurological outcomes for pediatric patients in the ED following submersion.
- The PRISM score demonstrated less accuracy in predicting outcomes for pediatric intensive care unit (PICU) patients compared to ED patients.
- The study highlights the PRISM score's utility in the ED but suggests limitations for critically ill patients in the PICU requiring more nuanced prognostic tools.
Objective:
To evaluate the Pediatric Risk of Morality Score (PRISM score) as a tool to distinguish which patients presenting to the emergency department (ED) or pediatric intensive care unit (PICU) would survive neurologically intact from those who would die or survive with severe neurologic impairment following a submersion incident.
Design:
Retrospective chart review.
Setting:
A regional tertiary care ED and PICU.
Materials:
Medical records of drowning and near-drowning patterns between the ages of 1 day and 18 years who were admitted to the ED or PICU from January 1986 through December 1995.
Main Outcome Measures:
For each patient, a PRISM score was calculated based on data collected at the time of arrival to the ED or PICU. A "probability of outcome" was calculated using the PRISM score. Outcomes were defined as survival with intact neurologic function, survival with severe neurologic impairment, or death, and were assessed using the Pediatric Cerebral Performance Category Scale. Scores and probabilities of outcome were compared with the actual outcome for both the ED and PICU patients using the Fisher exact test (2 tailed).
Results:
All Ed patients with PRISM scores less than 25 or a probability of outcome less than 50% (n = 40) survived with intact neurologic function (P < .001). All ED patients with PRISM scores of 25 or greater or a probability of outcome of 50% or greater (n = 10) either died or survived with severe neurologic impairment (P < .001). All PICU patients with a PRISM score of 5 or less (n = 25) or a probability of outcome less than 4% (n = 30) survived with intact neurologic function (P < .05). All PICU patients with a PRISM score greater than 20 or a probability of outcome greater than 50% either died or survived with severe neurologic impairment (P < .05). Outcomes could not accurately be predicted in PICU patients when the PRISM scores were 6 or greater and < or = 20 or less (n = 10), or when the probability of outcomes was 4% or greater and 50% or less.
Conclusions:
The PRISM scoring system accurately distinguished ED patients who would survive neurologically intact from those who would die or suffer neurologic impairment. There was not a specific PRISM score or probability of outcome that could distinguish PICU patients who would survive neurologically intact from those who would die or suffer severe neurologic impairment. The PRISM scoring system appeared to be more accurate in distinguishing intact survival from death or neurologic impairment in ED patients than in PICU patients.