Calcium channel blockers (CCBs) have seen an increase in rate of non-therapeutic exposure that is both accidental and intentional in nature. Patients experiencing the toxic effects of a CCB overdose are resource intensive and can quickly outstrip the capabilities of local health systems, necessitating transfer to larger tertiary or quaternary care centers. We present a case of intentional non-dihydropyridine CCB overdose and toxicity in a 20-year-old patient requiring initial stabilization at a referring critical access emergency department with continuation of treatment and support during a 60-minute rotor wing transport from the referring hospital to an academic quaternary care center. Emphasis is placed on the unique challenges in resuscitation and ongoing critical care administration during the transport phase of care. Proper stabilization of patients, planning, and consideration of potential problems associated with transport can help minimize stresses and risk of the transport, improving the outcome of extremely ill patients even under challenging circumstances.

intraosseous (IO) access. Our primary objective was to evaluate the rate of out-ofhospital return of spontaneous circulation (ROSC) in the cardiac arrest patient. The following were assessed and analyzed for direct or indirect correlation on ROSC; dispatch time to arrival, number of intravascular attempts per method (IV versus IO) and rate of success accordingly.Methods: Run sheets (n¼167) from all cardiac arrest patients with ROSC in Oakland and Genesee counties in the state of Michigan from January 1, 2012 to December 31, 2012 were collected via EMS. All run sheets were collected by the primary investigator. We recorded age, sex, and pertinent time intervals. The time intervals (in minutes) from time of EMS dispatch to arrival on scene, arrival to functional IV or IO and number of attempts, and the effect of each time marker had on return of spontaneous circulation (ROSC) were recorded. All run sheets include these time intervals and were utilized to record times for the calculations.Results: Dispatch time to scene arrival time varied, overall for the first attempt successful intravascular access group the mean was 6.09 minutes with SD of 3.15 minutes. For the more than one attempt group the mean was 5.96 minutes with SD of 3.03 minutes. The importance of this interval is not clear on how this would affect access success, although a quicker scene time correlates with earlier CPR and potentially better outcomes. Once on scene the analysis of the first attempt intravenous versus first attempt intraosseous showed a mean ROSC of 21.47 versus 17.15 minutes respectively from arrival on scene. This is a difference of 4.32 minutes. Results show a P value of 0.19. This is a 20.12% improvement with an IO versus IV for first successful intravascular attempts.Conclusion: Return of spontaneous circulation can be achieved more rapidly when intraosseous access is used as the first attempt method in obtaining vascular access in cardiac arrest in the out-of-hospital setting. There is a clear trend in shorter ROSC times among the first attempt IO group compared to the IV group; the difference did not reach statistical significance, most likely due to a lack of power from the smaller sample size of the IO group (power ¼ 49%).

Introduction: For out-of-hospital cardiac arrests (OHCAs) unwitnessed by emergency responders, contact with the 911 system provides the earliest point for consistent data collection. Building upon previous tools, we developed a 911 call data abstraction instrument and tested it to see if it reliably tracked key metrics from 911 calls for dispatch assisted CPR in order to guide quality initiatives for OHCA. Methods: Data abstractors applied this tool to a random sample of 23 emergency medical services (EMS)-confirmed, second-party, non-traumatic, non-overdose adult OHCAs occurring prior to first responder arrival from November 2017 to November 2019 in Washtenaw County, Michigan. For each call, data elements were collected by 2 independent reviewers. We focused on key variables: 1) whether the arrest was recognized by dispatch in eligible cases (n=23), 2) whether instructed compressions were provided in eligible cases (n=23), and 3) the 911-time-to-first-instructed-compression (n=11). To evaluate interrater reliability, we calculated kappa statistics for categorical variables and intraclass correlation coefficients (ICC) for continuous variables. Results: We included 23 calls with an average patient age of 64.2 (SD: 10.9) lasting an average of ~5 mins. Overall, 16 patients were men and 7 were women. Thirteen calls originated from private residences, 9 from a public place, and 1 could not be identified. We found that OHCA was recognized by dispatch in 18 of the 23 calls (78%). Reviewers reported instructed compressions occurred in 14 of 23 calls (61%). The median 911-time-to-first-instructed-compression of calls where consistent measurement was possible (n=11) was 197.5 seconds (IQR: 2:30.0-4:44.0). Among calls, kappa statistics for recognition of cardiac arrest and provision of instruction compressions was 1.00 (n=23) and 0.91 (n=23), respectively, while the ICC for time-to-first instructed compression was >0.99 (n=11). Conclusions: Reviewing 911 calls with this tool was capable of collecting reliable information from independent reviewers on key events including critically important times. Collection of these data is a critical first step for evaluating system performance to improve survival from OHCA.