Determination of prognostic markers of drowning cases in emergency department

Introduction: There are no defined clinical decision tool for the management of patients after drowning in ED. Prehospital findings of the cases were evaluated in the risk scores made to date. Use of the Szpilman clinical score which was developed to grading prehospital patients, remains unclear for ED. In this study, we aimed to evaluate the risk factors associated with prognosis by analyzing the symptoms, laboratory results and imaging findings of the patients in the ED and to determine the markers for safe discharge from the ED. Methods: All patients associated with drowning who were admitted to Dokuz Eylul University Medical Hospital Adult and Children's EDs between 01/01/2008-31/12/2018 were retrospectively reviewed. Patients recorded by drowning/near-drowning in the ED triage book, patients with ICD diagnostic codes associated with drowning, patients brought to the emergency department due to arrest and patients who were recorded as forensic status were identified by screening. Patient files, nurse observation forms and consultation results were examined and the research criteria were recorded. The characteristics of the patients and the characteristics of the event were determined and factors associated with the modified rankin score (MRS) at discharge and survival for all age groups and also factors associated with poor outcome (death, to be admitted to ICU or modified rankin score ≥4 at discharge) for the adult age group were analyzed by logistic regression test. Results: 292 patients were included in this study. The median age of the patients was 36.0 (9 months-89 years) and 64.4% (n: 188) of the patients were male. Most of the patients were admitted between 12:00-17:59 and on weekdays. Most of the drowning cases occurred at sea (n: 253; 86.6%). In 39 patients (13.4%), cardiopulmonary or respiratory arrest developed after the event, and in 21 patients (53.9%), BLS was applied by bystander. It was ascertained that 12 patients (4.1%) died related with drowning in ED, 6 patients died related with drowning after hospitalization and 5 patients were discharged from hospital as MRS 4 or 5. The patients who died were presented to ED with lower blood pressure, heart rate, respiratory rate and GCS. When only adult patients were evaluated in terms of poor outcome (development of cardiac arrest, discharge with poor neurological outcome and the need for hospitalization from the ICU) , it was found that 108 patients (52.9%) developed poor outcome and 96 patients (47.1%) were hospitalized or discharged from ED. It was seen that only one of the events that occurred in fresh water had a poor outcome and the cases that occurred in the early hours of the morning and patients that was seen on chest radiograph with extensive infiltration had worse outcome. Respiratory rate, oxygen saturation, GCS and chest X-ray findings were determined as independent risk factors for poor outcome. No patients died with Szpilman score less than 3 on the other hand when examined for poor outcome, the sensitivity of the Szpilman score below 3 was 66.4% and the selectivity was 89% in predicting poor outcome. Discussion: Although Szpilman staging predicts fatal patients, it is insufficient to predict poor outcome. A scoring method using respiratory rate, oxygen saturation, GCS and chest X-ray findings might be useful in patient management in drowning cases presented to ED. Keywords: Drowning, emergency department, prognostic factor, szpilman clinical score