Submersion in Children: Prognostic Indicators on ...

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Published: 19 April 2017. ISSN: 2476-2016. Copyright. © 2017 Elias Baracat et al. ... of all worldwide deaths result from unintentional drowning. It is the leading ...


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Archives of Emergency Medicine and Critical Care

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*Corresponding author Emílio Carlos Elias Baracat, PediatricsDepartment, Schoolof Medical Sciences, Universityof Campinas (UNICAMP), Rua Carlos Chagas, 150, Campinas, São Paulo, Brazil; Tel: 55-19-35217322; 55-19-32880727; Email:

Submersion in Children: Prognostic Indicators on PICU Admission

Submitted: 29 March 2017 Accepted: 18 April 2017 Published: 19 April 2017 ISSN: 2476-2016 Copyright

Emílio Carlos Elias Baracat1*, Mariana Resende Moreira2, Fernando Belluomini1, Marcelo Conrado dos Reis1, Marcelo Barciela Brandão1 and Andrea de Melo Alexandre Fraga1 1

© 2017 Elias Baracat et al. OPEN ACCESS

Keywords

Department of Pediatrics, School of Medical Sciences, Universityof Campinas

(UNICAMP), Brazil 2

Department of , School of Medical Sciences, Universityof Campinas (UNICAMP),

Brazil

• Drowning • Intensive Care • Mortality • Prognosis • Children

Abstract Determining the mortality markers for drowning victims admitted to intensive care is essential in guiding medical treatment and defining prognosis. Objective: Describe the epidemiological profile and identify adverse outcomes markers in submersion accident victims on admission in intensive care unit. Methods: Records of 0-13yo drowning victims admitted to PICU at two university hospitals in the metropolitan area of Campinas, state of São Paulo, Brazil, between 2005-2013 were reviewed, regarding age, gender, month of occurrence, place of drowning, child’s swimming ability, safety equipment use and adult supervision. At intensive care admission, systolic blood pressure, Glasgow Coma Scale and laboratory data (electrolyte, urea/creatinine, aminotransferases, blood gas analysis) were recorded. Patients were divided into ‘deceased’ and ‘surviving’ groups. Data was analyzed by SAS software, v9.4, adopting the 5% significance level. Results: The study included 42 patients (23 male), most under 3yo, with the accident occurring in swimming pools without safety equipment or adult supervision. Compared to the surviving group, the deceased group had lower serum pH (p=0.0001) and higher values of serum potassium (p=0.0293), serum creatinine (p=0.0042) and hepatic enzymes AST (p=0.0018) and ALT (p=0.0061). In logistic regression analysis, the presence of mydriasis (OR=33.3) and high serum potassium on admission (OR=3.17) were identified as death-associated factors. Conclusion: Most patients admitted to PICU after submersion accidents were below 3 years of age, with the accidents having occurred in swimming pools and without adult supervision. On hospital admission, the presence of mydriasis and high serum potassium were identified as associated factors for death.

ABBREVIATIONS PICU: Pediatric Intensive Care Unit; WHO: World Health Organization

INTRODUCTION

Drowning, as defined by WHO, is lung damage resulting from submersion/immersion in liquid [1]. According to WHO, 0.7% of all worldwide deaths result from unintentional drowning. It is the leading cause of worldwide deaths in children aged 5-14, accounting for about 1,000 deaths per year of children under 14 years in Brazil [2]. In addition, it is estimated that for every death by drowning, three people are treated by emergency services for non-fatal submersions, not including aquatic rescues, where hospital treatment is not involved [3]. The occurrence of drowning presents a bimodal distribution with respect to age, with a higher prevalence in children under 5 years, followed by a second peak in young adult men [1,3]. Factors that may influence

the occurrence of submersion accidents include gender, race, socioeconomic status, age and geographic location. In particular, a low socioeconomic status exposes children to various determinants with a risk for this type of occurrence. Lack of supervision, overcrowding, housing in outlying areas of the city with free and easy access to lakes and ponds and lack of prevention information for caregivers are all conditions associated with an increased exposure to risk factors for drowning amongst children and adolescents. Additionally, old habits can increase chances of submersion, such as the lack of use of safety equipment and the use of alcohol and/or drugs by adolescents [4]. Most people in a drowning event are rescued in time by passersby or professional rescuers. In situations where a lifeguard is present, less than 6% of all victims need medical attention and only 0.5% require cardiopulmonary resuscitation [5]. Thus, patients taken to hospitals and admitted to intensive care constitute a very small percentage of submersion accident victims, although they do represent the most serious cases.

Cite this article: Elias Baracat EC, Moreira MR, Belluomini F, dos Reis MC, Brandão MB, et al. (2017) Submersion in Children: Prognostic Indicators on PICU Admission. Arch Emerg Med Crit Care 2(2): 1024.

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Hypoxia is the common factor found in submersion accidents, regardless of the liquid medium in which the event occurred (fresh or salt water) [1,3]. The degrees of asphyxia and cerebral hypoxia determine the drowning victim’s prognosis. Clinical signs such as a value below 5 on the Glasgow Coma Scale, an initial body temperature of less than 33°C, hypotension and an absence of papillary reflex on hospital admission are all directly associated with poor outcomes [6]. Several studies have sought to identify other laboratory markers with a greater association with adverse outcomes. In laboratory analyses of patients admitted with more severe drowning classifications, it was found that a serum pH of less than or equal to 7.1, a high concentration of serum glucose and a low pO2 on admission are all described as being indicative of poor prognosis [3,6].

This study aims to describe the epidemiological profile of submersion accident victims admitted to pediatric intensive care, and to identify prognostic clinical and laboratory markers on admission, which are associated with adverse outcomes.

SUBJECTS AND METHODS

A retrospective study of all patients aged 0 to 13 years admitted to the Clinical Hospital of the State University of Campinas (UNICAMP) and Sumare State Hospital (São Paulo, Brazil), between the period 2005-2014, with drowning diagnoses as classified by the ICDs T751, W650, W670, W673, W678, W679 and W749. In 2010, the mortality rates for children under 1 year of age in the metropolitan area of Campinas were 11.8 deaths/1.000 live births and the gross domestic product per capita was US$ 20.445. The records, whether online or physical, were analyzed and from them the following data were extracted: age, gender, month of occurrence, place of drowning, child’s swimming ability, use of safety equipment and adult supervision. On admission to intensive care, the following data were recorded: systolic blood pressure and Glasgow Coma Scale, as well as the results of the following laboratory tests: electrolytic profile, urea/creatinine, aminotransferases and blood gas analysis. For the comparison of laboratory data ​​and the identification of factors associated with poor prognoses, the patients were divided into two groups, ‘deceased’ and ‘surviving’. Data were consolidated in an Excel spreadsheet, and consequent exploratory data analysis was performed, by measuring the frequencies of categorical variables and by descriptive statistics analysis of quantitative variables. Logistic regression analysis was used for the study of death-risk factors. For the comparison of the variables related to sequelae and death, the Mann-Whitney test was used. The significance level adopted for this study was 5%. For statistical analyses, the following computer program was used: The SAS System for Windows (Statistical Analysis System), version 9.4. The project was approved by the Research Ethics Committee of the UNICAMP Faculty of Medical Sciences, with the exemption of the “Informed Terms of Consent” under CAAE number 39754614.5.0000.5404, protocol 917.218.

RESULTS

The study included 42 patients admitted to the PICU with Arch Emerg Med Crit Care 2(2): 1024 (2017)

submersion accident diagnostics, according to ICD. 23 patients were male a�nd 19 female. Most patients were in the age range of one to five years (mean 4.1 years, median 3.1 years). There was no difference between the age variables (p=0.1282) and gender (p=0.2768) of the deceased and surviving groups. The period of the year when most submersion accidents occurred was October to March, which corresponds to the hottest period of the year in the region, with highest number of occurrences in January. As to aquatic environment, the swimming pool was the location of the majority of submersion events (76%), followed by lake/pond (12%), bath and bucket (both 4%) and river (2%). Table 1 describes the variables related to the accidents’ circumstances. Most of the children could not swim (90%), none of them used safety equipment, and many of the events occurred in the absence of adults. In most cases, the families took the children from the water. Most patients (88%) received their first effective medical care in emergency units.

On admission, 27 patients presented values on the Glasgow Coma Scale (GCS) of less than 15 (median = 8), with 15 having the minimum score of 3. Regarding papillary reactivity, 15 patients (36%) had mydriasis on admission. Concerning blood pressure on admission, 9 patients had hypotension (21%). Table 1: Descriptive variables related to the circumstances of child submersion accident victims admitted to the PICU. Frequency (n=42)

Percentage (%)

Swimming pool

32

76.19

Bath

2

4.76

Variable

Aquatic environment: Lake

Bucket River

Swimming ability:

5 2 1

11.90 4.76 2.38

Yes

2

4.76

No data

2

4.76

No

Use of safety equipment:

38

90.48

Yes

0

0

No data

2

4.76

No

Adult supervision:

40

95.24

Yes

7

16.68

No data

2

4.76

No

33

Responsible for child's removal from water:

78.56

Family

33

78.58

Friends

1

2.38

Rescue services No data

5 3

11.90 7.14

2/4

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On comparison of the variables between the deceased and surviving groups, statistically significant differences were found in the deceased group with decreased values in pH (p=0.0001) and serum bicarbonate (p