Prehospital and Critical Care Transport

Scientific Committee

The maintenance of the scientific content of the application is taken care of by the scientific committee. The scientific committee is divided into two sections, each headed by a content director. Each content director leads a team with different areas of expertise.

Adult section

Director of content :
• Dr Jean-François Couture, emergency medicine

Members

Physicians
• Dr Frédéric Lemaire, emergency medicine
• Dr Matthieu Vincent, adult and pediatric emergency medicine
• Dre Delphine Rémillard Labrosse, emergency medicine
• Dr Dany Burke, intensive care

Pharmacists
• Anne Létourneau, ICU pharmacist
• Mireille Brisson, emergency pharmacist
• Mathieu Desgroseilliers, ICU pharmacist

Nurse
• Gabriel Rivard, emergency nurse

Pediatric section

Director of content :
• Christopher Marquis, pediatric ICU pharmacist

Members

Physicians
• Dr Frédéric Lemaire, emergency physician
• Dr Matthieu Vincent, adult and pediatric emergency medicine
• Dre Delphine Rémillard Labrosse, emergency medicine
• Dre Lise DeCloet, pediatrician
• Dr Jean-Sébastien Tremblay-Roy, pediatric ICU
• Dre Céline Thibault, pediatric ICU

Pharmacists
• Mireille Brisson, emergency pharmacist
• Félix Thompson Desormeaux, pediatric ICU pharmacist

Specific expertise consultants
Dre Sophie Gosselin, toxicologist
David E Zimmermann, pharmacist specialized in dosage in obesity
Audrée Elliott, pharmacist specialized in toxicology

Functioning of scientific committee
Main goals
Revision of the content of the application in the light of available scientific evidence over a 3-year cycle.
Requests from our users
The progression of scientific evidence

Committee directors
Roles:
• Determine the quarterly objectives of the committee with the help of the general manager and his members
• Determine committee members
• Distribute tasks to members to achieve the set objectives
• Schedule meetings to resolve impasses and ensure that objectives will be met
• Ultimately responsible for the committee meeting its objectives

Volunteer meetings
The volunteer meetings are scheduled four times a year. The committees present what they have accomplished in the last three months and determine their objectives for the next quarter.

Process : content management
Adding content to the EZResus app is done with extreme rigor. All members involved are aware of the immense responsibility associated with this process. The process for adding a new medication or reviewing a medication follows the same steps. The only difference is that revision often requires less discussion than adding a new medication.

Collaboration platform
We use the “Monday” collaboration platform for the management of tasks related to the content of the application.

1st step: literature review
The first step is the entry of a new medication and its indication. A literature review is assigned to a physician and a pharmacist. Role of the physician:
• Specify the dose according to the clinical indication according to the literature
• Identify relevant studies to include supporting the dose
Role of the pharmacist:
• Enter drug-specific information
• Available medication concentrations
• Compatibility, diluant type
• Administration speed
• Administration specifics
• Determine minimum and maximum dose
• Double-check the dose determined by the physician
All of these entries are made at a specific place in the “Monday” platform.

2nd step: group revision
Step number 1 often leads to very specific questions where the literature is uncertain or conflicting about the best way to administer a medication. These decisions are made based on the expertise of the rest of the team. At this stage, the content director schedules a meeting with its members to present the medications that have been reviewed in the first stage. The team makes final decisions regarding the information to be entered into the application.

Step 3: entry of clinical data in the back-end
Once the medications have been reviewed as a group, they are entered in the backend. As a security measure, only content directors and the general manager have access to the back-end of the application. Medications are entered in an “inactive” mode to ensure there is no impact on content viewable by our users.

Step 4: testing
The medications are tested in a test version of the app by two external testers. These two testers must not have participated in any prior discussion in connection with these medications. This procedure limits potential biases and ensures that we have “a fresh look” at this new medication.

Step 5: final revision
Once the two external testers have approved the new medication, it goes into final review. At this point, the general manager approves each medication and switches them to “active mode”. This acts as the last filter before the medication is available to users.

Step 6: review in “active” mode
A final brief review is performed once the medication is in “active” mode.

Pediatric and neonatal references

Process
The process of reviewing and adding content is governed by the scientific committee (see above). Each element of the application (equipment, conditions or medication) is reviewed on a 3-year cycle by our team of volunteers.

Medications
The doses and modes of administration of each drug have been validated by an exhaustive literature review and compared to the following references:
• UpToDate [Internet]. Waltham, MA.: Lexicomp Inc.: www.uptodate.com.
• Micromedex Healthcare Series [Internet]. Greenwood Village, Colo: Thomson Micromedex; Disponible: www.micromedex.com
• Trissel LA: Handbook on injectable drugs, 17 edn: Amer Soc of Health System; 2013.
• Mario Bédard AM, Marilyn Emily Morris, Sangeeta Prasad: Manuel sur la pharmacothérapie parentérale de L'Hôpital d'Ottawa: Hôpital d'Ottawa; 2013.
• Taketomo CK: Pediatric & Neonatal Dosage Handbook, 23 edn: Lexi-Comp, Inc.; 2017.
• Gahart’s Intravenous Medications, 34 edn : Elsevier Inc. ; 2018.
• ACLS - PALS Guidelines
• VIHA IV monograph, Vancouver Island Health Authority, Victoria: BC
• Les antidotes en toxicologie d'urgence. INSPQ. Disponible: www.inspq.fr
• Racicot J, Huot H, Vachon A. Guide d'administration intraveineuse des médicaments critiques. Institut Universitaire de cardiologie et de pneumologie de Québec - Université Laval. 8e edition.
• Monographies des produits

Equipment
The choice of size for each piece of equipment was validated by an exhaustive literature review and compared to the following references:
• Broselow Tape 2019
• UpToDate [Internet]. Waltham, MA.: Lexicomp Inc.; www.uptodate.com.
• ACLS/ATLS/PALS/NRP Guidelines
• Roberts and Hedges Clinical Procedures in Emergency Medicine 6th edition
• Reichman’s emergency medicine procedures 3th edition
• Textbook of pediatric emergency procedures, King 2018
• Fleisher & Ludwig’s textbook of pediatric emergency medicine

Estimation of weight
Ideally, the exact weight of the child should be entered into the app for a more accurate calculation of the different doses.
If age is entered, calculations are made by using the “Best Guess Method”
• < 12 months: weight (kg) = (age in months +9) / 2
• 1-5 years: weight (kg) = (2 x age in years) +10
• 5-14 years: weight (kg)= 4 x age in years
If height is entered, calculations are made by using the “Broselow-Luten Tape system” • Note that this rule tends to underestimate the weight of patients in developed countries

Pediatric particularities
We had to make some editorial choices in relation to the differences in practice between the emergency room and pediatric intensive care. In order to limit the amount of volume infused in children with low weights, it is common practice in intensive care to use “syringe drivers”. Unfortunately, these devices are not available in all emergency rooms, especially in remote areas. We have therefore established safe recipes by diluting the doses in small volumes (25mL). It should be kept in mind that the administration of several medications in a low weight patient can represent a considerable amount of volume. Clinical judgment should always prevail.

References
1. Abdel-Rahman SM, Paul IM, James LP, Lewandowski A. Evaluation of the Mercy TAPE: performance against the standard for pediatric weight estimation. Annals of emergency medicine. 2013;62(4):332-9.e6.
2. Ackwerh R, Lehrian L, Nafiu OO. Assessing the accuracy of common pediatric age-based weight estimation formulae. Anesthesia and analgesia. 2014;118(5):1027-33.
3. Cattermole GN, Graham CA, Rainer TH. Pediatric weight estimation. Annals of emergency medicine. 2013;62(1):101.
4. DuBois D, Baldwin S, King WD. Accuracy of weight estimation methods for children. Pediatric emergency care. 2007;23(4):227-30.
5. Garcia CM, Meltzer JA, Chan KN, Cunningham SJ. A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape--A New Weight Estimation Tool. The Journal of pediatrics. 2015;167(1):173-7.e1.
6. Kelly AM, Kerr D, Clooney M, Krieser D, Nguyen K. External validation of the Best Guess formulae for paediatric weight estimation. Emergency medicine Australasia : EMA. 2007;19(6):543-6.
7. Marikar D, Varshneya K, Wahid A, Apakama O. Just too many things to remember? A survey of paediatric trainees' recall of Advanced Paediatric Life Support (APLS) weight estimation formulae. Archives of disease in childhood. 2013;98(11):921.
8. Thompson MT, Reading MJ, Acworth JP. Best Guess method for age-based weight estimation in paediatric emergencies: validation and comparison with current methods. Emergency medicine Australasia : EMA. 2007;19(6):535-42.
9. Tinning K, Acworth J. Make your Best Guess: an updated method for paediatric weight estimation in emergencies. Emergency medicine Australasia : EMA. 2007;19(6):528-34.
10. Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Pediatrics Society, Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada and Dietitians of Canada.
11. Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med 1988;17(6):576–81, http://dx.doi.org/10.1016/s0196-0644(88)80396-2.
12. Hughes G, Spoudeas H, Kovar IZ, Millington HT. Tape measure to aid prescription in paediatric resuscitation. Arch Emerg Med 1990;7(1):21–7.
13. The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide – A systematic review and meta-analysis Mike Wells∗, Lara Nicole Goldstein, Alison Bentley, Sian Basnett, Iain Monteith Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa

Obesity references

General
EZResus improves the calculation of medications in obese patients. If all the information is entered, the application recognizes that the patient is obese and calculates the appropriate medication dose based on total, ideal or adjusted weight. This feature is currently only available for the adult portion of the app.
This functionality would not have been possible without the contribution of our two experts in pharmacy for the obese, authors of the first book published on the subject: “Demystifying Drug Dosing in obese patients”

Definitions
Definitions of obesity :
BMI > 30 kg/m2

Calculation of ideal weight:
We decided to use Robinson's formula, since it is derived from factual and not empirical data (Pai & al. 2000). It gives results very similar to the Devine and Miller equation.

Man : 51.65 + 1.85 x (height in inches - 60)
Woman : 48.67 + 1.65 x (height in inches - 60)

Literature review
For each medication, a literature review was carried out to determine the optimal mode of administration in the obese population. When there was no literature available, we leaned towards the opinion of our experts, based on the pharmacokinetic properties of the different molecules.

References
1. Brunette DD: Resuscitation of the morbidly obese patient. Am J Emerg Med 2004, 22(1):40-47.
2. Cella M, Knibbe C, Danhof M, Della Pasqua O: What is the right dose for children? British journal of clinical pharmacology 2010, 70(4):597-603.
3. Erstad BL: Which weight for weight-based dosage regimens in obese patients? American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 2002, 59(21):2105-2110.
4. Erstad BL: Dosing of medications in morbidly obese patients in the intensive care unit setting. Intensive care medicine 2004, 30(1):18-32.
5. Honiden S, McArdle JR: Obesity in the intensive care unit. Clinics in chest medicine 2009, 30(3):581-599, x.
6. Ingrande J, Lemmens HJ: Dose adjustment of anaesthetics in the morbidly obese. British journal of anaesthesia 2010, 105 Suppl 1:i16-23.
7. Kendrick JG, Carr RR, Ensom MH: Pediatric Obesity: Pharmacokinetics and Implications for Drug Dosing. Clin Ther 2015, 37(9):1897-1923.
8. Martin JH, Saleem M, Looke D: Therapeutic drug monitoring to adjust dosing in morbid obesity - a new use for an old methodology. British journal of clinical pharmacology 2012, 73(5):685-690.
9. Matson KL, Horton ER, Capino AC: Medication Dosage in Overweight and Obese Children. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG 2017, 22(1):81-83.
10. Medico CJ, Walsh P: Pharmacotherapy in the critically ill obese patient. Critical care clinics 2010, 26(4):679-688.
11. Pai MP, Paloucek FP: The origin of the "ideal" body weight equations. The Annals of pharmacotherapy 2000, 34(9):1066-1069.
12. Robinson JD, Lupkiewicz SM, Palenik L, Lopez LM, Ariet M: Determination of ideal body weight for drug dosage calculations. American journal of hospital pharmacy 1983, 40(6):1016-1019.
13. Rowe S, Siegel D, Benjamin DK, Jr.: Gaps in Drug Dosing for Obese Children: A Systematic Review of Commonly Prescribed Emergency Care Medications. Clin Ther 2015, 37(9):1924-1932.
14. Young KD, Korotzer NC: Weight Estimation Methods in Children: A Systematic Review. Annals of emergency medicine 2016, 68(4):441-451.e410.