JOE HOLLEY, MD STATE EMS MEDICAL DIRECTOR NO RELEVANT FINANCIAL RELATIONSHIPS EXIST TO DISCLOSE NO INTENDED UNLABELED/ UNAPPROVED State EMS update 2014

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 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 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

ST (9/23/09) Tracheal Pressure Aortic Pressure Intracranial Pressure 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) mmHg cm Airway Pressure Aortic Pressure Right Atrial pressure Compression Depth Representative Hemodynamics

Coronary Perfusion Pressure and ETCO2 during the ALS phase Circulation is significantly improved during ALS with ACD/IPR

Effect of ALS Protocol of Heart and Brain Blood flow

dead Group A BLS: Standard CPR ALS: Standard CPR Group B BLS: Standard CPR ALS: ACD/ITPR Group C BLS: ACD/ITD ALS: ACD/ITPR Good neurologic outcome CPC Cerebral Performance Category (CPC) Scores with 3 ALS Protocols after 12 minutes of untreated VF 24 hour survival with favorable neurological function significantly improved with ALS using ACD/IPR

dead 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 Good neurologic outcome CPC ** * Cerebral Performance Category (CPC) Scores with 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+ITD 26 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° Neutron Activated Microsphere Neutron Activated Microsphere Neutron Activated Microsphere Neutron Activated Microsphere LUCAS CPR ITD- ResQPOD

0°30° Aortic pressure Intracranial Pressure Cerebral Perfusion Pressure 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 +30 o head-up CPR

Gravity-Assisted Head-Up CPR: Effect on compression and decompression phase perfusion pressures Cerebral 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 Conditioning SNaPE CPR  Nitroprusside, low dose Epi