Director NO RELEVANT FINANCIAL RELATIONSHIPS EXIST TO DISCLOSE NO INTENDED UNLABELED UNAPPROVED State EMS update 2014 ems update Over 21000 Licensed EMS Professionals Over 200 EMS Educators ID: 733477
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Joe Holley, MDState EMS Medical DirectorNO RELEVANT FINANCIAL RELATIONSHIPSEXIST TO DISCLOSENO INTENDED UNLABELED/UNAPPROVED
State EMS update2014Slide2
ems updateOver 21,000 Licensed EMS ProfessionalsOver 200 EMS Educators182 licensed EMS Ground ServicesOf 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 wingSlide3
ems update12 Paramedic Programs11 CAAHEP Accredited1 in application process10 In Community College credit programs1 in Continuing Education at University
1 in Metropolitan Fire Academy14 AEMT Programs11 Paramedic Programs1 Fire Academy2 Continuing Education
17 EMT Programs
12 Community College
2 Continuing education
3 Fire Academy Slide4
Ems update7 Critical Care Program4 Hospital Based3 Community CollegeSlide5
MIHC /Community ParamedicMobile 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 ProfessionalsDeveloping Needs assessment
Set Common Standards
Licensure requirementsSlide6
Ems updateBoard approved: Use of Intranasal naloxone for suspected opiate overdose by Emergency Medical Responders and Emergency Medical TechniciansClinical Issues is working on Destination Guidelines for Medical and TraumaLevels of licensure
Emergency Medical ResponderEmergency Medical TechnicianAdvanced Emergency Medical Technician
Paramedic
Critical Care ParamedicSlide7
Ems updateNew Ambulance RulesTwo categories of LicensureALS or BLSALS Require: AEMT and Paramedic on 95% of all emergency responsesBLS Require: Two AEMTs on 95% of all transports.Slide8
New staff New Assistant Director Brandon WardRadio System Analyst John MoyerSlide9
And now for something completely different…A peek into some fascinating information regarding CPR and resuscitation researchMost information is preliminary, and not quite ready for primetimePractical aspects may be easily adoptedSuggests what we may see in as the future of CPR, ACLS, and resuscitation care.Slide10
Pressure ManipulationManipulation of intrathoracic pressure results in significant improvements in cerebral flow.Enhancement of vacuum in the chest result in better blood return and better forward flowFlow is more important than pressureSlide11
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
OnSlide12Slide13
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 IPRSlide14
ACD + ITD (BLS phase)
Standard CPR (BLS phase)
ACD + ITPR (ALS phase)
mmHg
mmHg
mmHg
cm
Airway
Pressure
Aortic
Pressure
Right
Atrial
pressure
Compression
Depth
Representative
HemodynamicsSlide15
Coronary Perfusion Pressure and ETCO2 during the ALS phase
Circulation is significantly improved during ALS with ACD/IPRSlide16
Effect of ALS Protocol of Heart and Brain Blood flowSlide17
1
2
3
4
5 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/IPRSlide18
1
2
3
4
5 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 VFSlide19
Intrathoracic Pressure Regulation during CPR in Patients in Prolonged ArrestETCO2 values increased from 20.1 mmHg at baseline to 43.6 mmHg during Intrathoracic Pressure Regulation (IPR) treatmentROSC 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. Slide20
ConclusionsALS protocols utilizing ACD+IPR significantly improved heart and brain perfusion and the likelihood improved neurologically intact survivalUse 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 defibrillationSlide21
Gravity Assist CPR – A Discovery and SolutionOr how Elevators in Korea may enhance CPR outcomes
21Slide22
BackgroundConnections between thorax and brain instantaneously transmit pressure (respiratory variation in ICP with spinal tap)
Guerci et al: positive pressure ventilationSlide23
Intrathoracic pressure regulation for intracranial pressure management in normovolemic and hypovolemic pigsYannopoulos, McKnite
, Metzger, Lurie Critical Care Medicine 2006Slide24
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
24Slide25
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
25Slide26
Head Up CPR in a Pig with LUCAS+ITD26
Evaluation of CPR effectiveness with Head up, Supine, and Head downSlide27
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
+
+
+
+
+
-Slide28
0°30°
Aortic pressure
Intracranial Pressure
Cerebral Perfusion
Pressure
Effect of Gravity-Assisted CPR on
Cerebral Perfusion PressureSlide29
Gravity-Assisted Head-Up CPR: Effect on Heart and Brain Perfusion PressuresSlide30
Gravity-Assisted
H
ead-Up CPRSlide31
Gravity-Assisted H
ead-Up CPR: Effect on Heart and Brain Flow
Blood flow to brain significantly increased
with +30
o
head-up CPRSlide32
Gravity-Assisted
Head-Up CPR: Effect on compression and decompression phase perfusion pressures
Cerebral Perfusion Pressure
during compression and decompression
systole
diastole
compression
decompressionSlide33
Gravity-Assisted Head-Up CPR: Importance of the Combination of LUCAS + ITD
The
combination
of ITD+LUCAS is needed to optimize gravity-assisted CPRSlide34
Conclusions:Gravity-Assisted Head Up CPRA 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?Slide35
Saving the Brain: ConclusionsThe brain may be more resilient than the heart, in the absence of the TBI induced by CPREfforts 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 compressionImproved 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 livesSlide36
Supine to head up transitionSlide37
Entire Head up StudySlide38
The FutureHeads Up CPR?Elevate Head after ROSC?Similar to how TBI, intubated patients are treatedActive Compression-Decompression CPR?Stutter CPR/ Ischemic ConditioningSNaPE
CPRNitroprusside, low dose EpiSlide39
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