JOE HOLLEY, MDSTATE EMS MEDICAL DIRECTOR

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EXIST TO DISCLOSENO INTENDED UNLABELED/

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State EMS update2014

ems update

Over 21,000 Licensed EMS ProfessionalsOver 200 EMS Educators182 licensed EMS Ground Services

Of those approximately 7 are licensed BLS Around 175 are ALS

Meaning a Paramedic on 95% of all Emergency dispatched calls

Over 1600 Permitted Ground Ambulances10 Licensed Air Medical ServicesApproximately 50 permitted air craft both

rotor or fixed wing

ems update

12 Paramedic Programs 11 CAAHEP Accredited

1 in application process 10 In Community College credit programs 1 in Continuing Education at University 1 in Metropolitan Fire Academy

14 AEMT Programs 11 Paramedic Programs 1 Fire Academy 2 Continuing Education

17 EMT Programs 12 Community College 2 Continuing education 3 Fire Academy

Ems update

7 Critical Care Program 4 Hospital Based 3 Community College

MIHC /Community Paramedic

Mobile Integrated Health Care: Focus on patient-centered navigation and offer transparent population-specific care by integrating existing infrastructure and resources, bringing care to patients through technology, communications, and health information exchange.

Community Paramedic: Individual trained to work in the MIHC environment.

Task Force of EMS and other Healthcare Professionals Developing

Needs assessment Set Common Standards Licensure requirements

Ems update

Board approved: Use of Intranasal naloxone for suspected opiate overdose by Emergency Medical Responders and Emergency Medical Technicians

Clinical Issues is working on Destination Guidelines for Medical and Trauma

Levels of licensureEmergency Medical ResponderEmergency Medical TechnicianAdvanced Emergency Medical TechnicianParamedicCritical Care Paramedic

Ems update

New Ambulance Rules Two categories of Licensure

ALS or BLS ALS Require: AEMT and Paramedic on 95% of all

emergency responses BLS Require: Two AEMTs on 95% of all transports.

New staff

New Assistant Director Brandon Ward

Radio System Analyst John Moyer

And now for something completely different…

A peek into some fascinating information regarding CPR and resuscitation research

Most information is preliminary, and not quite ready for primetime

Practical aspects may be easily adopted Suggests what we may see in as the future of CPR,

ACLS, and resuscitation care.

Pressure Manipulation

Manipulation of intrathoracic pressure results in significant improvements in cerebral flow.

Enhancement of vacuum in the chest result in better blood return and better forward flow

Flow is more important than pressure

Tra

cheal

Pre

ssu

reA

ort

icP

ress

ure

Intr

acr

an

ial

Pre

ssu

re

Effect of IPR on Tracheal, Aortic, Intracranial Pressures in Apneic Pigs Immediately post ROSC

30 sec.

IPR On

Better Advanced Life Support (ALS)Improving ALS by Enhancing Circulation with Intrathoracic Pressure Regulation (IPR)

Objective: Improve chances for survival when Basic Life Support (BLS) fails

Problem: Current Advanced Life Support (ALS) often fails as circulation is too low and drugs not been shown to be effective

Hypothesis: Improved brain circulation during ALS will improve likelihood for better neurologically-intact survival

Comparison: ALS with standard CPR (S-CPR) vs methods to enhance cerebral perfusion based upon improve circulation with IPR

ACD + ITD (BLS phase)Standard CPR (BLS phase) ACD + ITPR (ALS phase)

mm

Hg

mm

Hg

mm

Hg

cm

AirwayPressure

AorticPressure

Right Atrial

pressure

CompressionDepth

Representative Hemodynamics

Coronary Perfusion Pressure and ETCO2 during the ALS phase

Circulation is significantly improved during ALS with ACD/IPR

BL ACD + ITD ACD + ITPR ACD + ITPR + EPI0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8Brain blood flow during the different

interventions (n=7)

Order of CPR Interventions (Total Time of 4' Each)

Blo

od

Flo

w (

ml/

min

/g)

P=0.03

Effect of ALS Protocol of Heart and Brain Blood flow

1

2

3

4

5 dead

Group ABLS: Standard CPRALS: Standard CPR

Group BBLS: Standard CPRALS: ACD/ITPR

Group CBLS: ACD/ITDALS: ACD/ITPR

Good

n

eu

rolo

gi

c o

utc

om

e

CP

CCerebral Performance Category (CPC) Scoreswith 3 ALS Protocols after 12 minutes of untreated VF

24 hour survival with favorable neurological function significantly improved with ALS using ACD/IPR

1

2

3

4

5 dead

Group ABLS: Standard CPRALS: Standard CPR

+ *ACD/IPR as rescue therapy

Group BBLS: Standard CPRALS: ACD/ITPR

Group CBLS: ACD/ITDALS: ACD/ITPR

Good

n

eu

rolo

gi

c o

utc

om

e

CP

C

* *

*

Cerebral Performance Category (CPC) Scoreswith 3 ALS Protocols after 12 minutes of untreated VF

Intrathoracic Pressure Regulation during CPR in Patients in Prolonged Arrest

ETCO2 values increased from 20.1 mmHg at baseline to 43.6 mmHg during Intrathoracic Pressure Regulation (IPR) treatment

ROSC rate was 73% v. 46% for control; mean BP 3 minutes after ROSC in the IPR group was 133/79 mmHg

19

Segal et al, Resuscitation, 2013 Apr;84(4):450-3.

Conclusions

ALS protocols utilizing ACD+IPR significantly improved heart and brain perfusion and the likelihood improved neurologically intact survival

Use of ACD+IPR in humans looks promising and may provide an additional approach to help ‘save the brain’ after cardiac arrest and failure of immediate defibrillation

Gravity Assist CPR – A Discovery and Solution

Or how Elevators in Korea may enhance CPR outcomes

21

Background

Connections between thorax and brain instantaneously transmit pressure

(respiratory variation in ICP with spinal tap)

Guerci et al: positive pressure ventilation

Intrathoracic pressure regulation for intracranial pressure management in normovolemic and hypovolemic pigs

Yannopoulos, McKnite, Metzger, Lurie Critical Care Medicine 2006

Fundamental Flaw of Supine S-CPR?

Chest compressions simultaneously increase arterial and venous pressure in the brain compressing the already ischemic brain within the closed space of the skull with a high intensity pressure wave with each compression

24

Hypothesis

In cardiac arrest, elevation of the head with simultaneous use of CPR technologies that provide enhanced circulation to the heart and brain compared with S-CPR will reduce cerebral venous pressure, lower ICP, and improve outcomes

25

Head Up CPR in a Pig with LUCAS+ITD26

Evaluation of CPR effectiveness with Head up, Supine, and Head down

Gravity-Assisted Head-Up CPR – Study Protocol(1)

6 min 4 min

0°

Baseline

VF

4 min

0°

4 min

+30°

4 min

-30°

2 min

+30°

2 min

+30°

NeutronActivated

Microsphere

NeutronActivated

Microsphere

NeutronActivated

Microsphere

NeutronActivated

Microsphere

LUCAS CPR + + + + + +

ITD- ResQPOD + + + + + -

0° 30°

Aortic pressure

Intracranial Pressure

Cerebral PerfusionPressure

Effect of Gravity-Assisted CPR on Cerebral Perfusion Pressure

Gravity-Assisted Head-Up CPR: Effect on Heart and Brain Perfusion Pressures

Gravity-Assisted Head-Up CPR

Gravity-Assisted Head-Up CPR: Effect on Heart and Brain Flow

Blood flow to brain significantly increased with +30o head-up CPR

Gravity-Assisted Head-Up CPR: Effect on compression and decompression phase perfusion

pressuresCerebral Perfusion Pressure

during compression and decompression

systole

diastole

compression

decompression

Gravity-Assisted Head-Up CPR: Importance of the Combination of LUCAS + ITD

The combination of ITD+LUCAS is needed to optimize gravity-assisted CPR

Conclusions:Gravity-Assisted Head Up CPR

A potential breakthrough in understanding how to save the brain during CPR.

Many new questions: optimal angle?head and neck up only? how long does effect last?does this improve survival?improved with ACD+ITD?

Saving the Brain: Conclusions

The brain may be more resilient than the heart, in the absence of the TBI induced by CPR

Efforts to reduce ICP during and after CPR may provide novel ways to enhance brain preservation

We may be inadvertently creating concussion physiology with every supine compression

Improved brain perfusion without increases in ICP, together with other means to preserved brain integrity and healing (eg. TH and P-188) should help save more intact lives

Supine to head up transition

Entire Head up Study

The Future

Heads Up CPR?Elevate Head after ROSC?

Similar to how TBI, intubated patients are treated

Active Compression-Decompression CPR?Stutter CPR/ Ischemic ConditioningSNaPE CPR

Nitroprusside, low dose Epi

JoeHolleymd@gmail.com

Thank You!