State EMS update
2014
JOE HOLLEY, MD
STATE EMS MEDICAL DIRECTOR
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RELATIONSHIPS
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ems update
 Over 21,000 Licensed EMS Professionals
 Over 200 EMS Educators
 182 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 Ambulances
 10 Licensed Air Medical Services
 Approximately 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 populationspecific 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 licensure
Emergency Medical Responder
Emergency Medical Technician
Advanced Emergency Medical Technician
Paramedic
Critical 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
Intracranial Aortic
Tracheal
Pressure
Pressure Pressure
Effect of IPR on Tracheal, Aortic, Intracranial Pressures
in Apneic Pigs Immediately post ROSC
IPR On
30 sec.
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
Representative Hemodynamics
Standard CPR (BLS phase) ACD + ITD (BLS phase)
mmHg
Aortic
Pressure
mmHg
Airway
Pressure
ACD + ITPR (ALS phase)
Right
Atrial
pressure
mmHg
Compression
Depth
cm
Pressure (mmHg)
Coronary Perfusion Pressure and ETCO2
during the ALS phase
60
40
20
0
CPP
ETCO2
A: BLS Std - ALS Std
B: BLS Std - ALS ACD/ITPR
C: BLS ACD/ITD - ALS ACD/ITPR
Circulation is significantly improved during ALS with ACD/IPR
Effect of ALS Protocol of Heart and
Brain Blood flow
0.8
Blood Flow (ml/min/g)
0.7
Brain blood flow during the different
interventions (n=7)
0.6
P=0.03
0.5
0.4
0.3
0.2
0.1
0.0
BL
ACD + ITD
ACD + ITPR
ACD + ITPR + EPI
Order of CPR Interventions (Total Time of 4' Each)
Cerebral Performance Category (CPC) Scores
with 3 ALS Protocols after 12 minutes of untreated VF
5 dead
CPC
4
3
Good
neurologic
outcome
2
1
Group A
BLS: Standard CPR
ALS: Standard CPR
Group B
BLS: Standard CPR
ALS: ACD/ITPR
Group C
BLS: ACD/ITD
ALS: ACD/ITPR
24 hour survival with favorable neurological function significantly
improved with ALS using ACD/IPR
Cerebral Performance Category (CPC) Scores
with 3 ALS Protocols after 12 minutes of untreated VF
5 dead
CPC
4
3
*
*
Good
neurologic
outcome
2
*
1
Group A
BLS: Standard CPR
ALS: Standard CPR
+ *ACD/IPR
as rescue therapy
Group B
BLS: Standard CPR
ALS: ACD/ITPR
Group C
BLS: ACD/ITD
ALS: ACD/ITPR
Intrathoracic Pressure Regulation during CPR in
Patients in Prolonged Arrest
19
 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
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
21
Or how Elevators in Korea may enhance CPR
outcomes
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?
24
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
Hypothesis
25
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
Head Up CPR in a Pig with LUCAS+ITD
26
Evaluation of CPR effectiveness with Head up, Supine,
and Head down
Gravity-Assisted Head-Up CPR – Study
Protocol(1)
Baseline
4 min 4 min 4 min
6 min
VF
4 min
2
min
+30°
+30°
-30°
Neutron
Neutron
Neutron
Activated Activated Activated
Microsphere
Microsphere
Microsphere
+
+
+
+
+
+
+
ITD- ResQPOD
+30°
0°
Neutron
Activated
Microsphere
LUCAS CPR
0°
2
min
+
+
+
+
-
Effect of Gravity-Assisted CPR on
Cerebral Perfusion Pressure
0°
Aortic pressure
Intracranial Pressure
Cerebral Perfusion
Pressure
30°
Gravity-Assisted Head-Up CPR: Effect on Heart
and Brain Perfusion Pressures
CPP
40
CerPP
Pressure (mmHg)
*
*
30
20
10
*
*
0
-10
0
+30
-30
0
+30
-30
CPR angle (°)
n=12. CPR angle relationship with Coronary Perfusion Pressure (CPP) and
Cerebral Perfusion Pressure (CerPP). *p<0.001 compare to 0°.
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 pressures
Cerebral Perfusion Pressure
during compression and decompression
Pressure (mmHg)
100
50
systole
compression
diastole
decompression
0
Baseline
0
CPR Angle (°)
30
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 Conditioning
 SNaPE CPR
 Nitroprusside, low dose Epi
 JoeHolleymd@gmail.com