Predictors of death and neurologic impairment in pediatric submersion injuries. The Pediatric Risk of Mortality Score.

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.