Optimizing the assessment of pediatric injury severity in low-resource settings: Consensus generation through a modified Delphi analysis.
BACKGROUND
Although a plethora of pediatric injury severity scoring systems is available, many of them present important challenges and limitations in the low resource setting. Our aim is to generate consensus among a group of experts regarding the optimal parameters, outcomes, and methods of estimating injury severity for pediatric trauma patients in low resource settings.


METHODS
A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. Qualitative data was extracted from the systematic review, including scoring parameters, settings and outcomes. In order to establish consensus regarding which of these elements are most adapted to pediatric patients in low-resource settings, they were subjected to a modified Delphi survey for external validation. The Delphi process is a structured communication technique that relies on a panel of experts to develop a systematic, interactive consensus method. We invited a group of 38 experts, including adult and pediatric surgeons, emergency physicians and anesthesiologists trauma team leaders from a level 1 trauma center in Montreal, Canada, and a pediatric referral trauma hospital in Santiago, Chile to participate in two successive rounds of our survey.


RESULTS
Consensus was reached regarding various features of an ideal pediatric trauma score. Specifically, our experts agreed pediatric trauma scoring tool should differ from its adult counterpart, that it can be derived from point of care data available at first assessment, that blood pressure is an important variable to include in a predictive model for pediatric trauma outcomes, that blood pressure is a late but specific marker of shock in pediatric patients, that pulse rate is a more sensitive marker of hemodynamic instability than blood pressure, that an assessment of airway status should be included as a predictive variable for pediatric trauma outcomes, that the AVPU classification of neurologic status is simple and reliable in the acute setting, and more so than GCS at all ages.


CONCLUSIONS
Therefore, we conclude that an opportunity exists to develop a new pediatric trauma score, combining the above consensus-generating ideas, that would be best adapted for use in low-resource settings.
Department of General Surgery, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada; Department of Pediatric Surgery, McGill University Health Centre, 1001 Décarie Boulevard, Montreal, Quebec, H4A 3JI, Canada. Electronic address: etienne.st-louis@mail.mcgill.ca.
Etienne
E
St-Louis
Department of General Surgery, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
Dan Leon
DL
Deckelbaum
Department of Pediatric Surgery, McGill University Health Centre, 1001 Décarie Boulevard, Montreal, Quebec, H4A 3JI, Canada.
Robert
R
Baird
Department of General Surgery, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
Tarek
T
Razek
D015998:Abbreviated Injury Scale; D002170:Canada; D002648:Child; D032921:Consensus; D003697:Delphi Technique; D004632:Emergency Medical Services / Q000191:economics; D005069:Evaluation Studies as Topic; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D014947:Wounds and Injuries / Q000175:diagnosis*
Delphi; Low- and middle- income country; Pediatric trauma; Trauma score